Abstracts from the 'Spark of Life' Conference

Resuscitation 40 (1999) 117 – 128

Abstracts from the ‘Spark of Life’ Conference Hosted by the Australian Resuscitation Council, 16 – 17 April, 1999, Melbourne, Australia

Occupational first aid—an overview E.P. Tyler Ella Tyler First Aid Consultants, Adelaide Occupational First Aid is well established in Australia but lacks an Australia-wide identity. No two States or Territories have identical standards and requirements for workplace first aid, with a mix of Regulations, Codes of Practice and Guidance Notes specific to each State. Training programs also vary between States and Territories with resultant confusion when a trained Workplace First Aider transfers from one State to another and needs to become familiar with all the legislative requirements that apply to the new location. Increasingly the Australian Resuscitation Council is cited as a reliable source of information on a number of Basic Life Support topics related to emergency care in the workplace, although not all State and Territory government departments are familiar with the existence of Council. This paper will review and summarise these issues and recommend approaches relevant to Australia.

Heart attack—the latest R.J. Whitbourn St. Vincent’s Hospital, Melbourne In Australia, despite a decline in cardiovascular mortality over the last three decades, there are greater than 40 000 deaths per year from myocardial infarction and about 500 coronary events per 100 000 population. The reduced mortality of myocardial infarction may be explained in part by earlier detection, resuscitation and transfer. The advent of Coronary Care Units, the use of B-blockers and the use of defibrillators to treat ventricular dysrhythmias have also had a profound effect on in-hospital survival. In the last 10 years, thrombolytic agents, such as streptokinase or tissue plasminogen activator (tPA), have been found to reduce the in-hospital mortality rate of acute myocardial infarction by up to 35%, with time to treatment strongly related to the degree of benefit. The thrombolytic trials appear to establish a slight benefit in mortality reduction for the more fibrin-specific thrombolytics, such as t-PA. However, the risk of intracranial haemorrhage may also be slightly greater with fibrin-specific thrombolytic agents. The use of antiplatelet agents such as aspirin have also been clearly shown to reduce mortality by about 30%-an effect additive and

almost equal to that of thrombolytic agents in myocardial infarction. Recent trials of rPA (reteplase) have suggested that rPA is equivalent to tPA with respect to survival, with similar results for death, nonfatal MI and stroke. Reteplase can be given as two IV boluses, 30 minutes apart, without need of an IV giving set or a requirement for weight adjustment of the dose. This may now make it possible and practical to initiate thrombolytic therapy earlier than ever before. Primary coronary artery angioplasty and stenting in acute myocardial infarction provides at least equivalent and probably better clinical outcomes and lower risk of bleeding complications compared to thrombolytics. Primary infarct angioplasty should be considered where facilities and expertise, especially for large infarcts, those complicated by haemodynamic compromise, heart block or where thrombolytics are contraindicated.

Is oxygen optional in resuscitation? H.F. Oxer St John Ambulance Australia-Western Australian Ambulance Ser6ice Inc., Perth Resuscitation training is all about procedures, yet the overwhelming need is to get sufficient oxygen to hypoxic and endangered tissues. Neither the ARC nor the AHA make mention of the need to give added oxygen as soon as possible, though the ARC has a separate Policy on Oxygen. Major First Aid training organisations essentially don’t mention use of oxygen in resuscitation. There seems to be a feeling in First Aid training that Oxygen administration is potentially dangerous and is an ‘advanced’ skill. Oxygen should be used as soon as available, in as near 100% as possible, in all resuscitation situations, and for the early management of injury and illness. Its use will never disadvantage a patient or their tissues under these circumstances. The simple concept of increasing the pressure gradient to maximise oxygen delivery to sick or injured tissues should be considered for inclusion in the simplest first aid training. This will maximise recovery of cells and tissues at risk from hypoxia. We should add into all resuscitation training that oxygen, as much as possible, should be administered as soon as possible. In these days of high technology for all, we should consider adding the simple skill of administration of oxygen, when available, to Basic Life Support and First Aid. An Oxygen supply should be as easily available as a fire extinguisher.

0300-9572/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 0 0 - 9 5 7 2 ( 9 9 ) 0 0 0 1 4 - 3

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Nurses and the internet Louise E. Niggemeyer The Alfred Hospital, Melbourne, Australia The Internet is made up by a huge network of worldwide computers which can allow access to a plethora of information on almost any topic that you could imagine. Its application for health care as we move into the next millennium, will see it become an invaluable adjunct for any health care provider. Accessing the Internet will bring you closer to information than ever before. This session will introduce the Internet to the novice or beginning user outlining how and why it can work for you. To connect to the Internet requires a computer, software, a telephone line, a modem and an Internet Service Provider (ISP) account. Getting on-line is then as simple as ringing a phone number. Once on-line, to access information you will need to use software that is called a web browser. Search engines are used to look for specific information. These allow you to enter terms of interest and the search engine looks for titles with the words included. Learning how to make efficient use of search engines does take practise, but the skills will develop with ease the more you surf. Information is usually published on the Internet before it goes into ‘hard copy’. This means that we are now seeing a level and speed of information dissemination faster than ever before. However, information from the Internet is not always from reputable appropriately peer reviewed sources. It is usually a good idea to check the information with known refereed sources. Many organisations have websites with home pages outlining all of the information contained in the website. Double clicking on highlighted words or sentences can help you move through the webstite and often leads you onto related websites. Remember you can always return by hitting the back arrow on the web browser. Book-marking interesting sites expedites your Internet time allowing you to go directly to that site anytime. In addition to the access of information, electronic mail (e-mail) is a fabulous feature that the Internet facilitates. Images, text, video and sound can all be sent over the net to anyone with a e-mail address. This transfer is veritably instantaneous. The transmission of computer viruses can be an issue and current anti virus software is essential to protect your soft & hardware assets. The Internet is not something to fear but enthusiastically embrace. The equity of access to information and communication makes the world a smaller place. Once you make the first step and with continued perseverance, surfing the Internet will become a necessary, commonplace addition to your activities of daily living.

plantable defibrillator technology, has acted as a catalyst for research into new technologies and waveforms, such as sequential monophasic and biphasic. This discussion outlines the development of defibrillation and the equipment used, and review the research in defibrillation waveforms which has produced the current state of knowledge in the field.

Reducing the incidence of fatal overdose by teaching basic life support skills A.L. O’Loughlin, I. van Beek Kirketon Road Centre, Sydney Kirketon Road Centre (KRC) is a primary health care (PHC) facility of Sydney Hospital located in Kings Cross, Sydney. KRC is involved in the prevention, treatment & care of HIV/AIDS & other transmissible infections amongst injecting drug users (IDUs), sex workers & ‘at risk’ youth.KRC conducts an outreach program staffed by registered nurses, counsellors & medical officers which extends PHC & needle syringe exchange services to ‘hard to reach’ clients in Kings Cross & Darlinghurst. In April 1997 KRC outreach extended PHC services to an area in Redfern, Sydney, known as ‘the Block’. This was in response to the marked increase in availability & usage of heroin with a concomitant increase in heroin overdose among the mainly Aboriginal population of the Block. KRC staff manage heroin overdoses at the Block on a regular basis: contacting the ambulance service, initiating Basic Life Support measures & where appropriate administering naloxone. The service looked at ways to help the community manage heroin overdose effectively & thus reduce the morbidity & mortality associated with heroin overdose. The priority was to provide training in overdose management for people in regular contact with IDUs. Since July 1997, as the designated Cardio-Pulmonary Resuscitation assessor at KRC, I have conducted 10 workshops on heroin overdose management & BLS skills for NSE workers & local people within the Aboriginal community, employed to remove discarded syringes from the Block. The outcome for the community at the Block has been positive. The incidence of drug overdose is still high but management is more effective & no fatalities have been reported amongst IDUs when attended to by those trained in BLS as a result of this initiative.

