Bystander-initiated cardiopulmonary resuscitation out-of-hospital. A first description of the bystanders and their experiences

RESUSCITATION

Resuscitation 33 (1996) 3-- 11

Bystander-initiated cardiopulmonary resuscitation out-of-hospital. A first description of the bystanders and their experiences Asa A xe1sson*, Johan Herlitz, Lars Ekstriim, Stig Hoimberg Division of’ Cardiology,

Sahlgrenska Hospital,

Rb’da strdket 4, S-41345 Giitehorg.

SW&~

Received 18 January 1996; revised 23 March 1996: accepted 26 March 1996

Abstract

At present there are about 1 million trained cardiopulmonary resuscitation (CPR) rescuers in Sweden. CPR out-of-hospital is initiated about 2000 times a year in Sweden. However, very little is known about the bystanders’ experiences and reactions. The aim of this study was to describe bystander-initiated CPR, the circumstances, the bystander and his experiences. All CPR bystanders in Sweden who reported their resuscitation attempts between 1990 and 1994 were approached with a phone interview and a postal questionnaire, resulting in 742 questionnaires. Bystander-initiated CPR most frequently took place in public places such as the street. The rescuer most frequently had problems with mouth-to-mouth ventilation (20%) and vomiting (18%). More than half (53%) of the rescuers experienced CPR without problems. Ninety-two percent of the bystanders had no hesitation because of fear of contracting the acquired immunodeficiency syndrome (AIDS) virus. Ninety-three percent of the rescuers regarded their intervention as a mainly positive experience. Of 425 interviewed rescuers, 99.5% were prepared to start CPR again. Keywords:

Cardiac arrest; Out-of-hospital; Bystander; Cardiopulmonary resuscitation: Psychological reactions; Technical prob-

lems

1. Introduction

Most deaths from ischaemic heart disease occur outside hospital and are mainly due to ventricular fibrillation [l]. During the past two decades a huge effort has been made to improve the prognosis in this patient population [l--3]. This effort can be described as work designed to develop the strength of each link in the ‘chain of survival’ concept: early access, early CPR, early defibrillation, early advanced care [4]. Weakness in any link lessens the chance of survival.

*Corresponding

author. Tel.: + 46 31 601000, fax: + 46 31

826540.

In order to strengthen the second link in the chain, both in Sweden and in many other parts of the world, educational programmes have been initiated with the aim of teaching people in the community how to perform cardiopulmonary resuscitation (CPR) when indicated. The training of rescuers among laymen started in 1984. In Sweden, there are currently some 1 million trained rescuers. Through the Swedish ambulance register, we know that CPR out-of-hospital is initiated about 2000 times a year in Sweden. Even if the physiological impact of CPR has been criticised [5], the importance of bystander CPR is well documented through several studies. It has thus been shown that CPR‘initiated by a bystander maintains ventricular fibrillation and increases the chance of surviving a cardiac arrest out-of-hospital

0300-9572/96~$17.000 1996 Elsevier Science Ireland Ltd. All rights reserved Pli s0300-9572(96)00993-8

[C, 101.

