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Bystander cardiopulmonary resuscitation: equipping communities to save lives.

Bystander Cardiopulmonary resuscitation: Equipping communities to save lives Out-of-hospital Cardiac arrest: Introduction

Out-of-Hospital cardiac arrest (OHCA), are those cardiac arrest events which occur outside the healthcare settings and cause considerable morbidity, mortality and a substantial burden on the health care system. Cardiac causes account for approximately three-fourths of these events [1]. Acute coronary syndrome and coronary vasospasm are the commonest causes among elderly and young individuals respectively. Various non-cardiac causes also contribute to OHCA, the commonest being trauma, drowning, drug overdose, asphyxia, electrocution and primary respiratory arrest [2].

Out of Hospital Cardiac arrest: Bystander's role

OHCA is an important public health problem because the probability of recovery is small though the process is potentially reversible [1]. Outcomes after OHCA as measured by survival rate and cerebral performance category are dismal compared to In-hospital cardiac arrest due to delay in recognition and provision of essential care [1]. In case of an OHCA, initial care in the first few critical minutes which includes CPR and use of an automated external defibrillator (AED) depends on the actions of the bystanders [3]. Bystander has a significant role in identification of the event and the victim's need for assistance, calling the emergency helpline number, carrying out the dispatcher's instructions and performing CPR [4].

Bystander CPR: The concept and statistics

Bystander CPR has been recognized as a vital link in improving survival of OHCA victims by two to three times [4,5]. The time interval between collapse to initiation of CPR, type of CPR administered namely conventional or chest compression-only CPR are important factors which greatly influence the outcomes following bystander assisted OHCA in addition to other factors such as health-related quality of life before arrests, location of arrest and cardiac rhythm at arrest [4,6-9]. Komatsu et al. [10] has reported that bystander CPR is a significant pre-hospital contributory factor in the survival and neurological outcomes in post-cardiac arrest syndrome following OHCA. Chan et al. [11] in their analysis on recent trends of OHCA survival in the United States demonstrate the potential role of bystander CPR in pre-hospital survival of OHCA which further positively influences the overall survival.

Hence, it is essential that CPR knowledge and adequate training be imparted to the common man to enable them play an effective role in saving the patient through the initial precious minutes. In adult OHCAs, bystanders performing chest compression only CPR is considered to be as effective as conventional CPR. Compression only CPR can be easily performed even by untrained bystanders [9]. Recent OHCA statistics available from few developed countries report low bystander CPR rates. Less than 50% of the occurrences received bystander CPR, 40.1% and 42% in United States and France respectively [10,11]. Studies on OHCA from Germany, Singapore and Taiwan reported bystander CPR rates between 15% and 22.9% [12-14]. Rajaram et al. [8] reported a bystander rate of 4.4% in OHCA in a study from urban India. Recent published literature have analysed the trends in bystander rates in population-based, prospective cohort studies. The trends in bystander rates as documented by OHCA related registries from United States (28.7% increase from 2005-2012) and Netherlands (increased by 23% from 2006-2012) reveal significantly positive trends which are encouraging [11,15-18].

Kitamura et al. [9] in their nationwide, 5-year prospective population study on OHCA's demonstrated a 2-fold increment in 1 month survival; with favourable neurological out-comes in OHCA's with effective bystander CPR. Similar significant improvement in survival outcomes has also been observed in a population-based cohort study from 2006 to 2012 by Blom et al. in Netherlands [18].

Despite OHCA being a potential public health problem, there is a deficit of research exploring the burden of OHCA and role of by-stander CPR in survival of these cases in many other countries of the world.

Bystander CPR as a public health measure: Challenges and solutions

The overall low prevalence of bystander CPR brings to attention the various obstacles in implementing this as an effective public health measure to improve survival rates. On an average only one-third of OHCA receive bystander CPR [13]. Studies from various countries reveal less than adequate, resuscitation-related knowledge and competence among health care personnel. The level of knowledge among common people is even lesser [19]. The following are the commonest reasons cited from various studies to explain the bystanders' reluctance to initiate CPR- sense of panic, concern for harming or injuring the victim further, fear of liability, fear of inadequate knowledge or incorrect performance of the technique, fear of transmission of communicable diseases through mouth-to-mouth ventilation, victim characteristics and region-specific sociocultural characteristics [5,17, 20, 21].

Strategies to improve bystander CPR must enable timely and comprehensive identification of cardiac arrest, encourage and empower bystanders to act, and help ensure effective CPR [17].

