EDITORIAL URRENT C OPINION
Cardiopulmonary resuscitation and postresuscitation care 2015: saving more than 200 000 additional lives per year worldwide Bernd W. Bo¨ttiger
Sudden cardiac death (SCD) is the third highest ‘killer’ in industrialized nations [1]. In Europe and in the United States, more than 700 000 patients are still dying from SCD annually despite cardiopulmonary resuscitation (CPR) procedures [2]. Improving survival in these patients is quite easy: it involves up to date management of CPR and the return of spontaneous circulation (ROSC) which follows, therapeutic hypothermia and targeted temperature management, ‘Cardiac Arrest Centers’, modern prognostication, CPR registries, telephone CPR, and education. The latter is particularly important for lay rescuers, and educating school children in CPR has a huge impact on overall patient survival [3]. All this is discussed by world experts in this issue of Current Opinion in Critical Care. ‘I, together with another school friend, started. . .’ said 16-year-old Kea, ‘resuscitating Nic, 12’. Nic – who had idiopathic cardiac abnormalities – went into ventricular fibrillation when he was hit in the chest by a soccer ball at school. At first, no one did anything. And then someone put him into the recovery position. Someone called Kea, who had been educated in CPR from the age of 8. After putting her friend in the position they started CPR immediately. It took more than 10 min until emergency medical service physicians and personnel arrived. They defibrillated Nick’s heart, he was brought to the hospital and cooled down for 24 h. Three months later, he was once again top of the class. When Kea and Nic – together with their parents – were sitting in my office 1 1/2 years ago, this was one of the most touching and emotional moments in my professional life. It was clear that Nic would not be with us without Kea – her friendship and her actions.
RELEVANCE, PROBLEMS, AND SOLUTIONS The current survival rate for out-of-hospital cardiac arrest is around 10% or less [4]. Unsuccessful CPR attempts in out of hospital settings occur 15–20
times more often than deaths by road traffic accidents in industrialized nations. And – as compared with other entities with high death rates like cancer, myocardial infarction, stroke, and heart failure – the number of research projects, overall funding, and public attention is much less in SCD and CPR [5]. Why is this so? Is this because more than 70% of SCDs occur at home? Or is this because this field of medicine and research is not as lucrative as the others? We should pay strong attention to this most important field of public health. This issue of Current Opinion in Critical Care is intensively focused on SCD, CPR, and postcardiac arrest care. In the year of the new international guidelines on CPR – which will be published on 15 October 2015 – we have very current and up to date summaries of what the standard of care is in 2015, and what is most important to our patients.
MECHANICAL DEVICES FOR CHEST COMPRESSION We have seen four large-scale randomized controlled trials in this area, with no study showing improved outcomes with the use of any mechanical chest compression device [6–9]. In contrast, two of these studies showed significantly worse neurological outcome with such devices [6,9]. This may be due to the fact that it always takes some time to apply the device, and we know that even short interruptions
Department of Anaesthesiology and Intensive Care Medicine, University of Cologne, Cologne, Germany Correspondence to Bernd W. Bo¨ttiger, MD, DEAA, FESC, FERC, Director Science and Research, European Resuscitation Council (ERC), Chairman, German Resuscitation Council (GRC), Professor and Head, Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Straße 62, 50937 Ko¨ln, Germany. Tel: +49 221 478 4807 and 478-87747; fax: +49 221 478 87811; e-mail: [email protected] Curr Opin Crit Care 2015, 21:179–182 DOI:10.1097/MCC.0000000000000208
1070-5295 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Cardiopulmonary resuscitation
of chest compressions can be harmful and dangerous and affect the outcome for the patient. Kouwenhoven and Knickerbocker – the ‘inventors’ of modern CPR – stated in 1960, that ‘All that is needed is two hands’ [10]. And this has been true thus far. However, mechanical devices may be useful for when the patient is using transport, for coronary interventions (PCI), and probably also for very prolonged CPR procedures – for example, following accidental hypothermia, intoxication, and others – and this needs further investigation.