4

A. Axelsson et al. /Resuscitation

However, very little is known about the bystanders’ experiences and reactions. Training the public in CPR means giving them a tremendous responsibility. They are expected to perform a directly resuscitative procedure. It would be unethical not to investigate the effects. Can laymen cope with this mission? The aim of this study was to describe bystander-initiated CPR, the circumstances, the bystander and his experiences. 2. Methods Sweden has a population of about 8 million. In Sweden, there are about 1 million trained CPR rescuers. Everyone who completes CPR training receives a course certificate. A report card is attached to this certificate. This card is to be used to report any resuscitation attempt to the central office. 2.1. Participants Participants included all CPR bystanders who between 1990 and 1994 (5 years) reported a resuscitation attempt through the report card they received with the course certificate after completed CPR training. We received 1555 report cards, which were evaluated. Of these, 687 were from emergency or medical personnel who had performed CPR on duty or persons who had just completed a CPR course; they were therefore not approached any further. What remained was 868 CPR bystanders, of whom 126 (15%) did not return the questionnaire. This study deals with the remaining 742 bystanders. Each rescuer was approached with a short phone interview, normally l-3 months after performing CPR. This interview was not standardised. It gave the rescuer an opportunity to talk about problems, feelings and questions associated with his/her intervention. During this call, the rescuers were also asked to answer a postal questionnaire about their experiences.This questionnaire contained 26 standardised questions. The results are based on the 742 postal questionnaires which included not only the standardised questions but also a free description of the intervention. The answers to the questions were checked and compared with these free descriptions and the phone interviews in order to obtain the truest possible picture of the rescuers’ experiences. This way of collecting information started with a very simple questionnaire with 13 standardised questions. During the investigation, it became necessary to add some questions which were essential. After 2.5 years, 12 questions were added. After 3 years, one further question was added. This explains why there can be a great difference in numbers in the results. In some of the first reports, information responding to questions added in

33 (1996) 3-11

later reports was available. This information was considered during the analysis (see Tables 2 and 4, where n = 438 and 596, respectively, though only 3 13 of 425 got the question). 2.2. The questionnaire The first report included the following questions: (1) The bystander’s age and occupation. (2) Date, time and place of the intervention. (3) Where did the collapse take place? (4) Name, age and sex of the person who collapsed? (5) Are you: Related to the victim? Known to the victim? Unknown to the victim? (6) Did anyone hear or seewhen the victim collapsed? (7) Time from collapse to start of CPR? (8) For how long did you (and any assistants, if relevant) continue CPR? (9) Action by the rescuer: Alt: CPR by 1 person, CPR by 2 persons, more than 2 persons. 10) Which action was taken by the ambulance men at ( the scene of the collapse? Alt: Oxygen, electric shock over the chest, i.v. infusion. 11) Do you know the outcome for the victim? Alt: Alive, dead, do not know. 12) How did you find performing CPR? Alternatives: Difficult to remember everything Problems with mouth-to-mouth ventilation Problems with chest compressions Problems with vomiting Problems with rib damage (13) Proposals for improving the education programme: answered by 742 bystanders. Added questions: (14) Did the victim suffer respiratory arrest? Cardiac arrest? Both? (15) Action by the rescuer(s): Alt: Only chest compressions, only mouth-tomouth ventilation, both chest compressions and ventilation. (16) Do you know the cause of the collapse? (17) Was it difficult to check whether the victim had any pulse? Alt: Yes, no, I felt unsure. (18) Did you hesitate about starting CPR because of a fear of AIDS? Alt: Very much, slightly, not at all. (19) Did you feel any resistance about initiating CPR because of any other fact? Alt: Yes, no. If yes, which? (20) How were you treated by the ambulance staff? Alt: Very positively, positively, negatively.

2, A.uelsson

et al. i Resuscitation

?? ( IY9h) .? I I

25-

20-

15-

IO-

5-

o10 119

20 129

30:

39

40 ‘49

50

59

60

79

Veers

Fig. 1. The age distribution

(21) Have you had anyone to talk to about performing CPR? Ah: Yes, no. If yes, who? If no, would you have liked someone to talk to? (22) What is your experience about participating in CPR? Alt: Very positive, positive, negative, very negative (only one choice). (23) Do you think that you were well prepared for the situation by the CPR training? Alt: Yes, no, with hesitation. (24) Have you had any repetition training? Alt: Yes, no. If yes, how many sessions? (25) Are you prepared to start CPR again? Ah: Yes, no, with hesitation. Answered by 425 bystanders. At a later stage, a further alternative was added to the answer to the question about performing CPR (question number 12): ‘No problems’. One further question was also added: (26) Where did you receive your CPR training? Answered by 313 bystanders. -7.3. D@nitions

Bystander: a person who has attempted to perform CPR non-professionally and out-of-hospital. Medical and emergency personnel performing CPR off-duty are bystanders. 2.4. infbrmation

received from hymen

There was no way to verify the cardiac arrest or the

of the bystanders 1~1:= .‘7()).

respiratory arrest. This was information from laymen. There was no information which made it possible to check either the patient or the circumstances. The important thing was that the rescuer had used his knowledge of CPR.