Implementation of the CPR2000 project T Tighe, M. Lynch

Defibrillation — new waveforms S. Zalstein Department of Emergency Medicine, The Royal Melbourne Hospital, Melbourne The use of electric shock to terminate life-threatening arrhythmias (defibrillation) in humans has been in use since 1947. Although initially alternating current defibrillation was commonly used, the current standard equipment delivers a direct current shock of a chosen energy and in a single direction (monophasic). Recent recognition of defibrillation as the crucial link in the chain of survival, particularly in cases of sudden cardiac death in the community, has accelerated the development of the semi-automatic defibrillator. The need for a lighter, more easily transportable and cheaper defibrillator for out-of-hospital use, combined with lessons learned from im-

Queensland Ambulance Ser6ice, Brisbane All too often projects are thrust on a community without adequate community consultation and involvement. Furthermore, mechanisms that ensure the program is maintained beyond the life of a research grant or government funding are rare. A somewhat unique facet of the CPR2000 project is that an Implementation process has been established and tested (piloted) prior to dissemination of the project across the state. Implementation will take the form of a progressive rollout. Project outreach will be dependent upon how rapidly community networks can be established. Implementation will be negotiated on a community by community basis. The basic implementation model will require a number of phases as outlined below: “ A meeting with key health care and first aid training personnel in the area to explain the project and seek their cooperation. “ Identification and training of local liaison person(s) to be the central point of contact within the area (Team Leaders).

Abstracts “ Selection and training of the Community Coordinators who are responsible for contacting community organisations and engaging them in the project “ Identification, training and ongoing support of Peer Trainers. Documenting, and evaluating this implementation process ensures that the project is progressed in a regulated fashion across the state. Furthermore, it will allow the program to be replicated elsewhere, including interstate, and internationally. Results of consumer satisfaction measures of Key Stakeholder Meetings, Train the Team Leader Workshops, Train the Community Coordinator Workshops, Train the Peer Trainer workshops and CPR2000 Community Training Sessions will be presented. Preliminary findings of skills assessment/outcomes for peer-trained community members will be discussed. Lessons we have learnt from piloting for the purpose of statewide dissemination and setting campaign targets will be discussed.

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place their hands on either the ‘‘centre’’ or the ‘‘middle’’ of the chest. We randomly selected 100 individuals from three different shopping malls and asked them either to identify the middle or the centre of the chest. Individuals then completed a questionnaire about previous exposure to CPR information. Analysis of the positions indicated on the chest showed distinct distributions between the two groups (see graph). The AHA guidelines state that chest compressions should be performed over ‘‘the lower half of the sternum’’. More individuals from the group asked to indicate the middle of the chest indicated the lower half of the sternum. More individuals from the centre group indicated a potentially dangerous position directly over the xiphisternum. Individuals who had previous CPR training were more likely to be close to the correct position than those who had not.

Analysis of rescue and resuscitation cases in surf life saving 1990 – 98 P.J. Fenner1, S. Leahy2 1 2

National Medical Officer, Surf Life Sa6ing Australia, Sydney National Manager-Life Sa6ing, Surf Life Sa6ing Australia, Sydney

Surf Life Saving Australia keeps an ongoing database of all its resuscitation cases and analysis of previous years has been previously published. The database was recently extended to include both rescues and resuscitation cases. We compare differences between the rescues and resuscitation statistics in the period 1990–1998. In many facts the relative percentage of people rescued was similar to those needing resuscitation. Those areas that showed clear differences include: age groups, with the 0–15 age group comprising 22% total rescues, but only 2% total resuscitation cases; 40–60 age group comprising 25% rescues whereas 42% of this age group needed resuscitation; 9% rescues and 18% resuscitation cases occurred outside average patrol times of 0800–1800: 71% of rescues and 60% resuscitations were outside patrol areas: resuscitation cases smelling of alcohol were double the number of those needing rescue. Most victims receive EAR within the first 5 mins, 5 patients had EAR for up to 2 hours. The use of masks increased greatly from previous studies, and oxygen was used in 5% of those rescued and 88% resuscitated. Rips were responsible for 38% of rescues and 18.5% of resuscitation groups: 10% rescued and 22% resuscitated had jaw clenching; 28% rescued and 58% people resuscitated regurgitated during resuscitation. Suggested reasons for the differences in each group and each area are discussed, and further facts presented.

Simplifying the landmarks for chest compression in CPR P. Mason1, N. Richardson1, T. Richardson2, L. Teoh3, P. Larsen3, D. Galletly3 Heart Foundation, 2Canterbury Health, Wellington School of Medicine, New Zealand

1 3

Christchurch,

and

Lay people being trained in CPR are traditionally instructed to identify the correct position for the hands by first locating the xiphisternum, and then applying the heel of the hand to a point two finger breadths superior to the base of the xiphisternum. We investigated the effect of simplifying this teaching by instructing them to

Figure: Histograms of positions indicated on the chest by subjects asked to identify the ‘‘middle’’ or the ‘‘centre’’ of the chest. More individuals asked to identify the middle of the chest were over the lower sternum.

Training first responders in defibrillation C.J. Zeitz, K.M. Zeitz, A. Inglis, G.A. Ward St John Ambulance Australia Operations Branch — South Australian District, Adelaide There is limited data available regarding the ability of first responders to be trained in defibrillation and to maintain the skill. We therefore developed a two tiered training program and evaluated the results. The trial was run in a metropolitan division and a rural corps, incorporating 4 divisions. An instructors training program (3 hours +assessment) was used to develop a pool of divisional instructors/accreditors in the use of automatic external defibrillators (AED). All members of the divisions involved in the trial, who were competent in CPR, were given the option of completing a 212 hour training program to enable the incorporation of the safe operation of AED’s into the management of cardiac arrest cases. An assessment was undertaken one week following the training session and repeat assessments were performed at 3 and 6 months. Members were denied access to formal training involving AED’s during the trial period. Results: 12 instructors successfully accredited 41/44 members in the initial training program. Assessment included a multiple choice theory paper, familiarization with protocol and equipment and successful completion of the task. 3 members were unavailable for either 3 or 6 month re-accreditation and were withdrawn from the trial. 53/53 members (including instructors) were successfully re-accredited at 3 and 6 months, having access to AED’s at first response duties on 331 occasions. Successful re-accreditation was independent of prior level of training. Conclusion: First responders, who are competent in CPR, can be successfully trained to incorporate defibrillation into the management of cardiac arrest cases with a 212 hour training program and 3 monthly re-accreditation.

