Background Dispatcher assistance can help to save lives during layperson cardiopulmonary resuscitation during cardiac arrest. The aim of this study was to investigate the influence of different camera positions on the evaluation of cardiopulmonary resuscitation performance during video-assisted cardiopulmonary resuscitation. Methods For this randomized, controlled simulation trial, seven video sequences of cardiopulmonary resuscitation performance were recorded from three different camera positions: side, foot and head position. Video sequences showed either correct cardiopulmonary resuscitation performance or one of the six typical errors: low and high compression rate, superficial and increased compression depth, wrong hand position or incomplete release. Video sequences with different cardiopulmonary resuscitation performances and camera positions were randomly combined such that each evaluator was presented seven individual combinations of cardiopulmonary resuscitation and camera position and evaluated each cardiopulmonary resuscitation performance once. A total of 46 paramedics and 47 emergency physicians evaluated seven video sequences of cardiopulmonary resuscitation performance from different camera positions. The primary hypothesis was that there are differences in accuracy of correct assessment/error recognition depending on camera perspective. Generalized linear multi-level analyses assuming a binomial distribution and a logit link were employed to account for the dependency between each evaluator's seven ratings. Results Of 651 video sequences, cardiopulmonary resuscitation performance was evaluable in 96.8% and correctly evaluated in 74.5% over all camera positions. Cardiopulmonary resuscitation performance was classified correctly from a side perspective in 81.3%, from a foot perspective in 68.8% and from a head perspective in 73.6%, revealing a significant difference in error recognition depending on the camera perspective (p = .01). Correct cardiopulmonary resuscitation was mistakenly evaluated to be false in 46.2% over all perspectives. Conclusions Participants were able to recognize significantly more mistakes when the camera was located on the opposite side of the cardiopulmonary resuscitation provider. Foot position should be avoided in order to enable the dispatcher the best possible view to evaluating cardiopulmonary resuscitation quality.

Background: Video assisted cardiopulmonary resuscitation (V-CPR) has demonstrated to be efficient in improving CPR quality and patient outcomes, as Emergency Medical Service (EMS) dispatchers can use the video stream of a caller for diagnostic purposes and give instructions in a CPR scenario. However, the new challenges faced by EMS dispatchers during video-guided CPR (V-CPR)-such as analyzing the video stream, providing feedback to the caller, and managing stress-demand innovative solutions. This study explores the feasibility of incorporating an open-source "machine-learning" tool (artificial intelligence - AI), to evaluate the feasibility and accuracy in correctly detecting the actual compression frequency and compression depth in video footage of a simulated CPR. Design: MediaPipe Pose Landmark Detection (Google LLC, Mountain View, CA, USA), an open-source AI software using "machine-learning" models to detect human bodies in images and videos, was programmed to assess compression frequency an depth in nine videos, showing CPR on a resuscitation manikin. Compression frequency and depth were assessed from compression to compression with AI software and were compared to the manikin's internal software (QCPR, Laerdal, Stavanger, Norway). After testing for Gaussian distribution, means of nongaussian data were compared using Wilcoxon matched-pairs signed rank test and the Bland Altman method. Main results: MediaPipe Pose Landmark Detection successfully identified and tracked the person performing CPR in all nine video sequences. There were high levels of agreement between compression frequencies derived from AI and manikin's software. However, the precision of compression depth showed major inaccuracies and was overall not accurate. Conclusions: This feasibility study demonstrates the potential of open-source "machine-learning" tools in providing real-time feedback on V-CPR video sequences. In this pilot study, an open-source landmark detection AI software was able to assess CPR compression frequency with high agreement to actual frequency derived from the CPR manikin. For compression depth, its performance was not accurate, suggesting the need for adjustment. Since the software used is currently not intended for medical use, further development is necessary before the technology can be evaluated in real CPR.

Background: Several studies have demonstrated that video assisted cardiopulmonary resuscitation (V-CPR) is efficient in improving cardiopulmonary resuscitation (CPR) quality and patient outcome. However, currently the technique depends on 911 dispatchers who evaluate the video footage and may thus be subject to inter-operator variations. Research Question: We hypothesized that using an open-source machine learning supported software (“artificial intelligence” – AI) would be able to provide real-time feedback on CPR frequency in a video of CPR. Aims: To evaluate the feasibility and accuracy of a selected AI software to correctly detect the actual compression frequency in video footage of CPR performed in a CPR manikin. Methods: MediaPipe Pose Landmark Detection (Google LLC, Mountain View, CA, USA), an open-source AI software using machine-learning models to detect human body postures in images and videos, was programmed to assess compression frequency of nine videos showing CPR on a manikin, each with a different fixed compression frequency and compression depth. Camera angle and distance were standardized. Frequency was assessed from compression to compression with AI software and the manikin’s internal software (QCPR, Laerdal, Stavanger, Norway). After testing for Gaussian distribution, means were compared using Wilcoxon matched-pairs signed rank test. Results: There were high levels of agreement between compression frequencies derived from AI and manikin’s software (Statistic comparisons are presented in Figure 1, correlations of measurements are presented in Figure 2 ). Conclusions: In this pilot study, an open-source landmark detection AI software was able to assess CPR compression frequency with high agreement to actual frequency derived from a CPR manikin. Since the software used is currently not intended for medical use, further development is necessary before the technology can be evaluated for real-life CPR.