3. Results 3.1. BJ.stcmders. training und loctrtion of attempt

In all, 742 reports were collected, of which 354 were from men and 388 were from women. The age distribution of the bystanders. with a range of If% 76 years, is shown in Fig. 1. Forty-one percent were hospital or ambulance personnel (Table I ). Thirty-seven percent of the bystanders had completed one course in CPR. Twenty-eight percent had attended one repetition or recertification course. Twenty percent had completed 3 ---Scourses and 3% had completed more than five courses. Thirteen percent did not specify how many courses they had completed; they do CPR training regularly due to their work or because they are CPR instructors. Most people had learnt C‘PR ar work or in school (Table 2). Nurses and physicians who had learnt CPR during their education were included as taught at work. Voluntary organisations like the Red Cross were also very important educators. As shown in Table 3, the bystander-initiated CPR most frequently took place in public places such as the street.

6

A. Axe&on et al. i Resuscitation 33 (1996) 3-l 1

Table 1 Occupation of the bystanders

Table 3 Place where CPR occurred (n = 732)

Occupation

n=

Technology, science, social services Health and medical service, social service Of whom (41%): Doctors Nurses, auxiliary nurses Medical students, student nurses Ambulance personnel

%

42

6

339

48

20

3

14 2 1 39 39

2

12 252 14 9

Administration, public finances, skilled office workers Commercial sector Agriculture, forestry, fishing Mining, quarrying, petroleum extraction Transport and communications Manufacturing industry Service sector, etc. Of whom (12%): Firemen Policemen, security officers Bathing attendants, lifeguards


%

In the street At home In the water At a sportsfacility At work Other places”

270 130 71 53 38 170

31 18 9 I 6 23

6 13 68

In 76% of the cases, the collapse was witnessed. In 15% the collapse was unwitnessed and in 9% of the cases the bystander did not know whether the collapse was witnessed or not.

18

3.3. CPR performance

1 2 10

In 48% of the witnessed cases, CPR started within 1 min of collapse. In 34%, it was started after more than 1 min but less than 3 min. This means that, in more than 80% of the witnessed cases, CPR was started by a bystander within 3 min. Fig. 3 shows the duration of bystander CPR. The median duration was 10 min with a range of 1- 180 min.

31 21 21

Total

n

“122 of these were different public places.

124

Unemployed Pensioners Students

Location

707

“Missing information: n = 35.

3.2. Characteristics of and relationship to the victim The gender distribution of the victims was 76% men and 24% women. More than half the victims were aged 60 years or older (Fig. 2). Nine percent of the bystanders were related to the victim, 23% were known to the victim and 68% of the bystanders initiated CPR on an unknown person. The bystanders’ understanding of why the person collapsed is shown in Table 4. As one might expect, heart disease was most frequent, but nearly a quarter of the bystanders did not have any idea of why the victim collapsed. , Table 2 Place where the bystanders had received their CPR training” (n = 438) Location

n

%

Workb School Red Cross Armed service Swedish Life Saving Society Civil Defence Medical services Other organisations

212 125 55 50 21 15 13 45

62 29 13 11 5 3 3 10

“One or more alternatives. bIncludes 113 hospital and ambulance personnel.