AIRWAY MANAGEMENT, HEMODYNAMIC, VENTILATOR, AND HOMEOSTATIC OPTIMIZATION Successful airway management by emergency medical service is the key for survival in cardiac arrest patients. There is an ongoing debate as to whether intubation of the trachea, the use of supraglottic airway devices, or the use of the bag valve ventilation is better in routine use and in specific circumstances [11]. We know for certain that normotension, normoglycemia, normoxia, and normocapnia following ROSC are all associated with better outcomes than the outcomes associated with respective states outside the normal ranges. The question however is whether active therapeutic intervention to integrate these kinds of conditions is inducing better survival. All this may just be based on coincidences. Nevertheless, there are arguments for treating patients in order to achieve ‘normo’ conditions, excluding temperature, for which normal conditions are not recommended.
THERAPEUTIC HYPOTHERMIA AND TARGETED TEMPERATURE MANAGEMENT Therapeutic hypothermia has been recommended for unconscious survivors with ROSC – based on large-scale randomized clinical trials [12,13] – for more than 10 years now [14]. A recent large-scale trial investigated the question around whether patients should be treated with 33 or 36 8C [15]. Surprisingly, the authors found no differences – neither between these two temperatures nor the side-effects [15]. So, is 36 8C enough for all our cardiac arrest patients? There was and is a lot of debate around this topic and study. In this very well conducted trial, more than 70% of patients received bystander CPR, 80% had ventricular fibrillation as the initial rhythm, the median duration of cardiac arrest before the start of any CPR was only 1 min (!), and the overall survival rate in both groups was around 50% [15]. Therefore, the question is about 180
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the proportion of severely damaged patients in this study. And, do these findings represent the patients that we are currently treating worldwide?
‘CARDIAC ARREST CENTERS’ We know from several studies, that ‘Cardiac Arrest Centers’ – that is, centers with PCI facilities performing hypothermia which have case load of at least 25 cardiac arrest patients per year – are associated with better survival [16,17]. This may be due to the fact that postcardiac arrest care is very professionally performed in such centers, but also to the fact that at least 50–60%, and potentially more, of our cardiac arrest patients suffer from acute coronary syndromes and infarction, and PCI may be urgently performed.
PROGNOSTICATION With regards to the period following implementation of temperature management and hypothermia, we know that some patients – even without any kind of sedation – awake many days after cardiac arrest, often not even awaking until many days after rewarming. And we also know that all established tests of prognostication have major limitations and low levels of sensitivity and specificity, in particular following hypothermia [18]. It is highly probable that – in the past – of those patients for whom we stopped therapy based on old schemes of prognostication, at least 10% would have been able to survive in good conditions. Therefore, it is a very positive step that we now have a very carefully written advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine on how to perform prognostication nowadays [18]. One of the major messages is to not do it before 72 h after ROSC, and even high levels of biomarkers can be associated with good neurologic outcomes and good overall survival [18].
EUROPEAN CARDIAC ARREST REGISTRY AND OTHER RESUSCITATION REGISTRIES It is due to cardiac arrest registries that we know how our systems perform and that we now recognize the important differences between countries [19]. In Germany, for example, our bystander CPR rate over the last 10 years was less than 20% [20]. When we discovered this – by using the German Resuscitation Registry – we took immediate action in this field. Now, 3 years later, we have managed to improve the rate of bystander CPR from 15 to 20% to over 30%. Therefore, registries may help to identify where we Volume 21 Number 3 June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
CPR and postresuscitation care 2015 Bo ¨ ttiger
need to take action in our system, region, country, and in the world. We are constantly generating hypotheses for further research and therapeutic approaches.