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Semi automatic external defibrillators in an acute hospital setting M. Clough, L.E. Grigg, L. Carberry Royal Melbourne Hospital, Melbourne It is well recognised that ‘‘…early defibrillation within a strong chain of survival will ensure the highest possible survival rate for both out of hospital and in hospital events.’’ Semi automatic external defibrillators (SAED) in hospital wards may decrease the time to defibrillate when compared to the system of calling an arrest team. As yet there is little data in the hospital setting to evaluate this premise. Our aim was to assess SAEDs on a general hospital ward to determine whether ward staff in non-critical care areas could use SAEDs safely and effectively and to assess whether time to defibrillation is reduced. The semiautomatic external defibrillator was trialed in a non-monitored area for an eight-month period. The defibrillator used was the Zoll 1600, which is currently used by the Victorian Ambulance Service. Education of general nursing staff was undertaken by Coronary Care nurses. In addition to calling a code the ward staff connected the patient to the defibrillator for rhythm analysis and defibrillation if recommended. The response team continued to provide emergency drugs and changed the machine into manual mode on arrival. There were eight arrests during the trial period. In eight out of eight cases ward staff were able to connect the patient safely and no inappropriate shocks were given. Initial rhythms recorded were ventricular fibrillation in one instance, electromechanical disassociation in two, and five instances of a supraventricular rhythm. The immediate survival rate was 50%. The mean response time was 2.3 minutes for the trial ward compared to 4.2 minutes for other hospital wards during the same time period. In conclusion our results show that the SAED can be introduced safely in a general ward and response time to defibrillation was reduced. As there was only one case of ventricular fibrillation, further research is recommended. Point 5 ARC Policy Statement on Early Defibrillation, July 1997, p4.

Resuscitation training using a high-fidelity patient simulator

crisis situations. A training program exists that focuses on both the medical & technical skills of managing critical events and on the behavioural skills of being a ‘‘crisis manager‘‘. These behavioural skills include such issues as leadership, crew co-ordination, effective communication, and mobilisation and use of all available resources. Realistic scenario training is used in the training of emergency medicine and anaesthesia personnel and is suitable for training of prehospital personnel. The presentation will review the features of these sophisticated mannequins and will show a videotape of a simulated resuscitation event.

Coastal drownings in australia in 1997/98 Stephen J. Leahy, Peter J. Fenner, Simone L. Harrison, Nigel W. Tebb Surf Life Sa6ing, Australia Objective: To consider contributing factors towards the number of drownings that occurred along Australia’s coastline during the 1997/ 98 season. Design: Retrospective case survey using data from Surf Life Saving Australia incident report forms. Setting: 300 Australian beaches patrolled by surf lifesavers between October 1997 and April 1998. Results: 64 drownings occurred in the 1997/98 summer surf season (80% males; average age 35 years). 62.5% of deaths occurred within one kilometre of a lifesaving service. 39% of drownings resulted from swimming in a rip; 14% drowned whilst fishing; 8% suffered a medical condition whilst swimming; 6% were swept off rocks, 6% fell overboard, 6% were riding surf craft; 6% drowned whilst rescuing someone else; 5% were diving; 5% committed suicide; 1 person jumped off a jetty; 1 was murdered and cause of death is unknown for 1 victim. One-third drowned in the company of family or friends and 4 while attempting to rescue someone. The initial victim survived in all but one case. 12.5% of victims were international tourists and 40.6% lived more than fifty kilometres from the incident. Conclusions: Most drowning deaths are preventable: people must behave more responsibly by swimming at patrolled locations. Money is needed to educate international tourists and Australians living inland about the dangers of aquatic activities, this will be particularly important as the Olympic Games in Sydney draws closer. Also, volunteer lifesavers should be supplemented with paid lifeguards during this period, again at a cost to the community.

B. Flanagan, S. Priestley

Overview and rationale of the CPR2000 project Southern Health Care Network Simulation Centre, Melbourne Realistic patient simulators are being increasingly used to teach clinical skills to health care professionals. Simulators consist of full-size patient mannequins with a sophisticated set of computer inputs, and are underpinned by a complex array of physiological and pharmacological models. Simulators can also provide an innovative means to systematically explore a wide variety of emergency medical situations (e.g. trauma scenarios, cardiac arrest) that require interaction of multiple personnel and the performance of multiple tasks in a highly realistic manner in a way that has not previously been possible. Simulators offer the advantage of prospective and repeated observation of the response to serious events whose aetiology and timing are known with certainty-and there is never any patient risk. Housed in a facility that enables replication of multiple environments (Operating Theatre, Emergency Department, Intensive Care Unit, ‘‘roadside’’) this technology enables training for a variety of medical domains in the special skills required to manage complex

M. Lynch, T. Tighe Queensland Ambulance Ser6ice, Brisbane CPR2000 is a community-based strategy that aims to significantly contribute to initiatives that will lead to an increase in survival from out-of-hospital cardiac arrest. CPR2000 is co-ordinated by the Australian Resuscitation Council (Queensland Branch), Queensland Health, and the Queensland Ambulance Service. The Queensland Ambulance Service (QAS) responds to over 1,500 Queenslanders each year who have had a sudden cardiac arrest outside of hospital. Currently, 5% of these people survive. Importantly, only one-third of these cardiac arrest victims receive CPR from a bystander, yet in many cases a cardiac arrests is reversible if the victim receives help immediately. Research shows that a survival rate as high as 20–30% is achievable, provided that each link in the Chain of Survival is initiated rapidly. CPR2000 addresses the EARLY ACCESS and

Abstracts EARLY CPR links in this chain of survival. During the initial phase of the program, CPR 2000 aims to provide brief and simple training in single operator adult CPR to adults over 40. This age group represents a segment of the community that is most at risk of both witnessing and/or becoming a victim of cardiac arrest, and yet is severely under represented in first aid training. A peer training model has been adopted as the most efficient way of extending CPR2000 training into this target community. It is estimated that CPR2000 has the potential to help save the lives of between 20 and 190 people in Queensland each year who would otherwise die unnecessarily from sudden out-of-hospital cardiac arrest. Ultimately, CPR2000 aims to increase the percentage of Queenslanders that have recent CPR training from the current figure of approximately 12% to 25%. Increasing the number of people with recent training thus increases the likelihood that a victim of cardiac arrest will receive CPR from a bystander.

CPR2000 community attitudes survey M. Lynch Queensland Ambulance Ser6ice, Brisbane As part of baseline data collections, CPR2000 conducted a statewide (QLD) telephone survey. This survey, conducted as part of a larger Queensland Health survey, focused on the Early Access and Early CPR links in the chain of survival. As well as collecting standard demographic information, the Community Attitudes Sur6ey explored awareness of signs and symptoms of a heart attack, awareness of the emergency number (‘‘000’’), percentage of households containing someone over 40 years of age, participation in training, recency of training, and likelihood of providing CPR. The sample was a random sample of adult Queenslanders over the age of 18 (N = 5594), and included equal numbers of male and female respondents. The sample was distributed evenly across rural and urban Queensland. Key results of this survey will be discussed. The survey will be repeated at the end of the evaluation phase of the project (December 2000) to measure the impact of CPR2000 in Queensland

The queensland (QEMS)