3.4. Action Respiratory arrest without cardiac arrest was judged to have occurred in 11% of the cases. Chest compressions without mouth-to-mouth ventilation were performed in 2% of the cases and mouth-tomouth ventilation without chest compressions was performed in 11% of the cases. In this study, 42% of the rescuers reported that they had performed the CPR alone until the arrival of the ambulance and 46% reported that there had been two rescuers helping one another. In the remaining 12% of the cases, there had been more than two rescuers. In 45% of the cases, the victim was reported to have been defibrillated. In terms of outcome, 36% reported that the victim had survived, whereas 51% thought that the victim had died and 13% did not know. 3.5. Technical problems As shown in Table 5, the rescuer most often had problems with mouth-to-mouth ventilation and vomiting. More than half the rescuers experienced CPR without problems. Nineteen percent of the rescuers found it difficult to check whether there was any pulse, whereas 59% did not have any difficulty and 22% felt unsure when they checked the pulse.

k. Axelsson et al. ! Resuscitation 31 (1996) 3 I I

Years Fig. 2. The age distribution of the victims as estimated by the bystander (II = 707)

3.6 Hesitution Ninety-two percent of the bystanders stated that the fear of contracting the AIDS virus had not caused any hesitation. Only 1% of the bystanders stated powerful hesitation. Three percent of the bystanders mentioned thoughts about AIDS after performing CPR. Causesfor hesitation other than AIDS were mentioned in 51 of the cases.There were comments like: disagreeable characteristics; uncertainty as to whether it was a cardiac arrest, or fear of causing injury or doing something wrong; had no ventilation mask; hesitation becauseof the person’s age or the fact that the rescuer found the situation futile. 3.7. Psychological reactions Fifty-nine percent of the rescuers only talked to Table 4 The bystanders’ interpretation of the cause of collapse (n = 596) Interpretation

n”

‘%

267 49 44 17 13 IO 8 3 41 138

45 8 I 3 2 2 1
____--

Heart disease Drowning accident Accident Lung disease Abuse Intoxication or choking Suicide Sudden infant death Other causesb Unknown causes

“Missing information in 146 cases: they were not asked about the cause of the patients’ lifelessness(see Section 2). blncluding stroke.

workmates, friends or close relatives after their intervention (Table 6). It was rare for the rescuer to have some kind of professional debriefing after the event. Thirteen percent had not had anyone to talk to at all and 65O/; of them would have liked someone to talk to about their experiences. In 83% of reports, the rescuer stated that he was positive or very positive about the treatment he received from the ambulance personnel at the scene of the intervention. In 17”/;, of cases the rescuer felt negative. Rating their experience of participating in CPR on a scale ranging from very positive to very negative, 52% regarded their intervention as a very positive experience, 41°K regarded it as positive. 2% as negative and 1% as very negative. Four percent described it as both a positive and a negative experience. As a result, 93% regarded their intervention as a mainly positive experience. Among 425 interviewed rescuers, 99.5% were prepared to start CPR again, whereas 0.5% were uncertain and nobody said no. 3.8. CPR training Eighteen percent thought it was difficult to remember everything from the CPR training, although 94% thought that they were well prepared to deal with the situation. One percent did not feel that they were well prepared. The rest were doubtful. In 245 of the reports, there were notes about improving of the training. There were many different requests, but 49% asked for the chance to repeat the training and

8

d. Axelsson et al. / Resuscitation 33 (1996) 3-l 1

0

o-2

314

516

9-10

11L12

13-14

15116

17-18

19120

21'-

Min

Fig. 3. Distribution of the duration of bystander CPR (n = 640).

10% asked for more practice and longer education. Twenty-six percent wished that everyone could learn CPR. More information about the practical aspects was requested by 13% and more information about natural emotional reactions in these situations was requested by 10%.

4. Discussion Many previous studies have shown that, among patients who suffer out-of-hospital cardiac arrest, the early initiation of CPR by a bystander is associated with an increased chance of survival [6]. The value of early CPR is that it buys time and increases the success rate when advanced cardiac life support (ALCS) is initiated. Previous studies have also shown that it is of the utmost importance that CPR is started within a few minutes of collapse [7]. In the present analysis we found that three of four of bystander-initiated resuscitations were performed in witTable 5 Technical problems involved in resuscitation” (n = 742) Problem Mouth-to-mouth ventilation Vomiting Rib damage Chest compression No problemsb

n

%

146 131

20

66 27 167

9 4 53

18

“One or more alternatives. bOnly 313 were given the alternative ‘no problems’ (see Section 2).