MOST IMPORTANT APPROACHES . . . In most areas of the world, professional out-of-hospital resuscitation care may not be provided within 5–10 min following the collapse. Critically, within 3–5 min, the brain starts to die. Therefore, there is an important time window for lay resuscitation [21]. Lay people can start immediately, and 60–70% of all cardiac arrests are witnessed. In most cases, it is enough that lay people perform thoracic compressions, because – at least for some minutes – there is still enough oxygen in the lungs and in the blood outside of the brain. If lay people start resuscitation, this leads to a two-fold and up to four-fold increase in survival rates [22]. We know from Denmark and elsewhere that – by increasing lay resuscitation rates from 20 to 50% – survival rates can be tripled [3]. One very effective way to increase bystander CPR rates immediately is telephone CPR, the dispatcher tells the layperson via the phone how to perform thoracic compressions [23]. The number needed to treat for telephone CPR may be as low as seven. And there are obviously no or only very minor costs associated with saving one out of seven out-of-hospital cardiac arrest victims. Across Europe – and worldwide – there are very different lay resuscitation rates. Germany had a rate of below 20%, and in Scandinavian countries the rate is higher than 60 and can reach up to 80% [24]. Why is this so different? Is it the culture? Are lay people afraid of doing something wrong? Or is it school children education in CPR? In Norway, the country with the highest bystander CPR rates (around 60–80%), school children training in resuscitation has been mandatory for decades. School children education in CPR seems to be logical and very helpful. Studies have demonstrated that it should start before puberty, and that 2 h of training per year are enough to implement and to maintain the skills and the knowledge [25]. School children will also serve as CPR teachers in a sense: they transfer their knowledge to their friends and family such as brothers and sisters, parents, and grandparents. In Germany, we were recently successful in convincing the delegates of the school ministers to recommend CPR training in our schools nationwide. And just a few weeks ago, the WHO has endorsed our statement on ‘Kids save lives.’ This joint statement from the European Patient Safety
Foundation, the European Resuscitation Council, the International Liaison Committee on Resuscitation, and the World Federation of Societies of Anesthesiologists recommends that school children from the age of 12 years and up – worldwide – should be trained in CPR for 2 h per year. SCD, CPR, modern techniques, lay CPR, telephone CPR, and school children education in CPR need much more attention, support and research, and a bigger place in our hearts and societies. The current issue of this journal hopes to help this cause. If we continue with all of these important steps, we will be able to save more than 200 000 additional lives per year in the years to come. Acknowledgements None. Financial support or sponsorship None. Conflicts of interest Board Director Science and Research, European Resuscitation Council (ERC). Chairman, German Resuscitation Council (GRC).
REFERENCES 1. Taniguchi D, Baernstein A, Nichol G. Cardiac arrest: a public health perspective. Emerg Med Clin North Am 2012; 30:1–12. 2. Bo¨ttiger BW, Van Aken HK. Saving 100 000 lives each year in Europe. Best Pract Res Clin Anaesthesiol 2013; 27:291–292. 3. Wissenberg M, Lippert FK, Folke F, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA 2013; 310:1377– 1384. 4. Bo¨ttiger BW, Arntz HR, Chamberlain DA, et al., TROICA Trial Investigators; European Resuscitation Council Study Group. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med 2008; 359:2651– 2662. 5. Ornato JP, Becker LB, Weisfeldt ML, Wright BA. Cardiac arrest and resuscitation: an opportunity to align research prioritization and public health need. Circulation 2010; 122:1876–1879. 6. Hallstrom A, Rea TD, Sayre MR, et al. Manual chest compression vs. use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest: a randomized trial. JAMA 2006; 295:2620– 2628. 7. Wik L, Olsen JA, Persse D, et al. Manual vs. integrated automatic loaddistributing band CPR with equal survival after out of hospital cardiac arrest. The randomized CIRC trial. Resuscitation 2014; 85:741–748. 8. Rubertsson S, Lindgren E, Smekal D, et al. Mechanical chest compressions and simultaneous defibrillation vs. conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. JAMA 2014; 311:53–61. 9. Perkins GD, Lall R, Quinn T, et al., PARAMEDIC trial collaborators. Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Lancet 2015; 385:947–955. 10. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA 1960; 173:1064–1067. 11. Wang HE, Szydlo D, Stouffer JA, et al., ROC Investigators. Endotracheal intubation versus supraglottic airway insertion in out-of-hospital cardiac arrest. Resuscitation 2012; 83:1061–1066. 12. Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002; 346:549–556. 13. Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002; 346:557–563.