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Formulating an advanced life support distance education program J. Dennett, S. Nerlich, K. Theobald, M. Yearwood Confederation of Australian Critical Care Nurses, Melbourne The Advanced Life Support (ALS) Distance Education (DE) Program has been developed to provide the registered nurse (RN) with the direction and theory in the initiation and provision of complex life sustaining assessments and interventions. The program reflects current guidelines and policies of the ARC in relation to basic life support and ALS. The program focuses on six (6) key areas, namely priorities of care, management of the airway and breathing, rhythm interpretation, defibrillation, emergency pharmacology and paediatrics. The package aims to provide important theoretical underpinnings and discussion of current techniques in ALS for RN’s. To complete the DE the RN must successfully complete written assignments and a theoretical paper. To receive a Confederation of Australian Critical Care Nurses (CACCN) ALS certificate, the participant must first meet all requirements of the DE and then complete a practical assessment in ALS. A small working party was formed to develop the DE (comprising 4 members of the CACCN national ALS subcommittee). These members represented 4 Australian states. Problems identified during the design of the DE included the marrying of the practical and theoretical components of ALS, the distance and communication between members of the working party and achieving the necessary funding to complete the project. CACCN is a professional group representative of critical care nursing in Australia. The nature of critical care nursing involves the potential for rapid deterioration in patient condition. Critical care nurses need to be competent in initiating and maintaining life saving measures in a timely and appropriate fashion. CACCN membership extends across not only major metropolitan areas but to small regional centres and areas where registered nurses work in remote isolation. Thus development of this package is relevant for all areas of nursing practice.

systems

G. Fitzgerald, T. Tighe

Analysis of in-hospital cardiopulmonary resuscitation (CPR) in patients with opiate overdose

Queensland Ambulance Ser6ice, Brisbane

E.A. Tishkov

An Emergency Medical System (EMS) is a proven concept that delivers improvements to out-of-hospital patient care. The Queensland government has established an interdepartmental committee to develop policies, processes and measurable outcomes for a Queensland Emergency Medical System (QEMS) providing a blueprint to deliver optimum emergency patient care in this state. The key outcomes for QEMS are:

Dept. of Intensi6e Care Medicine, Municipal Hospital N33, Moscow, Russia

“ A clear conceptual framework for implementation; “ Demonstrable linkages and feedback mechanisms between government, service providers and the patient; “ Ongoing system monitoring and adjustment; “ Reduction of duplicity of service; “ Identification of component areas in need of strengthening; “ An integrated system which functions more effectively and reduces a range of human and economic costs. QEMS is in an advanced stage of implementation. This paper will outline the history of the development of QEMS and outline a model for implementation.

INTRODUCTION. The patients with severe opiates overdose present serious problems for resuscitators and these increase problems of in-hospital mortality. The purpose of this study was to determine objective factors influencing patients outcome after massive opiates overdose. METHODS. The records of 120 patients with opiates overdose, who underwent resuscitative and intensive therapy efforts over 3.5 years period (410 patients) were retrospectively analyzed. Data collected has included at time of cardiac arrest, duration of resuscitation, unit where arrest occurred, age, sex, response time, equipment problems, intubation time, admission diagnosis, initial conditions (opiates serum level and intoxication, brain coma, respiratory depression and of hypoxia, aspiration syndrome, hypothermia, hypotension, cardiac rhythm disorders). Co-morbid conditions were also analyzed. RESULTS. CPR was performed on 120 patients (95 M, 25 F, Age 25(2.1 years). Respiration and positive inotropic support, cardiac

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massage, adequate infusion therapy were carried out. 94 patients (78.3%) survived to be discharged from the hospital. 26 patients (21.7%) died: 6-without treatment (during the transportation to ICU) and 20-during CPR (20 min-1.5 hour) and after treatment in the emergency room (under of brain mors after of brain edema and lung edema). Survivors patients depend on the conditions (age, co-morbid diseases, primary cause and the time from beginning cardiac arrest or CPR and adequate intensive therapy, length of CPR, inotropic support prior to CPR, aspiration of lung and fatal hypoxia, metabolic acidosis). We had 10 patients who arrested more than once (2 or 4 arrests). When comparing various units, outcome is relatively poor in our toxicology unit versus intensive care unit, through equipment problems. CONCLUSIONS. The transportation of patients in the proper time and the beginning of CPR allow good results in a significant improvement restoration of spontaneous circulation, and show a beneficial effect on long term-outcome in majority cases. Age greater than 30 with co-morbid disease (pneumonia, renal and hepatic failure, heart disease, etc) portends a poor prognosis following CPR.

A method of teaching rural doctors ACLS G. Marshall Central West Di6ision Of General Practice, Bathurst We devised a booklet to provide accurate recent information on ACLS for local GP’s. A testing system with weighted scoring was devised to assess the doctors in four areas — BLS and ALS, Arrhythmia Determination, Paediatrics and Knowledge of Equipment.89 GP’s voluntarily participated in the process. It was held at their choice of site at a time that suited them, usually in a morning at their surgery.Assessment was done by a trained peer. Results of the survey, including cost effectiveness, will be presented.

Emergency medical response (EMR) pilot K.L. Smith, A. Peeters, J.J. McNeil on behalf of the EMR Steering Committee Department of Epidemiology and Pre6enti6e Medicine, Monash Uni6ersity, Melbourne A study in Melbourne in 1995, revealed that survival from out-ofhospital cardiac arrest in Melbourne was only 3%, which compares unfavourably with cities in the USA where considerable progress has been made in community responses. A pilot program has been devised, in which two State Government Departments (Human Services and Justice), the Metropolitan Ambulance Service (MAS), the Metropolitan Fire and Emergency Services Board (MFESB), Intergraph Bureau of Emergency Services and Telecommunications (Intergraph BEST VIC Pty Ltd (IBV)) and Monash University are working closely together. The objective of the pilot is to determine whether the concurrent dispatch of ambulances and suitably trained and equipped fire brigade units to scenes of suspected cardiac arrests will significantly reduce the time to arrival at scene and time to defibrillation. The start date of the pilot was Tuesday 14th July 1998 and concurrent dispatch of MFB and MAS resources to cases of suspected cardiac arrest will run for 6 months in a designated area of the MFESB’s metropolitan fire district. A review of the 6-month pilot and results will be given.

The best method for lay caregivers to detect their infant’s heartbeat/pulse: a comparison of four methods M. Tanner, S. Nagy, J. Peat Royal Alexandra Hospital for Children. Westmead, Sydney Measuring the pulse of an infant remains a problem for many parents and lay people, with several reports documenting inability of lay rescuers and healthcare providers to reliably locate or count the pulse of the victim. The aim of this study was to determine the best method for caregivers to detect their infants heartbeat / pulse. Method: A sample of 200 caregivers in a baby ward were recruited for the project. Each caregiver was asked to find and count their infant’s pulse at four different sites; these being:- the carotid, the brachial, with their fingers over the left nipple and finally listen with their ear over the left nipple. The caregivers were not given time to practise but were instructed in the method of detection prior to the data being collected. The caregivers results were compared with that of the nurse who simultaneously listened with a stethoscope. The caregivers pulse was also observed so that there were no discrepancies of impulse rates. Results: Measurements were made of the time taken to find the impulse, ability to detect the impulse, accuracy of the detection of the impulse. Listening with an ear over the left nipple proved to be the fastest most accurate method of detecting the infant’s heartbeat. Both the brachial and listening with an ear over the left nipple were able to found relatively easily with 86% of caregivers being able to find these, compared to 63% able to detect the heartbeat over the nipple with their fingers and 23% feeling for the carotid. Conclusion: As parents were found to find a pulse most speedily by placing an ear over the infant’s left nipple, it is recommended that parents and caregivers be instructed to use this method.

