Cardiopulmonary resuscitation

BMJ 2012; 345 doi: (Published 3 October 2012)
Cite this as: BMJ 2012;345:e6122

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Dear Sir,

We thank Nolan et al. for their review on cardiopulmonary resuscitation (CPR). However, the review did not address the important issue of ethnic or racial differences in provision of CPR, and therefore subsequent survival from cardiac arrest.

It is incorrect to assume that provision of CPR is standard across all ethnic/racial groups. A recent systematic review and meta-analysis conducted by us concluded that Black patients are less likely to receive bystander CPR, have a witnessed arrest or have an initial favourable rhythm of ventricular fibrillation/ ventricular tachycardia.1 Subsequent to this Black patients are less likely to have a favourable outcome following out of hospital cardiac arrest (OOHCA) with lower rates of survival to hospital admission and discharge compared to Caucasians.1 Our study also identified that there is paucity of data regarding ethnic/racial differences and OOHCA characteristics including CPR outside the USA as well as for other ethnic/racial groups.1 Only one study, to our knowledge, has explored differences in OOHCA arrest characteristics and outcomes, in other racial groups, showing comparable care between South Asians and Whites.2 The study showed that although South Asians were likely to suffer an OOHCA at a younger age compared to their White counterparts, there was no significant difference in provision of bystander CPR, initial rhythm, response times and importantly survival to hospital admission or discharge.2

Nolan et al. highlight in their review that there are still several questions that will govern the direction of future research. Exploring racial and ethnic inequalities in provision of pre hospital care has been somewhat neglected. Further research is now needed to close the gaps in the knowledge and understanding of the underlying reasons contributing to racial discrepancy in OOHCA care.

Thank you.

1. Shah KS, Shah AS, Bhopal R. Systematic review and meta-analysis of out-of-hospital cardiac arrest and race or ethnicity: Black US populations fare worse. European Journal of Preventive Cardiology 2012 June 12 (Epub ahead of print).

2. Shah AS, Bhopal R, Gadd S, Donohoe R. Out-of-hospital cardiac arrest in South Asian and white populations in London: database evaluation of characteristics and outcome. Heart (British Cardiac Society) 2010;96(1):27-29.

Competing interests: None declared

Keval Sureshchandra Virpal Shah, Medical Student (1)

Anoop Sureshchandra Virpal Shah (2), Raj Bhopal,

1. University of Southampton; 2. Centre for Cardiovascular Science, The University of Edinburgh, Chancellor's Building, Edinburgh. EH16 4SU

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Dear Editor,

We report a recent event in which an automated external defibrillator (AED) being available on a train may have resulted in a reduction in future patient morbidity and our findings from an investigation into the availability of AEDs on trains in the UK and the feasibility of their introduction onto all UK trains.

One of the authors was recently involved in a medical emergency on a mainline train and was surprised to find no automated external defibrillator (AED) was carried. AEDs are portable electronic devices capable of detecting and treating ventricular fibrillation by electrical cardioversion. AEDs require minimal training, are designed for use by non-medical operators and often include both audio and visual instructions to enable use by visually impaired or hearing impaired persons. For an immediate or life threatening emergency the target UK ambulance response time is eight minutes which may not be possible if the train is between stations (1).

Following this incident, we subsequently contacted all major national and local UK train services (n=26) regarding whether they carried AEDs. A response was received from eighteen companies (69%), none of which carried AEDs on their trains.

AEDs have already been shown to be effective in saving lines in aircraft and trains in the United States (2,3). An AED may be purchased for as little as £771. For a train carrying 200 passengers the estimated cost of an AED per person for that single trip would be £3.86 per person. If that train were to carry 1000 passengers a day on average for a year then the cost of providing an AED on that service would be less than one penny per passenger.

It is the recommendation of this study that given the low cost of providing AEDs, their proven benefit and their ease of use, all UK trains should carry AEDs.