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181
Cardiopulmonary resuscitation 14. Nolan JP, Morley PT, Vanden Hoek TL, et al., International Liaison Committee on Resuscitation. Therapeutic hypothermia after cardiac arrest: an advisory statement by the advanced life support task force of the International Liaison Committee on Resuscitation. Circulation 2003; 108:118–121. 15. Nielsen N, Wetterslev J, Cronberg T, et al., TTM Trial Investigators. Targeted temperature management at 33 -C versus 36 -C after cardiac arrest. N Engl J Med 2013; 369:2197–2206. 16. Schober A, Holzer M, Hochrieser H, et al. Effect of intensive care after cardiac arrest on patient outcome: a database analysis. Crit Care 2014; 18:R84. 17. Wnent J, Seewald S, Heringlake M, et al. Choice of hospital after out-ofhospital cardiac arrest – a decision with far-reaching consequences: a study in a large German city. Crit Care 2012; 16:R164. 18. Sandroni C, Cariou A, Cavallaro F, et al. Prognostication in comatose survivors of cardiac arrest: an advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine. Resuscitation 2014; 85:1779–1789. 19. Gra¨sner JT, Herlitz J, Koster RW, et al. Quality management in resuscitation – towards a European cardiac arrest registry (EuReCa). Resuscitation 2011; 82:989–994.
182
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20. Wnent J, Bohn A, Seewald S, et al. Bystander resuscitation: the impact of first aid on survival. Anasthesiol Intensivmed Notfallmed Schmerzther 2013; 48:562–565. 21. Breckwoldt J, Schloesser S, Arntz HR. Perceptions of collapse and assessment of cardiac arrest by bystanders of out-of-hospital cardiac arrest (OOHCA). Resuscitation 2009; 80:1108–1113. 22. Bo¨ttiger BW, Grabner C, Bauer H, et al. Long term outcome after out-ofhospital cardiac arrest with physician staffed emergency medical services: the Utstein style applied to a midsized urban/suburban area. Heart 1999; 82:674–679. 23. Hu¨pfl M, Selig HF, Nagele P. Chest-compression-only versus standard cardiopulmonary resuscitation: a meta-analysis. Lancet 2010; 376:1552– 1557. 24. Lindner TW, Søreide E, Nilsen OB, et al. Good outcome in every fourth resuscitation attempt is achievable – an Utstein template report from the Stavanger region. Resuscitation 2011; 82:1508–1513. 25. Bohn A, Van Aken HK, Mo¨llhoff T, et al. Teaching resuscitation in schools: annual tuition by trained teachers is effective starting at age 10. A four-year prospective cohort study. Resuscitation 2012; 83:619–625.
Volume 21 Number 3 June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Cardiopulmonary resuscitation and postresuscitation care 2015: saving more than 200 000 additional lives per year worldwide Bernd W. Bo¨ttiger
Sudden cardiac death (SCD) is the third highest ‘killer’ in industrialized nations [1]. In Europe and in the United States, more than 700 000 patients are still dying from SCD annually despite cardiopulmonary resuscitation (CPR) procedures [2]. Improving survival in these patients is quite easy: it involves up to date management of CPR and the return of spontaneous circulation (ROSC) which follows, therapeutic hypothermia and targeted temperature management, ‘Cardiac Arrest Centers’, modern prognostication, CPR registries, telephone CPR, and education. The latter is particularly important for lay rescuers, and educating school children in CPR has a huge impact on overall patient survival [3]. All this is discussed by world experts in this issue of Current Opinion in Critical Care. ‘I, together with another school friend, started. . .’ said 16-year-old Kea, ‘resuscitating Nic, 12’. Nic – who had idiopathic cardiac abnormalities – went into ventricular fibrillation when he was hit in the chest by a soccer ball at school. At first, no one did anything. And then someone put him into the recovery position. Someone called Kea, who had been educated in CPR from the age of 8. After putting her friend in the position they started CPR immediately. It took more than 10 min until emergency medical service physicians and personnel arrived. They defibrillated Nick’s heart, he was brought to the hospital and cooled down for 24 h. Three months later, he was once again top of the class. When Kea and Nic – together with their parents – were sitting in my office 1 1/2 years ago, this was one of the most touching and emotional moments in my professional life. It was clear that Nic would not be with us without Kea – her friendship and her actions.
RELEVANCE, PROBLEMS, AND SOLUTIONS The current survival rate for out-of-hospital cardiac arrest is around 10% or less [4]. Unsuccessful CPR attempts in out of hospital settings occur 15–20
times more often than deaths by road traffic accidents in industrialized nations. And – as compared with other entities with high death rates like cancer, myocardial infarction, stroke, and heart failure – the number of research projects, overall funding, and public attention is much less in SCD and CPR [5]. Why is this so? Is this because more than 70% of SCDs occur at home? Or is this because this field of medicine and research is not as lucrative as the others? We should pay strong attention to this most important field of public health. This issue of Current Opinion in Critical Care is intensively focused on SCD, CPR, and postcardiac arrest care. In the year of the new international guidelines on CPR – which will be published on 15 October 2015 – we have very current and up to date summaries of what the standard of care is in 2015, and what is most important to our patients.