Intramuscular use of naloxone for narcotic overdoses in the pre-hospital setting I.G. Jacobs, H.F. Oxer Western Australian Pre-hospital Care Research Unit, Perth Background: The narcotic antagonist Naloxone is considered a useful adjunct in the pre-hospital management of narcotic overdoses. Traditionally Naloxone has been administered intravenously thus requiring the establishment of intravenous access. While Naloxone is well absorbed via the intramuscular route, its use in this fashion has not been well described in the literature. The purpose of this study was to evaluate the efficacy and safety of Naloxone administered intramuscularly in the pre-hospital setting. Methods: A clinical trial of Naloxone given intramuscularly in the pre-hospital setting. A single dose of Naloxone (0.4mg) was administered to all patients who were unconscious due to suspected narcotic overdose and had a respiratory rate of B 7 per min. Naloxone was not used in cases where cardiac arrest had occurred. Demographic and clinical data were collected and patient care record forms reviewed. The study period was from August to December 1997 inclusive. Results: There were 368 cases (2.4 per day) during the study period and 4.3% of these died at the scene. Naloxone was administered in 37.8% of cases and in these patients 75% had a GCS ] of 14 and respiratory rate ] 12 within 10 minutes of receiving Naloxone. Regurgitation of the airway occurred in 2.1% of cases and concomitant use of drugs9 alcohol occurred in 37.8% of patients. Only 16.5% of

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Abstracts patients still required positive pressure ventilation upon arrival at hospital. No patients died or represented to ambulance services within 24 hours who were given Naloxone and subsequently refused transport to hospital. Conclusion: Naloxone given intramuscularly is safe and useful in the pre-hospital management of narcotic overdoses.

Carotid pulse checks—a complex technique or a teaching challenge? E.P. Tyler, B. Watters

initial training and proportions returning for further training. 502 members of public were recruited for the study, using television, newspapers, church networks, etc. The recruits were randomized to each of the training cohorts and trained using a single Resuscitation Training Officer helped by two groups of trained lay demonstrators. Tests were carried out immediately after training using Recording Annes and video cameras. The test were then marked using the VIDRAP and CARE protocols. The study is continuing but all initial training is completed and the first refresher cycle run. After conventional training only 19% returned for further training, while after Bronze level 59% return for Silver training. This study is supported by the British Heart Foundation and the Resuscitation Council (UK).

Ella Tyler First Aid Consultants, Adelaide The 1997 Advisory Statement from the Basic Life Support Working Group of the International Liaison Committee on Resuscitation (ILCOR) discusses the value of accurate carotid pulse checks for a non-responsive (unconscious) adult victim. Several researchers have suggested that the average lay person requires far more than 5 – 10 seconds to confidently palpate and count a carotid artery pulse or to identify an absent pulse. For example, one researcher found that more than 30 seconds was required to achieve a diagnostic accuracy of 45% in normotensive volunteers. During an international CPR conference in 1998, informal discussions with several experienced Basic Life Support Instructors from Australia, Canada, UK, USA, and New Zealand made it clear that the teaching methodology used to teach accurate carotid pulse palpation varied greatly. It seemed likely that the instructional factor might well account for the poor performance of some laypersons assessed during competent research studies. The researchers decided to investigate the teaching methodologies used in Australia for carotid pulse palpation, and to assess any differences between the results from various community groups taught by different instructors from different organisations. The instructional protocol used was based on Australian Resuscitation Council Policy Statement 6.2.2, published in July 1997. The results of the study have validated the hypothesis that the quality of the initial instruction and the opportunity for adequate ‘‘hands-on’’ experience are critical factors in attainment of competence in carotid pulse assessments in normothermic and normotensive adult volunteers.

Staged CPR training versus conventional CPR training Douglas Chamberlain, Peter Donnelly, David Assar

Preparing response

firefighters

for

emergency

medical

I. Millar1, D. Shugg2, D. Rich1 Metropolitan Fire & Emergency Ser6ices Board 1 & Ambulance Officers Training Centre 2, Melbourne Under the supervision of a Government appointed Steering Group, a Pilot program of Emergency Medical Response by Melbourne firefighters was undertaken from July 14, 1998 to January 14, 1999. The Pilot parameters and results are reported elsewhere on this program. Preparation for this new activity included the drafting of detailed guidelines and operating procedures for all aspects of the expected operations, selection of equipment and establishment of the training program. Training and equipment was specifically designed to be appropriate for the expected short duration, urban environment co-response to Metropolitan Ambulance Service ‘‘Priority 0’’ cases. These cases have a high probability of being cardiac arrest. Large, hard case oxygen resuscitator and first aid kits were specifically designed for the role to enable quick access and ready identification of kit contents. Oxygen resuscitation equipment included oro-pharyngeal airways, venturi suction, adult and child self inflating bag resuscitators, a demand valve/manually triggered ventilator and pocket mask. A small, rugged, lithium battery, shock advisory defibrillator was selected. Firefighters undertook an 8 day training course provided by the Ambulance Officers Training Centre according to a skills based curriculum with a large component of scenario training. Communication skills were emphasised. The curriculum skimmed over or omitted many areas traditionally included in first aid training where these were thought irrelevant to short duration, urban response targeted at critical patients only. Pilot operations have been supported by a dedicated EMS Department with inter-service audit, quality assurance and continuing education arrangements.

The Uni6ersity of Wales College of Medicine Cardiff, Wales, United Kingdom Concerns over current CPR skills acquisition and retention in the community has prompted the comparison of cohorts trained in two different ways. The first is a conventional 2 hour CPR course which offers reinforcing refreshers after 2 month and 4 months. The second, called Bronze, Silver and Gold, uses a staged approach with initial emphasis on chest compression and simple airway management, with reinforcement and instruction in ventilation after two months. Training to full ERC guidelines follows two months later. The evidence why Bronze level CPR is effective in its own right will be presented The study will report three facts: 1)The effectiveness of trainees immediately after training. 2) How many people return at each stage. 3) Effectiveness at 6 months and 12 months. This paper will be the first report of the effectiveness of

Research findings into H.A.IN.E.S. & lateral recovery positions N. Eizenberg, J. Haines et al. The Uni6ersity of Melbourne / Australian First Aid P/L, Melbourne Introduction: Awareness of the risk of spinal cord damage by moving an unconscious person with a suspected neck injury into the ‘lateral recovery position’, coupled with the even greater risk of inadequate airway management if the person is not moved, has resulted in a suggested modification to the lateral recovery position for use in this circumstance.

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Hypothesis: It is proposed that the modification to the lateral recovery position reduces movement of the neck. In this modification, one of the patient’s arms is raised above the head (in full abduction) to support the head and neck. The position has been termed by the authors of the research, Eizenberg; et. al, The University of Melbourne, the ‘HAINES modified recovery position’ (after John Haines, the originator of the development). ‘H.A.IN.E.S.’ is also an anagram for ‘High Arm IN Endangered Spine’. Methods: Neck movements in two healthy volunteers were measured (using video image analysis and radiographic studies) when they were rolled from the supine position to both the lateral recovery position and the H.A.IN.E.S. modified recovery position. Results: For both subjects, the total degree of lateral flexion of the cervical spine in the H.A.IN.E.S. modified recovery position was less than half of that in the lateral recovery position (while an open airway was maintained in each). Conclusion: An unconscious person with a suspected neck injury should be positioned in the H.A.IN.E.S. modified recovery position. There is less neck movement (and less degree of lateral angulation) than with the lateral recovery position and hence less risk of spinal cord damage.

