Article

Public knowledge and perceptions about cardiopulmonary resuscitation (CPR): Results of a multicenter survey

1900 Correspondence / American Journal of Emergency Medicine 36 (2018) 18951921

M. Zouari, MD

H. Louati, MD

A.K. Ben Abdalah, MD

H. Ben Ameur, MD

M. Jallouli, MD

R. Mhiri MD

R. Mhiri MDDepartment of Pediatric Surgery, Hedi-Chaker Hospital, 3029

Sfax, Tunisia E-mail address: [email protected].

https://doi.org/10.1016/j.ajem.2018.01.102

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    Public knowledge and perceptions about cardiopulmonary resuscitation (CPR): Results of a multicenter survey

    Out-of-hospital cardiac arrest (OHCA) is a leading cause of death in the United States with an incidence of N350,000 cases reported in 2016 [1]. With N70% of arrests occurring at patients’ homes, knowl- edge and performance of quality cardiopulmonary resuscitation (CPR) by bystanders, prior to the arrival of paramedics, can improve the odds of survival [2]. Patients, caregivers, and family may often struggle with decisions about whether or not to undertake CPR and other potentially life-sustaining treatment. It has been reported that for cardiac arrest patients, there is an average survival rate to hospital discharge of approximately 10.6% [3]. Favorable outcomes for patients suffering from arrest are influenced by many factors in- cluding time elapsed since arrest, initial rhythm, and long-term care [4]. Previous studies have found that lay persons often vastly overestimate the survival and recovery rates of patients to whom CPR is administered [4,5]. The decision to initiate or continue CPR is often not a straight-forward one and may be influenced by infor- mation garnered from personal experience, public media, the inter- net, or friends and family. The purpose of this study was to survey 1000 adult volunteers to determine perceptions about CPR, includ- ing the likelihood of survival and the patient making a Complete recovery.

    Cross-sectional prospective surveys were conducted at four academic medical centers (including a children’s hospital) during a two-month study period. A validated, written questionnaire was administered by trained researchers to a convenience sample of non-critically ill patients and/or their families during randomly selectED shifts. Requested information included demographics, sources of information regarding CPR, and four anchoring vignettes.

    vignettes with age, education, income level, and the frequency of media exposure.

    Among 1000 participants, the mean age was 43 years (range 18 to 87 years), 63% were female, and 65% reported Household incomes of more than $30,000. Thirty-nine percent had provisions for a Living will. Personal medical training was cited most often as a primary source of information concerning CPR (68%), followed by television (39%), per- sonal experience (21%), internet (9%), and friends or family with medi- cal training (7%). The majority of respondents (71%) watched television medical dramas on a regular basis; 12% felt these programs were a reli- able source of health information.

    In one CPR vignette, participants consistently overestimated the success rate of CPR (72% predicted postcardiac survival) as well as long-term outcome (65% predicted a complete neurological recovery) in a 54-year-old who suffered a heart attack at home and required CPR by paramedics. Respondents also overestimated the success rate of CPR (57% predicted survival) as well as long-term outcome (53% predicted a complete neurological recovery) in a 80- year-old who suffered a cardiac arrest in the hospital after surgery. In the vignette describing a traumatic arrest in an 8-year-old, the success rate of CPR was estimated at 71%; long-term survival was predicted to be 64%. Bivariate correlations analysis showed signifi- cant correlation between the number of correct responses and educational level (r = 0.311, p b 0.001).

    The majority of people in our study overestimated the chances of survival as well as neurological recovery following CPR. This is reflected in previous studies which have shown that the majority (72%) of lay persons estimate the chance of survival after CPR was

    >=75% [6]. Unrealistic expectations places an extra burden on emergency clinicians as they must discuss decisions about the end of life with patients and family who will most likely be misinformed about probable outcomes. This misinformation may lead them to choose to undergo resuscitation in situations in which survival is extremely unlikely. It has previously been found that half of a sample of elderly patients who initially opted for CPR changed their mind after learning the true Probability of survival [7]. Informing the public about the scarceness of positive outcomes may influence people to put Advance directives in place, or to discuss with family members the usefulness of a “do-not-resuscitate” order. Tempering the unrealistic expectations of the public will allow for well-informED decision making and may lessen the burden on healthcare providers, especially those in the pre-hospital realm and emergency department.

    Lindsey Ouellette, MPH1 Michigan State University College of Human Medicine, Department of Emergency Medicine, Grand Rapids, MI, United States

    Amanda Puro, MD2 Michigan State University College of Human Medicine, Department of Emergency Medicine, Grand Rapids, MI, United States Department of Emergency Medicine, Spectrum Health Hospitals, Grand

    Rapids, MI, United States

    Jeffrey Weatherhead, MD3

    Michigan State University College of Human Medicine, Department of

    The vignettes asked respondents to estimate the chance of recovery

    (using visual analog scales) following cardiopulmonary arrest in pediatric and elderly patients, in both prehospital and in-hospital scenarios. Bivariate Pearson’s correlations were performed to assess the association between the number of correct answers to the

    1 15 Michigan St NE 736, Grand Rapids, MI 49503, United States.

    2 Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E Chicago Ave, Chicago, IL

    60611, United States.