MECHANICAL DEVICES FOR CHEST COMPRESSION We have seen four large-scale randomized controlled trials in this area, with no study showing improved outcomes with the use of any mechanical chest compression device [6–9]. In contrast, two of these studies showed significantly worse neurological outcome with such devices [6,9]. This may be due to the fact that it always takes some time to apply the device, and we know that even short interruptions
Department of Anaesthesiology and Intensive Care Medicine, University of Cologne, Cologne, Germany Correspondence to Bernd W. Bo¨ttiger, MD, DEAA, FESC, FERC, Director Science and Research, European Resuscitation Council (ERC), Chairman, German Resuscitation Council (GRC), Professor and Head, Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Straße 62, 50937 Ko¨ln, Germany. Tel: +49 221 478 4807 and 478-87747; fax: +49 221 478 87811; e-mail: [email protected] Curr Opin Crit Care 2015, 21:179–182 DOI:10.1097/MCC.0000000000000208
1070-5295 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.co-criticalcare.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Cardiopulmonary resuscitation
of chest compressions can be harmful and dangerous and affect the outcome for the patient. Kouwenhoven and Knickerbocker – the ‘inventors’ of modern CPR – stated in 1960, that ‘All that is needed is two hands’ [10]. And this has been true thus far. However, mechanical devices may be useful for when the patient is using transport, for coronary interventions (PCI), and probably also for very prolonged CPR procedures – for example, following accidental hypothermia, intoxication, and others – and this needs further investigation.
AIRWAY MANAGEMENT, HEMODYNAMIC, VENTILATOR, AND HOMEOSTATIC OPTIMIZATION Successful airway management by emergency medical service is the key for survival in cardiac arrest patients. There is an ongoing debate as to whether intubation of the trachea, the use of supraglottic airway devices, or the use of the bag valve ventilation is better in routine use and in specific circumstances [11]. We know for certain that normotension, normoglycemia, normoxia, and normocapnia following ROSC are all associated with better outcomes than the outcomes associated with respective states outside the normal ranges. The question however is whether active therapeutic intervention to integrate these kinds of conditions is inducing better survival. All this may just be based on coincidences. Nevertheless, there are arguments for treating patients in order to achieve ‘normo’ conditions, excluding temperature, for which normal conditions are not recommended.
THERAPEUTIC HYPOTHERMIA AND TARGETED TEMPERATURE MANAGEMENT Therapeutic hypothermia has been recommended for unconscious survivors with ROSC – based on large-scale randomized clinical trials [12,13] – for more than 10 years now [14]. A recent large-scale trial investigated the question around whether patients should be treated with 33 or 36 8C [15]. Surprisingly, the authors found no differences – neither between these two temperatures nor the side-effects [15]. So, is 36 8C enough for all our cardiac arrest patients? There was and is a lot of debate around this topic and study. In this very well conducted trial, more than 70% of patients received bystander CPR, 80% had ventricular fibrillation as the initial rhythm, the median duration of cardiac arrest before the start of any CPR was only 1 min (!), and the overall survival rate in both groups was around 50% [15]. Therefore, the question is about 180
www.co-criticalcare.com
the proportion of severely damaged patients in this study. And, do these findings represent the patients that we are currently treating worldwide?
‘CARDIAC ARREST CENTERS’ We know from several studies, that ‘Cardiac Arrest Centers’ – that is, centers with PCI facilities performing hypothermia which have case load of at least 25 cardiac arrest patients per year – are associated with better survival [16,17]. This may be due to the fact that postcardiac arrest care is very professionally performed in such centers, but also to the fact that at least 50–60%, and potentially more, of our cardiac arrest patients suffer from acute coronary syndromes and infarction, and PCI may be urgently performed.