The effect of three advanced life support training strategies on the knowledge and skills of registered nurses D.M. Ridgwell Perth The possibility of having to respond to a cardiac arrest victim causes fear and anxiety for many registered nurses. Furthermore, the literature indicates that nurses’ basic and advanced life support skills are poor at varying periods after training. As the registered nurse is the most likely person to discover the hospital cardiac arrest victim, basic and advanced life support knowledge and skills are integral to the registered nurse’s role. ALS training has traditionally consisted of didactic sessions, practical skill sessions, and simulated cardiac arrests. However, the precise contribution of simulated cardiac arrests in comparison to didactic sessions on the knowledge and skills of registered nurses has never been systematically examined. This study aimed to provide empirical support for the use of simulated cardiac arrests as a resuscitation training strategy. A 3 groups × 3 test times factorial design with repeated measures on the test time factor was used to compare simulation, simulation plus didactic and didactic only ALS training strategies, on the knowledge (multiple choice test) and skills (simulated cardiac arrest test) of ward based registered nurses. Seventy two volunteer registered nurses were randomly allocated to the three training strategies. Nurses were tested prior to training, seven days after training to assess initial learning and twelve weeks after training to assess retention. Results show that all three training strategies are equivalent and enable achievement of ALS knowledge and skills to a statistically significant level, immediately after training. Additionally, ALS skills were maintained to a statistically significant level over the twelve week period, however, a slight decline was observed in nurses’ knowledge.

Incidence, duration and survival of vf in out-of-hospital cardiac arrest in Sweden M. Holmberg, S. Holmberg, J. Herlitz Sahlgrenska Uni6ersity Hospital, Gothenburg, Sweden This study was based on the Swedish cardiac arrest registry. In 10966 cases, of out-of-hospital cardiac arrest, resuscitation was attempted. Incidence and duration of VF: The first ECG showed VF 43% of the cases. For the 5011 bystander witnessed cases the incidence of VF was 54% and for the 3275 non-witnessed cases 31%. In the 1089 ambulance-crew witnessed cases the incidence of VF was 42%.In 1257 witnessed cases with probable heart disease, where both time of cardiac arrest and first ECG was known, the patients were divided into 2-minute interval groups according to delay time, and the proportion of patients still in VF was analysed. With very short delay times the incidence of VF was approximately 80% and after 30 minutes approximately 50% of the patients were still in VF. Survival of patients in VF: Overall survival for patients in VF was 9.5%. In 2462 cases presenting with VF at first ECG and with known time of cardiac arrest and first defibrillation, the patients were divided into the same 2-minute interval groups according to delay time. The proportion of patients surviving to one month was analysed for each group. With delay times less than 2 minutes survival was approximately 50% only to rapidly decrease with increasing delay time. Conclusions: In out-of-hospital cardiac arrest patients the initial proportion of patients in VF was approximately 80% and decreased only slowly to approximately 50% after 30 minutes. The survival rate for patients in VF was approximately 50% if defibrillated very early, but decreased rapidly with increasing delay time.

Effects of bystander-CPR in out-of-hospital cardiac arrest in Sweden S. Holmberg, M. Holmberg, J. Herlitz Sahlgrenska Uni6ersity Hospital, Gothenburg, Sweden This study was based on the Swedish cardiac arrest registry and illustrates the effect of 15 years of large scale CPR training on the willingness and ability to perform bystander-CPR(B-CPR) in Sweden. In 9877 cases of out-of-hospital cardiac arrest resuscitation was attempted. The first ECG showed VF in 45% of the cases. The median delay time from arrest to first ECG was 14 minutes. In 67% of the cases the arrest was witnessed. In 69% the arrest took place at home. In 3572(36%) cases B-CPR was performed. Among the witnessed cases 40% were given B-CPR as opposed to 21% among the nonwitnessed. In the cases where the arrest took place at home 23% were given B-CPR and among those suffering their arrest in a public place 40%. In the 2634 cases with known bystander characteristics 56% were laypersons, 25% medical personnel and 5% police or ambulance personnel off duty. Survival to one month was 8.2% for those given B-CPR compared to 2.5% for those not receiving B-CPR. Among the wit-

Abstracts nessed cases survival was 10.0% vs. 3.7%. Among the witnessed cases found in VF survival to one month was 16.6% if B-CPR was performed by medical personnel and 10.3% for those where the bystander was a layperson. Conclusions: After 15 years of CPR training in Sweden 36% of all cardiac arrest patients were given B-CPR and among the witnessed cases 40%. If the arrest took place at home only 23% were given B-CPR as opposed to 40% if the arrest took place in a public place. If B-CPR was performed overall survival increased approximately three times.

Co-ordinated activities in Europe: possibilities and potential Laurent Van Rillaer Belgian Red Cross-Flanders, European Reference Centre For First-Aid Education. B-1050 Brussels, Belgium The European Working Group For First-Aid Education harmonise the programmes of National Societies improve quality of first-Aid Education The European First-Aid Certificate common certificate similar: objectives, duration, educational methods, evaluation and certification methods, quality process The European Reference Centre For First-Aid Education general objectives tasks The European Congress On CPR And Prehospital Care every 4 years purpose: present experience on implementation of First-Aid programmes to the population The European First-Aid Competition purpose: promoting quality and harmonisation The Collaboration Between The European Working Group For First-Aid Education And The European Resuscitation Council Future Steps adoption of a system-wide strategy and achievement of integrated approach’ the measurement of impact the analysis of the financial performance a process for the enhancement of quality First-Aid programmes and services a First-Aid policy and its corresponding guidelines: 1999

The incidence of latex allergy in first responders and its significance in the prehospital setting

125

in patient care in the pre-hospital scenario. Members of St John Ambulance Australia Operations Branch and the staff of SA Ambulance Service were asked to complete a questionnaire. The questionnaire surveyed personal data, potential exposure, hand washing practice, compliance, style of glove used, duration of glove usage, manifestations of allergic illness and action taken by the member as a result of developing symptoms. This presentation defines the problem of latex allergy, outlines its nature, submits results from the survey and considers the different effects of glove-wearing on both care provider and patient. The development of latex allergy in a person involved in clinical patient care results in a major change in both employment and social activities. Action to prevent sensitisation is important. If a person with latex allergy requires emergency medical care, the potential exposure to latex in some form is a life threat in both pre-hospital and hospital situations. This potential has to be considered, the risks minimised and effective treatment given when needed. A knowledge of present practices allows directed teaching for change if needed and a knowledge of the present incidence of latex allergy will allow subsequent comparison.

Bicycles—powered by the chain of survival A.K. Eade St John Ambulance Australia (Victoria), Melbourne St John Ambulance Australia (Victoria) introduced bicycles as a means of reducing ‘‘at patient’’ response times at large public gatherings or community events in September 1997. The impact was immediate, the benefit beyond all expectations. This presentation seeks to outline the formation of a bicycle EMS system, and review its first 12 months of operation. The provision of EMS to large community events or major public gatherings has been plagued for many years by the problem of providing suitable coverage of either large geographical areas, or large crowds in a densely populated environment. The use of vehicles whilst possible in the first instance is impossible in the second, regardless, both are fraught with danger given the unpredictable nature of crowds. Responding on foot is also possible in each case however unlikely to be able to achieve a suitable response time or deliver the EMS provider in suitable state for the provision of services. The middle ground is the humble bicycle, which has incredible versatility in adapting to both environments. Bicycles have proven to be an effective method of reducing response times, and strengthening the chain of survival, by providing early CPR, and even in some cases early defibrillation. The effect of a bicycle response team on public event EMS has been dramatic. Following a review of the response time data for the years pre and post the introduction of bicycles the benefits to the patient and also to an enhanced Chain of Survival are remarkable.