nessed cases and, of these, CPR had started within 3 min of collapse in 80%. Information about how many of the cases were defibrillated is lacking. In fact, not all ambulances were equipped with deflbrillators at the time of evaluation, although at present more than 90% of the ambulance organisations in Sweden have a defibrillator in each ambulance. In terms of bystander occupation, we found that hospital and ambulance personnel constituted a large percentage of the rescuers. Whether these high figures represent the true distribution of rescuers is not known. Previous studies from the USA and Belgium show an even higher proportion of health care workers performing CPR, up to 60% of the bystanders [11,12]. Our definition of a bystander is very close to the definition made in the Utstein report [13]. ,However, they define a second group, ‘professional first responder CPR’, which means CPR by physicians, nurses Table 6 Various persons to whom the bystander had talked (one or more) (n = 344) Persons

n

Workmates or friends” Family Doctor or nurse Ambulance staff CPR instructor Priest or almoner Other personsb

209

61

157 54 26

46 16 8 6 4 16

21 15 55

“Includes nurses who talked to colleagues at work. bIncludes relatives of the patient.

%

A. Axrlsson et ul. ; Resuscitatiotl

and paramedics. In our definition, we include such people in the bystander group if CPR took place when they were off duty. We found that most of the rescuers had learned CPR at work or at school. We believe that, if everyone learnt CPR at school, this could form the basis of more widespread knowledge of CPR in society. Although it is known that the majority of out-ofhospital cardiac arrests take place at home [12,14,15], only 18% of the reported interventions in this study took place at home and less than 10% of the rescuers were related to the victim. This could mean that the idea of educating people in Sweden in CPR has failed to reach the most important group, i.e. the relatives of people with heart disease. The importance of family members learning and being able to perform CPR has already been highlighted in previous studies [16- 191. Although CPR education in school appears to be a good investment, it is also important to find ways of reaching middle-aged and older people. The duration of CPR performance by the bystander varied considerably from a few minutes to 180 min. The explanation for this is that some bystanders accompanied the ambulance to hospital and assisted the ambulance personnel during transportation. In some cases, the transport time was very long due to long distances. Some heroic efforts are made by bystanders who perform CPR for about 30-45 min on their own. However, it must be remembered that these figures are based on estimates by the rescuers. The most frequently reported technical problems experienced by the rescuers were mouth-to-mouth ventilation and vomiting, which are connected with one another. Previous studies have identified vomiting associated with cardiac arrest and CPR in 20-30% of the cases [20,21]. However, a large proportion of rescuers reported no technical problems. This does not necessarily mean that vomiting or rib damage, for example, did not occur, but the rescuer did not experience it as a problem. No pulse is the most important sign in order to verify cardiac arrest. As many as 40% of the rescuers thought it was difficult or felt uncertain about how to evaluate whether a pulse was absent or not. In fact, many rescuers asked for more practice in pulse palpation. A very low proportion of rescuers reported fear about contracting the AIDS virus and it did not even appear to make them hesitate. However, it is important to stress that we are only dealing with people who have started CPR and the true impact of fear about AIDS infection could therefore not be evaluated in the present analysis. Pane et al. asked 891 participants at a mass CPR training event in California whether they would perform CPR on a known AIDS patient. Thirty-two per-