PROGNOSTICATION With regards to the period following implementation of temperature management and hypothermia, we know that some patients – even without any kind of sedation – awake many days after cardiac arrest, often not even awaking until many days after rewarming. And we also know that all established tests of prognostication have major limitations and low levels of sensitivity and specificity, in particular following hypothermia [18]. It is highly probable that – in the past – of those patients for whom we stopped therapy based on old schemes of prognostication, at least 10% would have been able to survive in good conditions. Therefore, it is a very positive step that we now have a very carefully written advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine on how to perform prognostication nowadays [18]. One of the major messages is to not do it before 72 h after ROSC, and even high levels of biomarkers can be associated with good neurologic outcomes and good overall survival [18].
EUROPEAN CARDIAC ARREST REGISTRY AND OTHER RESUSCITATION REGISTRIES It is due to cardiac arrest registries that we know how our systems perform and that we now recognize the important differences between countries [19]. In Germany, for example, our bystander CPR rate over the last 10 years was less than 20% [20]. When we discovered this – by using the German Resuscitation Registry – we took immediate action in this field. Now, 3 years later, we have managed to improve the rate of bystander CPR from 15 to 20% to over 30%. Therefore, registries may help to identify where we Volume 21 Number 3 June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
CPR and postresuscitation care 2015 Bo ¨ ttiger
need to take action in our system, region, country, and in the world. We are constantly generating hypotheses for further research and therapeutic approaches.
MOST IMPORTANT APPROACHES . . . In most areas of the world, professional out-of-hospital resuscitation care may not be provided within 5–10 min following the collapse. Critically, within 3–5 min, the brain starts to die. Therefore, there is an important time window for lay resuscitation [21]. Lay people can start immediately, and 60–70% of all cardiac arrests are witnessed. In most cases, it is enough that lay people perform thoracic compressions, because – at least for some minutes – there is still enough oxygen in the lungs and in the blood outside of the brain. If lay people start resuscitation, this leads to a two-fold and up to four-fold increase in survival rates [22]. We know from Denmark and elsewhere that – by increasing lay resuscitation rates from 20 to 50% – survival rates can be tripled [3]. One very effective way to increase bystander CPR rates immediately is telephone CPR, the dispatcher tells the layperson via the phone how to perform thoracic compressions [23]. The number needed to treat for telephone CPR may be as low as seven. And there are obviously no or only very minor costs associated with saving one out of seven out-of-hospital cardiac arrest victims. Across Europe – and worldwide – there are very different lay resuscitation rates. Germany had a rate of below 20%, and in Scandinavian countries the rate is higher than 60 and can reach up to 80% [24]. Why is this so different? Is it the culture? Are lay people afraid of doing something wrong? Or is it school children education in CPR? In Norway, the country with the highest bystander CPR rates (around 60–80%), school children training in resuscitation has been mandatory for decades. School children education in CPR seems to be logical and very helpful. Studies have demonstrated that it should start before puberty, and that 2 h of training per year are enough to implement and to maintain the skills and the knowledge [25]. School children will also serve as CPR teachers in a sense: they transfer their knowledge to their friends and family such as brothers and sisters, parents, and grandparents. In Germany, we were recently successful in convincing the delegates of the school ministers to recommend CPR training in our schools nationwide. And just a few weeks ago, the WHO has endorsed our statement on ‘Kids save lives.’ This joint statement from the European Patient Safety
Foundation, the European Resuscitation Council, the International Liaison Committee on Resuscitation, and the World Federation of Societies of Anesthesiologists recommends that school children from the age of 12 years and up – worldwide – should be trained in CPR for 2 h per year. SCD, CPR, modern techniques, lay CPR, telephone CPR, and school children education in CPR need much more attention, support and research, and a bigger place in our hearts and societies. The current issue of this journal hopes to help this cause. If we continue with all of these important steps, we will be able to save more than 200 000 additional lives per year in the years to come. Acknowledgements None. Financial support or sponsorship None. Conflicts of interest Board Director Science and Research, European Resuscitation Council (ERC). Chairman, German Resuscitation Council (GRC).