Competing interests: None declared

Matthew David Hale, Medical Student

Riituparna Banerjee, Dudley Bush

Leeds General Infirmary, Department of Anaesthesia, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX

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Dr Samuel highlights the difficulties of producing a comprehensive review given the diverse readership of the BMJ. We were commissioned to provide a general overview of current guidelines, introduce recent developments and highlight areas of current controversy. We included links to the in-depth international CPR guidelines for those readers seeking additional information.

To address the specific queries raised by Dr Samuel, we refer readers to the International Liaison Committee for Resuscitation (ILCOR) systematic review on treatment of cardiac arrest secondary to pulmonary embolus (PE).1 In brief, fibrinolytic therapy should be considered when PE causes cardiac arrest.2 Survival and good neurological outcome have been reported in cases requiring over 60 min of CPR.1 Consider performing CPR for at least 60–90 min before terminating resuscitation attempts. Detailed information on other reversible causes are contained within these guidelines.1,2

We agree that effective team leadership skills are required for optimal team performance. Recent data link better team leadership with improved technical skills performance in simulated cardiac arrest setting.3 Non-technical skill training is now included in the Resuscitation Council (UK) ALS Course.

The decision about when to stop CPR is challenging. Although termination rules have been validated for out of hospital cardiac arrest, the ILCOR systematic review of CPR termination rules found limited evidence supporting in-hospital termination rules.4 In our practice, termination of resuscitation efforts is based on ruling out reversible causes, the duration of the resuscitation and information about co-morbidities and functional status prior to cardiac arrest. Recent data indicate better outcomes (higher likelihood of return of spontaneous circulation (adjusted risk ratio 1·12, 95% CI 1·06–1·18; p<0·0001) and survival to discharge (1·12, 1·02–1·23; 0·021) in hospitals in the quartile with the longest median duration of resuscitation attempts in non-survivors (25 min [IQR 25–28]) compared with hospitals in the quartile with the shortest median resuscitation attempts (16 min [IQR 15–17]).5

1. Deakin CD, Nolan JP, Soar J, Sunde K, Koster RW, Smith GB, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation 2010;81(10):1305-52.
2. Deakin CD, Morrison LJ, Morley PT, Callaway CW, Kerber RE, Kronick SL, et al. Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2010;81 Suppl 1:e93-e174.
3. Yeung JH, Ong GJ, Davies RP, Gao F, Perkins GD. Factors affecting team leadership skills and their relationship with quality of cardiopulmonary resuscitation. Crit Care Med 2012;40(9):2617-21.
4. Soar J, Mancini ME, Bhanji F, Billi JE, Dennett J, Finn J, et al. Part 12: Education, implementation, and teams: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2010;81 Suppl 1:e288-330.
5. Goldberger ZD, Chan PS, Berg RA, Kronick SL, Cooke CR, Lu M, et al. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study. Lancet 2012;380:1473-81.

Competing interests: JPN, JS and GDP are members of the Executive Committee of the Resuscitation Council (UK). All were authors of the 2010 cardiopulmonary resuscitation guidelines (RC (UK) and European Resuscitation Council).

Jerry P Nolan, Consultant Anaesthetist

Jasmeet Soar, Gavin D. Perkins

Royal United Hospital, Bath, Combe Park, Bath BA1 3NG

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Whilst the review by Nolan et al provided a useful overview of Cardiopulonary resuscitation, I feel it has limited educational value for secondary care clinicians, and especially emergency medical teams who manage this scenario regularly. The overview fails to even mention "special circumstances" such as Pulmonary Embolus, where prolonged resuscitation appears to be more effective and is now recommended following thrombolysis1. Add to this any mention of assessing the reversible causes of cardiac arrest and the role of the team leader in overseeing this assessment.

In addition, one of the most challenging and contentious issues relating to CPR is deciding when to end attempts to resuscitate; the discussions and factors that need to be taken into consideration are also overlooked, despite discussing DNAR orders. 2010 ALS Guidelines

Competing interests: None declared

David G Samuel, ST3 Gastroenterology

Prince Phillip Hospital, Dafen, Llanelli SA14 8QF

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