    3 C.S. Mott Children’s Hospital, 1540 E Hospital Dr., Ann Arbor, MI 48109, United States.

    Correspondence / American Journal of Emergency Medicine 36 (2018) 18951921 1901

    Emergency Medicine, Grand Rapids, MI, United States Department of Emergency Medicine, Spectrum Health Hospitals, Grand

    Rapids, MI, United States

    Michael Shaheen, MD4 Michigan State University College of Human Medicine, Department of Emergency Medicine, Grand Rapids, MI, United States Department of Emergency Medicine, Spectrum Health Hospitals, Grand

    Rapids, MI, United States

    Todd Chassee, MD5 Michigan State University College of Human Medicine, Department of Emergency Medicine, Grand Rapids, MI, United States Department of Emergency Medicine, Spectrum Health Hospitals, Grand

    Rapids, MI, United States

    David Whalen, MD6

    Mercy Health St. Mary’s, Grand Rapids, MI, United States

    Jeffrey Jones, MD Michigan State University College of Human Medicine, Department of Emergency Medicine, Grand Rapids, MI, United States Department of Emergency Medicine, Spectrum Health Hospitals, Grand

    Rapids, MI, United States

    Corresponding author at: 15Michigan St NE Suite 701, Grand Rapids, MI

    49503, United States.

    E-mail address: [email protected].

    https://doi.org/10.1016/j.ajem.2018.01.103

    References

    American Heart Association. CPR & first aid: emergency cardiovascular care. http:// cpr.heart.org/AHAECC/CPRAndECC/General/UCM_477263_Cardiac-Arrest-Statistics. jsp; 2017, Accessed date: 1 April 2018.

  5. American Heart Association. CPR facts and stats. http://cpr.heart.org/AHAECC/ CPRAndECC/AboutCPRFirstAid/CPRFactsAndStats/UCM_475748_CPR-Facts-and- Stats.jsp; 2017, Accessed date: 1 April 2018.
  6. Sudden Cardiac Arrest Foundation. AHA releases 2015 heart and stroke statistics. http://www.sca-aware.org/sca-news/aha-releases-2015-heart-and-stroke-statistics; 2014, Accessed date: 1 November 2018.
  7. Marco CA, Larkin GL. Cardiopulmonary resuscitation: knowledge and opinions among the U.S. general public. State of the science-fiction. Resuscitation 2008;79:490-8.
  8. Jones GK, Brewer KL, Garrison HG. Public expectations of survival following cardio- pulmonary resuscitation. Acad Emerg Med 2000;7(1):48-53.
  9. Shif Y, Doshi P, Almoosa KF. What CPR means to surrogate decision makers of ICU pa-

    tients. Resuscitation 2015;90:73-8.

    Murphy DJ, Burrows D, Santilli S, et al. The influence of the probability of survival on patients’ preferences regarding cardiopulmonary resuscitation. N Engl J Med 1994; 330:545-9.

    4 Kaiser Permanente, San Diego Medical Center, 4647 Zion Ave., San Diego, CA 92120, United States.

    5 15 Michigan St NE Suite 701, Grand Rapids, MI 49503, United States.

    6 200 Jefferson Ave SE, Grand Rapids, MI 49503, United States.

    Ventricular fibrillation in conscious patients witnessed by the emergency medical service

    Dear Sir:

    Current Resuscitation guidelines endorse a simple evaluation to rec- ognize cardiac arrest; an unconscious and not normally breathing vic- tim. This simple algorithm may not completely align with the physiological reality of cardiac arrest . Some studies state that dur- ing the first minute of a witnessed ventricular fibrillation (VF) breathing patterns could remain normal. Likewise, the level of consciousness could be maintained for a Short period of time, which contradicts the current guidelines.

    Statement of the problem

    Over the last twenty years the Advanced Life Support Emergency Medical team FPUS 061 from Lugo (population 97,995), headed by a physician, have reported 2 cases of witnessed VF in conscious patients, respectively 68 and 85 years of age. The patients were conversant and completely awake and refused to receive chest compressions when the team tried to deliver them. Afterwards, both patients were immedi- ately defibrillated and an organized rhythm (sinus) was restored with the return of spontaneous circulation (ROSC). Both remained conscious throughout the process and were transferred to Primary PCI, which re- vealed a 100% obstruction of the infarct-related artery.

    Due to the uniqueness of these cases, a search was conducted on the Medline database, resulting in the discovery of 5 in-hospital CA reports (Table 1) describing 10 patients presenting VF while remaining awake. The longest period of consciousness reported was 92 s sustained by rhythmic coughing (Cough CPR) in a cardiac catheterization laboratory. In July 2017, a survey was e-mailed to all Advanced life support providers in the EMS 061-Galicia (Spain) inquiring if at any time during their professional career they had ever assessed a victim as re- sponsive (completely conscious) and normally breathing with the ECG rhythm on the monitor changing from an organized rhythm to a VF. 15 out of 22 (53%) practitioners (10 physicians and 5 nurses) answered positively, reporting a total of over 30 cases. As monitoring the heart rhythm is considered a standard part of ALS in all STEMI patients, VFs

    were immediately detected.

    The participants were also offered the chance to share their experi- ences. 9 detailed episodes, 8 OHCA and 1 IHCA were reported. Initially, this unique situation led to diagnostical doubts, the patients were re- sponsive enough to deter resuscitation. 2 cases were initially interpreted as Polymorphic ventricular tachycardia (Torsades de pointes), but they were pulseless.

    What should be done in these cases?

    The Guidelines highlight the importance of immediate defibrilla- tion, which was considered. However, it is painful when used on a conscious patient. A broad list of opiates and Sedative agents (fenta- nyl, midazolam, etomidate, ketamine, propofol) were available to the EMS team, but because the patients were pulseless the adminis- tration through a peripheral venous was not effective. Two alterna- tives remained; wait for the patient to become unconscious (the team could not know how long consciousness would last) or defibril- late a conscious patient. Most patients were immediately defibrillated and the maximum waiting time was 50 s. After defibril- lation some patients lost confidence in the medical team (it is report- ed that one patient was quite frightened and tried to escape from the emergency department after using the paddles). The effects of the sedative agents were visible after the ROSC, and helped to calm the patients. However, in two cases advanced airway management was required due to excessive sedation effects.

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