Kids save lives - Training School Children in CPR Worldwide

“Anyone, anywhere, can now initiate cardiac resuscitative procedures. All that is needed is two hands“. This revolutionary statement was already formulated in 1960 by Jude, Kouwenhoven and Knickerbocker [1]. Introduced more than 50 years ago we know nowadays that resuscitation is simple, cheap and can be done by almost anyone, potentially saving thousands of lives per year. Following this notion, lay cardiopulmonary resuscitation (CPR) should have already been established widely in public. But what is the current reality? Out of hospital cardiac arrest (OHCA) is still one of the leading causes of death worldwide and bystander resuscitation is not generally delivered. Only every third to fifth patient suffering from cardiac arrest receives bystander CPR [2]. In this context, even simple measures can improve survival after OHCA more than twofold and everybody can learn it – even kids. If we want to reduce the number of deaths from cardiac arrest dramatically and save hundreds or even thousands of lives every year, let us pronounce our knowledge about CPR! What could be better than begin this tuition even in children – our future? The best way is to establish resuscitation training in the curriculum of schools. Let "Kids Save Lives" [3]!

Epidemiology of out of hospital cardiac arrest and survival

In the United States more than 300,000 people suffer from sudden cardiac arrest annually, and this number is consistently high in the last few decades [4][5]. Current extrapolations reported even up to 600,000 deaths per year in the United States attributed to cardiac arrest [6][7]. This corresponds to approximately 1.5 cases per 1000 person years [7]. Altogether cardiac arrest is the 3rd most frequent cause of death, thus becoming a global public health issue, equivalent to cancer, HIV and Malaria with nearly 2,000 deaths per day worldwide [8][9]! Though cardiac arrest is common, this does not apply for survival after cardiac arrest: Even if cardiac arrest occurs in hospitals, less than a quarter of affected patients survive – in the case of public cardiac arrest survival is much worse; in average less than 6% of patients survive [7].

Effects of training on bystander CPR and survival – No CPR without training!

In the United States more than 300,000 people suffer from sudden cardiac arrest annually, and this number is consistently high in the last few decades [4][5]. Current extrapolations reported even up to 600,000 deaths per year in the United States attributed to cardiac arrest [6][7]. This corresponds to approximately 1.5 cases per 1000 person years [7]. Altogether cardiac arrest is the 3rd most frequent cause of death, thus becoming a global public health issue, equivalent to cancer, HIV and Malaria with nearly 2,000 deaths per day worldwide [8][9]! Though cardiac arrest is common, this does not apply for survival after cardiac arrest: Even if cardiac arrest occurs in hospitals, less than a quarter of affected patients survive – in the case of public cardiac arrest survival is much worse; in average less than 6% of patients survive [7].

Effects of training on bystander CPR and survival – No CPR without training!

Resuscitation is easy and saves lives. Nevertheless, the incidence of bystander CPR (individuals present at cardiac arrest) is often low and in many countries less than 50% [2]. For example, in Europe, known to be a patchwork of 47 states, there is an inhomogeneous distribution in rates of bystander CPR ranging from 6 to over 70 % [2]. Various reasons, e.g. feelings of helplessness and fear to do something wrong, may be responsible for the dramatic differences in the incidence of bystander CPR between the countries of Europe, as illustrated in Table 1.


Table 1: Teaching lay resuscitation means to be responsible for fears and anxieties of the participants of CPR training. The table shows examples of these fears. These anxieties and fears may be the reasons why bystander resuscitation is not performed.

One of the main preconditions for bystander performed CPR is that bystanders previously have participated in a CPR training – without training, it is unlikely that resuscitation is initiated. Without training, only 4.8% of bystanders initiated CPR in the case of cardiac arrest. In contrast, this rate is substantially higher (35.1%) when a training has been completed (Figure 1) [10]. Despite training not all bystander initiate CPR: Swor et al. identified reasons, why CPR-trained bystanders (N=279) do not initiate CPR: The most frequently used argument was that they were panicking (38.7%), that they were afraid of performing CPR incorrectly (10.8%) or potentially harm the patient (1.8%) [10]. Surprisingly only a small fraction of respondents did not perform CPR because of mouth-to-mouth ventilation (1.4%) and no one because of concerns about infectious diseases [10]. In this context, the available data suggest that one single training session is not enough to initiate live long resuscitation competency. Therefore, repetitive training should take place at least every 12-24 months [11]. In conclusion, it can be stated that there will be no CPR without training. In addition, teaching lay resuscitation means to be responsible for fears and anxieties of the participants of CPR training (Table 1). These anxieties and fears may be the reason why bystander resuscitation is not performed and, further, it can be assumed that the rate of bystander CPR can be increased by addressing feelings and concerns of bystanders.