F.H.G. Bridgewater, K. Zeitz, C.H. Katelaris St John Ambulance Australia, Canberra ‘‘Latex allergy’’ and ‘‘latex sensitivity’’ have become catch cries in the medical literature of the 1990s. Since the time of the introduction of the concept of ‘‘Universal Precautions’’ in the late 1980s there has been an exponential rise in the usage of latex gloves. Latex allergy, a rarely reported phenomenon prior to that time, is now well recognised and seemingly becoming more common. The two events can be hypothetically linked. Internationally, surveys of latex allergy in medical, dental and nursing staff have reported. The majority of these previous reports on latex allergy have primarily dealt with institutionbased personnel. A survey has been conducted to determine the incidence of latex allergy in a large group of first responders involved

What to advise, that is the question? Or planning for the health implications associated with large public gatherings, a preventative approach Rodney I. Fawcett District Medical Officer St John Ambulance Australia (Victoria), Area Medical Co-ordinator Medical Displan K Regional (Geelong) Manager Clinical Resource Unit The Geelong Hospital, Australia In order to be able to deliver personnel capable of providing resuscitation capability at large public gatherings, an overall infrastruc-

126

Abstracts

ture is required. If not, then the delivery of such services is likely to be delayed, unco-ordinated and thereby compromise the chain of survival as the potential for linkage breakdown is considerable. This presentation gives an overview of the necessary planning required to ensure an appropriate infrastructure is developed to support the provision of health and resuscitation services at large public gatherings. In March of 1997 a workshop was held at the Australian Emergency Management Institute at Mount Macedon. The purpose of this workshop was to develop a broad set of guidelines to facilitate the planning for, and response to the health implications associated with large public gatherings; the title of the workshop being Mass Gathering Medicine. The workshop was held under the auspices of Emergency Medicine Australia. The resulting document will ultimately be published as an additional chapter to the Australian Emergency Manual titled Disaster Medicine. The purpose of this paper is to highlight the issues associated with the planning for the health response, inclusive of preventive approaches, associated with large public events such as an air show, a rock concert, a festival or a large sporting event. Topics that will be highlighted include pre-event planning, site access and perimeters, spectator management and crowd control, stages, platforms and other performance venues, temporary structures, security, public health issues in particular, healthcare provision at the event, safely issues, ancillary considerations and contingency plans for specific high risk events such as automobile races, or air shows and displays. In presenting this material it will be brought to life using the author’s experience associated with the planning and implementation of the health response plan for the 1999 Airshows Downunder International Airshow held in February 1999 at Avalon near Geelong.

Cardiac arrest team workshop—a training programme for registered nurses in a private hospital without 24 hour medical coverage

Hospital Mackay to enhance its provision of health care particularly in emergency cardiac arrest situations. This has been achieved by a training programme developed and implemented with multi-disciplinary input.

Baa baa black sheep helps you to remember CPR P.C. Wilson PREMIUMHEALTH, Melbourne Heart and blood vessel disease remains the single most prevalent cause of death in Australia. Sudden collapse through heart attack is the most common reason for a bystander to initiate life saving measures by performing cardiopulmonary resuscitation. For a bystander to initiate CPR the most important element in its commencement is to recall the complex ratios, rates and rhythms. Significant deterioration of psychomotor performance as well as knowledge has been found in lay persons 2 – 6 months after CPR training. Numerous studies have determined that the retention of CPR knowledge and skills is a major problem regardless of teaching methods employed. The challenge in the debate of CPR retention is to create a programme that has a simplified approach to basic life support instruction. This instruction must allow the rescuer to remember the complex task of 15 chest compressions to 2 ventilations four times in one minute. Recall of the correct rate and rhythm is critical to effective performance of CPR. The Premium Health method (copyright) employs the use of a mnemonic which significantly assists the retention of cardiopulmonary resuscitation rates and rhythm in single rescuer adult CPR1.

1

P. Bastable, D. Jones, M. Haynes Mater Misericordiae Hospital, Mackay Aim: The aim of this paper is to highlight the implementation of a programme to train nursing staff in basic and advance life support skills. Thus enabling efficient resuscitation of patients within a private health facility. Content: Setting is a 158 bed accredited acute care not for profit hospital situated 1000 km north of Brisance. In 1991 the Mackay Mater Hospital developed in collaboration with a visiting medical practitioner a cardiac arrest team workshop. At the time the programme was developed the hospital did not have 24 hour medical coverage, thus nursing staff were often the initiators of the management of cardiac arrest. In conjunction with the programme a cardiac arrest team was established. This team provides for designated staff members who have been trained via the workshop to respond to cardiac arrest within the hospital. The workshop conforms to the Australian Resuscitation Council guidelines and is co-ordinated by a visiting medical officer with accident and emergency certification, Nurse Co-ordinator Intensive Care Unit and Education Facilitator. This one day workshop focuses on the basic life support management of cardiac arrest, malignant arrhythmia recognition, defibrillation, roles of the cardiac arrest team and case scenarios. Since 1991 a total of 153 registered nurses have trained through the workshop with 63 staff able to competently assume the team leader role. Workshops are held four times a year and yearly updates are also provided to staff. Recent initiates include the attention of the programme to be undertaken by local general practitioners and as well as nursing staff within other acute care facilities within the town Conclusion: The introduction of a training programme for nursing staff in advance life support has enabled the Mater Misericordiae

Wilson, P. Does the use of a mnemonic, aid the cognitive and psychomotor retention skills of single rescuer adult cardiopulmonary resuscitation (CPR) rates and rhythm, for laypersons in a 6 hour training programme, Monash University 1997 (Research into the PREMIUMHEALTH method was carried out by Phillipa Wilson as her thesis in partial fulfillment of her Master of Public Health degree).

Asystolic cardiac arrest in Melbourne A.D. McR Meyer, S. Bernard, K.L. Smith, P.A. Cameron, J.J. McNeil et al. Victorian Out of Hospital Research Interest Group, Melbourne The majority of survivors of out of hospital cardiac arrest present as ventricular fibrillation (VF) or ventricular tachycardia (VT). Asystole is being reported with increasing frequency both in Australia and the USA. Existing Australian experience with asystole indicates that the outcome is universally poor. It has been argued that ‘‘less vigorous’’ resuscitation efforts be made and postulated that no resuscitation be offered to those found in asystole. This paper aims to determine the outcome of adult patients in whom cardiac arrest has occurred and in whom asystole was the presenting rhythm. A retrospective case note review has been performed for all adults attended by the Metropolitan Ambulance Service (MAS) for 1997. Patients who survived to hospital had their case notes reviewed to determine outcome. There were 658 cases identified. The data analysis thus far indicates that overall survival from out of hospital asystolic arrest is poor, however survival is improved if the arrest is witnessed and if bystander cardiopulmonary resuscitation (CPR) is performed.