Table 1 summarises the challenges in implementing bystander CPR as a public health measure from the bystanders' and the policy- makers' perspective and possible solutions.

In conclusion, Bystander CPR applied under right circumstances could mean the difference between life and death. Equipping people with this vital skill empowers them to act in times of emergency and would greatly improve survival rates and neurological outcomes in OHCA events.

Conflicts of Interest

None declared.

Financial disclosure

No external source of funding.


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Mani G. (*), Danasekaran R, Annadurai K.

Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Kancheepuram District, Tamil Nadu, India

(*) Corresponding sauthor:

Geetha Mani

Plot no. 428, Arul Nagar, Nandhivaram Guduvancheri

Kancheepuram District

Tamil Nadu, India

Tel.: +919444220555


Received: 29.06.2014

Accepted: 11.08.2014
Table 1. Improving bystander CPR rates: challenges and

Challenges                     Solutions
Bystanders perspectives

Lack of motivation             Widespread media campaigns and health
  [5, 17, 21]                    education programmes promotion of
                                 early response and assistance from
                                 Emergency medical services.
                               Mandatory CPR training as part of
                                 issuing or renewing driver's licence;
                                 as part of higher secondary education
                                 completion [23]
Failure to recognise           Widespread media campaigns and health
  cardiac arrest [5]             education programmes,
                               Simplification of arrest identification
                               Regionally developed user-friendly
                                 flow-charts describing the signs and
                                 symptoms of cardiac arrest and
                                 step-wise actions to impart basic
Reluctance to perform          Chest compressions only CPR [22]
  mouth-mouth ventilation      Reassurance [23]
  due to the intimacy of
  the act and fear of
  transmission of
  infectious diseases [5,17]

Complexity of resuscitation    Just-in-time' dispatcher assisted
  guidelines [5,22]              CPR [22]
Poor retention of knowledge    Periodic refresher training,
  and skills [24]                Dispatch-assisted CPR instructions,
                                 promoting self-training modules and
                                 videos [23]
                               Encouraging self-practising on manikins
Fear of failure and lack       Community-level CPR training
  of confidence [25]
                               Virtual learning methods for eligible
Fear of legal liability [5]    Reassurance and suitable legislations to
                                  protect bystander resuscitators
                               Creating awareness about the central
                                 toll-free helpline numbers for
                                 immediate assistance [24]
                               Empowering with knowledge to activate
                                 the Emergency Medical services
                                 at the earliest [24]
Psychological stress           Post-event psychological counselling
  associated with witnessing     for the rescuer and the bystanders
  a cardiac arrest [20]          [20]

Policymaker's perspectives

Lack of adequate               Epidemiological registries of OHCAs,
  epidemiological data           similar to Cardiac Arrest Registry
                                 to Enhance Survival (CARES) in United
                                 States and Amsterdam
                               Resuscitation Study (ARREST) in The
                                 Netherlands [2, 18]
                               Identification of neighbourhood
                                 characteristics, bystander
                                 characteristics, bystander CPR rates
                               Common database for notification of
                                 OHCAs encountered by hospitals
                                 and physicians
                               Use of Geographic Information System
                                 (GIS) to locate OHCA's, identify
                                 the associated factors and use of
                                 information to improve bystander CPR
                                 rates [26]
Implementation of training     Separate modules for fresher courses
  programmes                     and refresher courses
                               Separate modules for specific to the
                                 various training groups like students,
                                 public and health professionals
                               Assistance to corporate and government
                                 organisations to identify and
                                 employ of feasible initiatives to
                                 train employees
                               Engaging professional organisations
                               School curriculum-based training on
                                 basic life support [27]
                               BLS training should be imparted as part
                                 of training of scouts, guides and
                                 cadet corps
                               Effective co-ordination between
                                 professional organisations, non-
                                 governmental organisations and
                                 regional health institutions in
                                 implementation of training courses and
                                  provision of bystander assistance
                                 in OHCAs
                               CPR training in potential vacation spots
                               Web based interactive applications
                               Smart phone user friendly applications
Identification of potential    Family members of cardiac patients,
  groups to impart CPR           utilisation of consultation and
  training                       follow-up sessions to provide CPR
                                 training for first-degree relatives
                                 and caregivers [23]
                               Providing CPR courses as part of teacher
                                 training and driving schools
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Author:Mani, G.; Danasekaran, R.; Annadurai, K.
Publication:Progress in Health Sciences
Article Type:Report
Geographic Code:9INDI
Date:Dec 1, 2014
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