But does bystander CPR affect survival? Yes! Already in 1999 Böttiger et al. reported that patients had a significantly higher survival after cardiac arrest if CPR was initiated by bystanders: One-year survival after bystander-initiated CPR was 15.9% (n = 88) compared to 10.4% in patients without bystander CPR (n = 250; p = 0.09) – this corresponds to an approximately 1.5-fold increase in survival through bystander CPR [12]! How can this be explained? It is generally known that survival of human cells depends on oxygen supply. The critical organ in cardiac arrest is the brain – few minutes after cardiac arrest irreversible cell damage occurs (Figure 2). It is an illusion to speculate that within this period a professional resuscitation by Emergency Medical Services (EMS) is initiated. In fact, it is this period, which is decisive for survival and neurological outcome, and both, survival and neurological outcome, crucially depend on bystander initiated CPR [13][14][16]. Through an early start of bystander-initiated CPR, the time frame until occurrence of irreversible brain damage may be extended and thus bridge the time until arrival of EMS.

In a recent publication Hasselquist-Ax et al. reported on the experience of bystander CPR in Sweden by evaluating the Swedish Cardiac Arrest Registry, which included more than 90% of all persons who had an out of hospital cardiac arrest from January 1, 1990, through December 31, 2011 and 30,381 witnessed OHCA were examined. In Sweden, a country with 10 million inhabitants, to now almost three million citizens are trained in CPR [13]. Initiation of bystander CPR before the arrival of EMS was associated with a more than 2 times higher survival (odds ratio 2.15 for higher 30-day survival rate; 95% confidence interval, 1.88 to 2.45) [13]. Figure 3 shows the number of those who participated CPR training in Sweden since 1990. Notably, the cases of bystander CPR strictly follows the number of persons who completed a CPR training – without the development of a plateau!
The effect of bystander CPR on survival and neurological outcome was repeatedly demonstrated in recent studies and in average, survival increased two to three times [13][15][16][17]. For the United States this means saving more than 100,000 lives a year!

Considerations regarding CPR training in schools – Let "Kids Save Lives"!
As illustrated by the example of Sweden above, survival after cardiac arrest crucially depends on the proportion of CPR-trained individuals in a population. Therefore, it is the logical consequence to integrate CPR training in the curriculum of schools and thus increase the proportion of CPR-trained individuals in a population over time [3]. Meanwhile, there are many publications on teaching children in CPR and table 2 summarizes the current knowledge. Briefly, an age of 12 years is optimal for the start of CPR training and 2 hours tuition each year are enough [3].

Recently the statement ”Kids save lives – Training school children in cardiopulmonary resuscitation worldwide“ was published by the European Patient Safety Foundation (EuPSF), the European Resuscitation Council (ERC), the International Liaison Committee on Resuscitation (ILCOR) and the World Federation of Societies of Anesthesiologists (WFSA) (Read the “Kids save lives”-statement, written by Hugo K.Van Aken and Bernd W. Böttiger, at the end of this text). Fortunately, this statement was endorsed by the World Health Organization (WHO) in Geneva on Jan 20th, 2015.
Meanwhile, it is encouraging that more and more countries begin to integrate CPR lessons in their curricula. In Germany, for example, the ministers of education of the 16 German states decided that CPR training in schools should become mandatory for pupils beginning in 2015.

Also in the United States, more and more states add CPR training into the curricula of schools and even make it prerequisite for high school graduation (Figure 4).
In summary, it is now a great opportunity, challenge and obligation for all countries around the world to implement school children training in CPR worldwide. This will help to save thousands of lives worldwide! Let "Kids Save Lives".


Table 2: What we already know about teaching kids in cardiopulmonary resuscitation (CPR) [3].

Reproduction of the “kids save lives” statement endorsed by the World Health Organisation [3]:

This statement highlights the importance of teaching CPR to all school children around the globe. The document reinforces the effect that early CPR can have on survival outcomes following sudden cardiac arrest (SCA), an issue that causes 2,000 deaths worldwide every day. By introducing just two hours of CPR teaching per year for all children over 12, the WHO believes that SCA survival rates would improve and in turn lead to improved global health.

Literature

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