Abstracts This study shows a poor outcome from asystolic out of hospital cardiac arrest. Compared to overseas studies, the Melbourne survival rate is low. The factors which may influence the survival figures will be discussed

The advanced medical priority dispatch system— the Melbourne experience M. Lewis, A. Bacon, F. Archer Metropolitan Ambulance Ser6ice, Melbourne Criteria based dispatch systems, such as the Advanced Medical Priority Dispatch System (AMPDS), have been utilised in the communication and dispatch process in overseas emergency medical services for 15 years. AMPDS provides a medically predetermined sequence of questions for call takers to ask the caller, assigns an event code and priority which is linked to a medically predetermined response for each of the event codes. Criteria based dispatch systems, such as AMPDS, have a proven track record overseas and research studies have found very little risk of potentially serious under-prioritisation. The AMPDS system was introduced in Melbourne in January 1997 and its computer version (PROPQA) in march 1998. AMPDS is also being introduced in other Australian ambulance services. The expectation is that AMPDS will improve call taking and dispatch processes as measured by shorter communication centre times and provide better discrimination in assigning appropriate ambulance responses, including fewer unnecessary dual responses. The major implication for callers requesting an emergency ambulance response is that there is now a pre-determined set of questions asked in a structured way which is different to those used in the past. Calltakers also receive training in appropriate strategies to respond to the caller’s emotions and panic which may be present. This paper will outline and inform all participants of this International Spark of Life Conference on the rationale, structure of questions, and benefits of the AMPDS system from the Melbourne experience

Evolution in resuscitation teaching: an historical perspective C. Hooper, M. Naylor, J. Talbot St John Ambulance Australia (ACT), Canberra This paper examines the changes in resuscitation teaching, in content, targets and delivery. It provides a lighthearted view of early literary references which could be interpreted as expired air resuscitation (EAR) or cardiopulmonary resuscitation (CPR), starting with the Old Testament, then takes a closer look at twentieth century developments. Using St John Ambulance texts dating back to the early decades of the century, the authors have identified the principles applied, and have found some interesting social concepts underlying the formation of resuscitation classes. Delivery of teaching was also significantly different, with strong emphasis on repetition of rules and little consideration of modern teaching principles such as student-centred learning. Since the sixties, there have been major changes with the introduction of citizen CPR, development of sophisticated manikins, and a plethora of equipment to assist the responder. Mixed gender classes became the norm, and the minimum age for students dropped

127

dramatically. The nineties have seen a swing back towards a cautious approach, with infection control becoming a major concern, and fear of accusations of sexual misbehaviour causing strict guidelines to be written which limit instructors to demonstrating on students of the same gender. The move towards international standards has generated a focus on principles rather than specific rules, and the development of pre-hospital emergency services has meant that resuscitation classes are predicated on utilising these resources, instead of focussing solely on the actions of the first aider. Instructors, regardless of their medical knowledge, are expected to have teaching skills, and instructor training courses have become mandatory within the major teaching organisations in Australia. Even the definition of basic life support has expanded to include use of oxygen and defibrillation

Australian directory of pre-hospital research F. Archer, M. Chilton, M. Boyle Ambulance Officers’ Training Centre, Melbourne The Australian Directory of Pre-hospital Research is an initiative driven by two forces: the emergence of the principles of evidencebased medicine and their increasing application to the full spectrum of health care settings, including pre-hospital care; and, the lack of pre-hospital care research identity in Australia. The evolution of the Directory commenced by reviewing similar directories in vocational education and training, occupational health and safety, nursing and medical education from Australian and international sources. From these the key variables were collated and a proforma designed trialed and finalised. The proforma has subsequently been sent to over 600 agencies and individuals throughout Australian and New Zealand seeking input into the Directory. The aim is to identify Australian researchers and projects in the pre-hospital sector. Access to the Directory will be made available to the Australian pre-hospital care community and it will be regularly updated. Following receipt of many completed proformas as well as expressions of interests in the final product, visits are being made to each of the Australian States and Territories and to New Zealand which, together with a literature search, will augment and consolidate the Directory. This paper outlines the rational, objectives, process and response to the distribution of the Directory proforma, will present a profile of the current pre-hospital care research scene in Australia and New Zealand, and will suggest possible directions for investigation.

Royal Australian navy ships’ medical emergency team training A.J. Hayward, C.A. Hyde Medical School-HMAS Penguin, Sydney The RAN Ships Medical Emergency Teams (SMET) are comprised of non core medically trained personnel who have completed an 8 day pre-hospital casualty care course. The training is conducted at Medical School-HMAS PENGUIN in Sydney with completion and final assessment being continued as on the job training during operational deployment at sea. The aim of the training is to provide selected Ships’ Company Personnel with the necessary skills to enable them to competently assist Ship’s Medical Staff in providing emergency medical care. Members are trained in resuscitation skills, trauma management, basic triage, and evacuation procedures. The course is both theory

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and practically based, with a strong emphasis placed on hands on training. Training exercises involving mass casualty situations are regularly conducted. Continuation training and assessment is performed involving the travelling Sea Training Group who monitor and record SMET performance, during emergency exercises at sea. These scenarios are whole ship evolutions and are very manpower intensive. SMET is an integral part of the Medical organisation within HMA Fleet units both in peace and times of conflict.

Sodium bicarbonate increases likelihood of successful resuscitation J.C. Bendall, E.C.M. Leong, A.C. Brown, R. Einstein Department of Pharmacology, Uni6ersity of Sydney, Sydney This study was designed to evaluate the effects of sodium bicarbonate treatment on restoration of spontaneous circulation and short term survival after 5 or 10 min cardiac arrest in dogs. After the arrest period, resuscitation was initiated with (i) immediate defibrillation shock (200J) followed by adrenaline (0.1 mg/kg) and treatment (NaCl 2 ml/kg or NaHCO3 2 mmol/kg) and 2 min CPR (Thumper Cardiopulmonary Resuscitator) or (ii) adrenaline (0.1 mg/kg) and treatment (NaCl 2 ml/kg or NaHCO3 2 mmol/kg) and 2 min CPR followed by defibrillation. All animals then received standard advanced life support until ROSC or for 30 min. The Table shows outcome and pH.

.

Time Treatment Group (min) Immediate defibrillation

Immediate treatment

ROSC Survi- Venous pHn ROSC Survi- venous pH n (%) val (%) (%) val (%) 5 5 10 10

NaCl 83 NaHCO3 100 NaCl 17 NaHCO3 100

83 83 17 100

7.01 9 0.05 6 7.30 9 0.03 6 7.03 9 0.03 6 7.18 9 0.05 4

17 83 17 83

0 83 0 67

6.94 9 0.01 6 7.2890.06 6 6.90 90.07 6 7.15 90.09 6

The pH (5 min after start of resuscitation) of NaCl-treated animals was significantly lower than that of the NaHCO3-treated animals. After 5 min of arrest, the treatment had no significant effect on the outcome of resuscitation of animals which received immediate defibrillation. When treatment was administered first, defibrillation was delivered at 7 min and ROSC occurred in significantly more of the NaHCO3-treated animals, than in NaCl-treated animals. Thus, after the first 5 min of arrest, any additional delay to defibrillation has a major impact on the chance of ROSC. This was confirmed by the results after 10 min arrest, where, in the absence of NaHCO3 treatment, ROSC could be achieved in only 17% of animals. Regardless of arrest time, the combination of immediate defibrillation and NaHCO3 was always the most effective. There was no evidence for any deleterious effect of NaHCO3. The data support the current practice of immediate defibrillation but also indicate that inclusion of early administration of NaHCO3 may improve outcome.