33 (1996) .:! II

(2

cent said yes and 45% said they would perform C‘PR on a suspected AIDS patient 1221. In its guidelines. The American Heart Association (AHA) writes that “the probability of a rescuer’s becoming infected with hepatitis B virus (HBV) or human immunodeficiency virus (HIV) as a result of performing CPR is minimal. To date, transmission of HBV or HIV infection during mouth-to-mouth resuscitation has not been documented”. The AHA also writes that ‘.the rescuer should remember that delayed ventilation could mean death or disablement for an otherwise healthy person, while risk to the rescuer, even with a known HBVIHIV-positive victim, is considered very low” 1231. Most bystanders regarded their encounter with the ambulance personnel at the scene of the intervention as positive. However, the 17% who had N negative experience perhaps indicate that there is a need to make the ambulance personnel aware of the vulnerable position of the bystander. We found that rescuers regarded their intervention as a mainly positive experience. This study is retrospective and the rescuers were approached 1 3 months after the intervention. They had therefore had lime to adjust to the event and their emotional reactions. Perhaps after some time they have found positive aspects about having the courage to intervene .- -‘they tried to help’. If the same questions were asked the day after the intervention, the possibility of different reactions and answers cannot be excluded. Such comments indicate the need for the rescuer to have someone to talk to soon after the event. Such a requirement is obvious and the majority of rescuers who did not have anyone to talk to felt it was lacking. Most of the rescuers only had a friend, a workmate or someone in the Family to talk to, thereby leaving mimy questions unanswered. In this case, the emergency medical service system has the opportunity to make a great effort in order simply to be available ior the rescuer to answer questions about the event. We bellece rhat some kind of organised system to take care of rescuers is essential. Having someone to talk to is important when trying to understand, adapt and move on In this evaluation, CPR training in Sweden received good reports from the rescuers. Almost everyone thought that they were well prepared to deal with the situation. However, this does not rnertn ?hat it is not possible to improve the system. There is a need to make repeat courses more easily avail;tble. The retention of CPR skills is poor and the objective need for repetition and recertification is Woolf documented [10.24]. There is also a need to inform potential rescuers about the practical aspects of CPR. What is the natural reaction in this situation? How many victims survive’? How does the victim look’? What are the problems when it comes to vomiting, etc.? Adequate knowledge

10

d. Axelsson et al. 1Resuscitation 33 (1996) 3-11

and preparation can decrease hesitation or resistance to act, thereby saving precious seconds prior to CPR initiation.

[4]

5. Limitations [5]

We do not know whether the participants in this study represent the whole bystander population in Sweden, as they constitutes less than 10% of the bystanders. The way the reports were collected could produce an uneven recruitment. The fact that the bystanders have chosen to send in the report card, as well as the contact through the phone interview, may have influenced the result. Questions were added during the study, although this has been taken into consideration during the analysis. The present study only contains the experiences of people who have performed CPR and cannot answer any questions about those people who have witnessed a cardiac arrest but have not initiated CPR.

[6]

[7]

[8]

[9]

[lo]

6. Conclusions In this study of people who have performed CPR, we found that the rescuers rarely hesitated about initiating CPR. Technical problems were common but do not appear to have had a great impact on the bystanders. The fear of AIDS was virtually non-existent. Less than 10% of the rescuers were related to the victim, which indicates that relatives of heart patients should be encouraged to follow CPR training. There was a large request for retraining, which points to the need to make repeat courses more available. Over 90% regarded their intervention as mainly positive. Almost everybody was prepared to start CPR again.

[ll]

[12]

[13]

[14]

Acknowledgements [15]

This study was supported by grants from the Leardal Foundation for Acute Medicine.

References [l] Cobb LA, Werner JA, Trobaugh GB. Sudden cardiac death: I. A decade’s experience with out-of-hospital resuscitation. Mod Concepts Cardiovasc Dis 1980; 49: 31-36. [2] Weaver W, Cobb LA, Hallstrom AP, Copass MK, Ray R, Emery M, Fahrenbruch C. Considerations for improving survival from out-of-hospital cardiac arrest. Ann Emerg Med 1986; 15: 1181-1186. [3] Ekstrijm L, Herlitz J, Wennerblom B, Axelsson A, Bang A, Holmberg S. Survival after cardiac arrest outside hospital

[16]

[17]

[18]