REFERENCES 1. Taniguchi D, Baernstein A, Nichol G. Cardiac arrest: a public health perspective. Emerg Med Clin North Am 2012; 30:1–12. 2. Bo¨ttiger BW, Van Aken HK. Saving 100 000 lives each year in Europe. Best Pract Res Clin Anaesthesiol 2013; 27:291–292. 3. Wissenberg M, Lippert FK, Folke F, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA 2013; 310:1377– 1384. 4. Bo¨ttiger BW, Arntz HR, Chamberlain DA, et al., TROICA Trial Investigators; European Resuscitation Council Study Group. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med 2008; 359:2651– 2662. 5. Ornato JP, Becker LB, Weisfeldt ML, Wright BA. Cardiac arrest and resuscitation: an opportunity to align research prioritization and public health need. Circulation 2010; 122:1876–1879. 6. Hallstrom A, Rea TD, Sayre MR, et al. Manual chest compression vs. use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest: a randomized trial. JAMA 2006; 295:2620– 2628. 7. Wik L, Olsen JA, Persse D, et al. Manual vs. integrated automatic loaddistributing band CPR with equal survival after out of hospital cardiac arrest. The randomized CIRC trial. Resuscitation 2014; 85:741–748. 8. Rubertsson S, Lindgren E, Smekal D, et al. Mechanical chest compressions and simultaneous defibrillation vs. conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. JAMA 2014; 311:53–61. 9. Perkins GD, Lall R, Quinn T, et al., PARAMEDIC trial collaborators. Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Lancet 2015; 385:947–955. 10. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA 1960; 173:1064–1067. 11. Wang HE, Szydlo D, Stouffer JA, et al., ROC Investigators. Endotracheal intubation versus supraglottic airway insertion in out-of-hospital cardiac arrest. Resuscitation 2012; 83:1061–1066. 12. Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002; 346:549–556. 13. Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002; 346:557–563.
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181
Cardiopulmonary resuscitation 14. Nolan JP, Morley PT, Vanden Hoek TL, et al., International Liaison Committee on Resuscitation. Therapeutic hypothermia after cardiac arrest: an advisory statement by the advanced life support task force of the International Liaison Committee on Resuscitation. Circulation 2003; 108:118–121. 15. Nielsen N, Wetterslev J, Cronberg T, et al., TTM Trial Investigators. Targeted temperature management at 33 -C versus 36 -C after cardiac arrest. N Engl J Med 2013; 369:2197–2206. 16. Schober A, Holzer M, Hochrieser H, et al. Effect of intensive care after cardiac arrest on patient outcome: a database analysis. Crit Care 2014; 18:R84. 17. Wnent J, Seewald S, Heringlake M, et al. Choice of hospital after out-ofhospital cardiac arrest – a decision with far-reaching consequences: a study in a large German city. Crit Care 2012; 16:R164. 18. Sandroni C, Cariou A, Cavallaro F, et al. Prognostication in comatose survivors of cardiac arrest: an advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine. Resuscitation 2014; 85:1779–1789. 19. Gra¨sner JT, Herlitz J, Koster RW, et al. Quality management in resuscitation – towards a European cardiac arrest registry (EuReCa). Resuscitation 2011; 82:989–994.
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20. Wnent J, Bohn A, Seewald S, et al. Bystander resuscitation: the impact of first aid on survival. Anasthesiol Intensivmed Notfallmed Schmerzther 2013; 48:562–565. 21. Breckwoldt J, Schloesser S, Arntz HR. Perceptions of collapse and assessment of cardiac arrest by bystanders of out-of-hospital cardiac arrest (OOHCA). Resuscitation 2009; 80:1108–1113. 22. Bo¨ttiger BW, Grabner C, Bauer H, et al. Long term outcome after out-ofhospital cardiac arrest with physician staffed emergency medical services: the Utstein style applied to a midsized urban/suburban area. Heart 1999; 82:674–679. 23. Hu¨pfl M, Selig HF, Nagele P. Chest-compression-only versus standard cardiopulmonary resuscitation: a meta-analysis. Lancet 2010; 376:1552– 1557. 24. Lindner TW, Søreide E, Nilsen OB, et al. Good outcome in every fourth resuscitation attempt is achievable – an Utstein template report from the Stavanger region. Resuscitation 2011; 82:1508–1513. 25. Bohn A, Van Aken HK, Mo¨llhoff T, et al. Teaching resuscitation in schools: annual tuition by trained teachers is effective starting at age 10. A four-year prospective cohort study. Resuscitation 2012; 83:619–625.
Volume 21 Number 3 June 2015
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