[19]

over a 1Zyear period in Gothenburg. Resuscitation 1994; 27: 181-187. Cummins RO, Ornato JP, Thies WH, Pepe PE, The Advanced Cardiac Life Support Committee and the Emergency Cardiac Care Committee, American Heart Association. Improving survival from cardiac arrest: the ‘chain of survival concept. Circulation 1991; 83: 1832-1847. White BC, Wiegenstein JG, Winegar CD. Brain ischemic anoxia: mechanism of injury. J Am Med Assoc 1984; 251: 1586-1590. Cummins RO, Eisenberg MS. Prehospital cardiopulmonary resuscitation. Is it effective? J Am Med Assoc 1985; 253 (16): 2408-2412. Cummins RO, Eisenberg MS, Hallstrom AP, Litwin PE. Survival of out-of-hospital cardiac arrest with early initiation of cardiopulmonary resuscitation. Am J Emerg Med 1985; 3: 114-119. Ritter G, Wolfe RA, Goldstein S, Landis JR, Vasu CM, Acheson A, Leighton R, Medendrop SV. The effect of bystander CPR on survival of out-of-hospital cardiac arrest victims. Am Heart J 1985; 110: 932-937. Herlitz J, Ekstriim L, Wennerblom B, Axelsson A, Bang A, Holmberg S. Effect of bystander initiated cardiopulmonary resuscitation on ventricular fibrillation and survival after witnessed cardiac arrest outside hospital. Br Heart J 1994; 72: 408-412. Cobb LA, Hallstrom AP. Community-based cardiopulmonary resuscitation: what have we learned? Ann NY Acad Sci 1982; 382: 330-342. Murphy RJ, Luepker RV, Jacobs Jr DR, Gillum RF, Folsom AR, Blackburn H. Citizen cardiopulmonary resuscitation training and use in a metropolitan area: the Minnesota Heart Survey. Am J Public Health 1984; 74 (5): 513-515. Bossaert L, van Hoeyweghen R. Bystander cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest. The cerebral resuscitation study group. Resuscitation 1989; 17 (Suppl): S55-S69. Cummins RO, Chamberlain DA, Abrahamson NS, Allen M, Baskett PJ, Becker L, Bossaert L, Delooz HH, Dick WF, Eisenberg MS. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein style. A statement for health professionals from a task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke foundation of Canada, and the Australian Resuscitation Council. Circulation 1991; 84 (2): 960-975. Litwin PE, Eisenberg MS, Hallstrom AP, Cummins RO. The location of collapse and its effect on survival from cardiac arrest. Ann Emerg Med 1987; 16 (7): 787-791. Scott IA, Fitzgerald GJ. Early defibrillation in out-of-hospital sudden cardiac death: an Australian experience. Arch Emerg Med 1993; 10 (1): 1-7. Goldberg JR, Gore JM, Love DG, Ockene JK, Dalen JE. Layperson CPR - are we training the right people? Ann Emerg Med 1984; 13: 701-703. Dracup K, Moser Heaney D, Taylor SE, Guzy PM, Breu C. Can family members of high-risk cardiac patients learn cardiopulmonary resuscitation? Arch Intern Med 1989; 149 (1): 61-64. Dracup K, Moser Heaney D, Guzy PM, Taylor SE, Mardsen C. Is cardiopulmonary resuscitation training deleterious for family members of cardiac patients? Am J Public Health 1994; 84 (1): 1166118. Sigsbee M, Geden EA. Effects of anxiety on family members of patients with cardiac disease learning cardiopulmonary resuscitation. Heart Lung 1990, 19 (16): 662-665.

[20] MC Cormack AP, Damon S, Eisenberg MS Disagreeable characteristics affecting bystander CPR. Ann Emerg Med 1989; 18: 2833285. [‘I] Kirscher JP, Fine EC. Davis JH. Nagel EL. Complications of cardiac resuscitation. Chest 1987: 92 (2): 2877291. [ZZ] Pane GA. Salness KA. Survey of participants in a mass CPR training course. Ann Emerg Med 1987: 16 (10): 1112. 1116.

[23] The Emergency Cardiac Care Committee of the American Heart Association. Risk of infection during CPR training and rescue: supplemental guidelines. Respir (‘are 1990: 35 (I): 114-~ll5. [24] Moser Heaney D. Coleman S. Recommendations for improving cardiopulmonary resuscitation skills re!ention. Heart Lung 1992: 21: 372 380.