In this model of massive gastric aspiration, we compared two different laryngoscopes (VieScope and Macintosh) in a randomized, controlled simulation study. The primary endpoint was time to intubation; the secondary endpoints were intubation success (i.e., tracheal tube position) and amount of pulmonary aspiration. Thirty-four anesthetists performed endotracheal intubation using VieScope and Macintosh laryngoscopy in a randomized order on an airway manikin simulating massive regurgitation of gastric fluid. The primary endpoint “time until intubation” could be achieved significantly faster (mean −12.4 s [95% confidence intervals (CI) −19.7 s; −7.3 s]) with Macintosh compared to VieScope (p < 0.001). Concerning “correct tube position”, no statistical difference was found between the devices (p = 1.0). The mean time to first ventilation was −11.1 s [95% CI −18.3 s; −5.3 s] when using Macintosh (p = 0.001). The mean volume of aspirated gastric fluid was lower in the Macintosh group: −90.0 mL [95% CI −235.0 mL; −27.5 mL] (p = 0.011). Data from this simulation study suggest that in a model of massive gastric regurgitation, airway management can be achieved faster and with less gastric aspiration when using a Macintosh laryngoscope compared to a VieScope laryngoscope.

Introduction: Video-assisted cardiopulmonary resuscitation (V-CPR) describes an advanced telephone-assisted CPR (T-CPR), in which emergency medical service (EMS) dispatchers view a live video steam of the resuscitation. Dispatchers ’ general attitudes toward and self-assessment in V-CPR have not been previously investigated. Material and Methods: We conducted this quantitative analysis along with a pilot study on V-CPR. After conducting V-CPR with laypersons in a simulation, EMS dispatchers were given questionnaires with 21 items concerning their personal attitude toward V-CPR and their self-assessment in providing instructions. The actual CPR performance achieved was recorded and compared to the dispatchers’ self-assessments. Results: Dispatchers completed 49 questionnaires, and the data is presented descriptively. Over 80% strongly agreed that V-CPR was helpful in guiding and that their feedback improved CPR quality. Fifty-one percent agreed that video images supported them in making a diagnosis, while 44.9% disagreed. A vast majority (80-90% each) strongly agreed that V-CPR helped them recognize CPR issues such as compression point, compression rate, and deterioration. In contrast, data for improved compression depth and release were weaker. Thirty percent found V-CPR to be more stressful or exhausting than T-CPR. A majority stated they would prefer V-CPR as an addition to T-CPR in the future. There was a huge gap between dispatchers’ own view of CPR effort and measured CPR quality. Conclusion: Dispatchers generally embrace V-CPR and praise the abilities it provides. Our results indicate that the use of V-CPR did not automatically result in an overall improvement in guideline-compliant CPR quality.

Oxygen application and apneic oxygenation may reduce the risk of hypoxemia due to apnea during awake fiberoptic intubation or failed endotracheal intubation. High flow devices are recommended, but their effect compared to moderate deep oropharyngeal oxygen application is unknown. Designed as an experimental manikin trial, we made a comparison between oxygen application via nasal prongs at 10 L/min (control group), applying oxygen via oropharyngeal oxygenation device (at 10 L/min), oxygen application via high flow nasal oxygen with 20 L/min and 90% oxygen (20 L/90% group), oxygen application via high flow nasal oxygen with 60 L/min and 45% oxygen (60 L/45% group), and oxygen application via sealed face mask with a special adapter to allow for fiberoptic entering of the airway. We preoxygenated the lung of a manikin and measured the decrease in oxygen level during the following 20 minutes for each way of oxygen application. Oxygen levels fell from 97 ± 1% at baseline to 75 ± 1% in control group, and to 86 ± 1% in oropharyngeal oxygenation device group. In the high flow nasal oxygen group, oxygen level dropped to 72 ± 1% in the 20 L/90% group and to 44 ± 1% in the 60 L/45% group. Oxygen level remained at 98 ± 0% in the face mask group. In conclusion, in this manikin simulation study of apneic oxygenation, oxygen insufflation using a sealed face mask kept oxygen levels in the test lung at 98% over 20 minutes, oral oxygenation device led to oxygen levels at 86%, whereas all other methods resulted in the decrease of oxygen levels below 75%.

Purpose Aspiration is a feared complication that may occur during airway management, and can significantly contribute to morbidity and mortality. Availability of a suctioning device with a suction catheter capable of clearing the airway is mandatory for airway management. However, suction performance may be significantly different amongst different suction catheters. The aim of this study was to compare suction rates of a standard 14 Ch suction catheter (SC), a Yankauer catheter (Y) and a DuCanto catheter (DC) using 4 fluids with different viscosity. Methods In this simulation trial, 4 preparations with standardized viscosity were prepared using a Xanthane-based medical fluid thickener. Lowest viscosity was achieved using tap water without thickener, syrup-like viscosity was achieved by adding 10 g per liter tap water, honey-like viscosity was achieved by adding 20 g per liter, and a pudding-like viscosity was achieved by adding 30 g of thickening powder per liter tap water. Each preparation was suctioned for 15 s with the three different suctioning devices. Measurements were repeated four times. The amount of removed preparation by suctioning was measured using a tared scale. Results Suction rates for water were 580 ± 34 mg for SC, 888 ± 5 mg for Y and 1087 ± 15 for DC; for syrup-like viscosity it was 383 ± 34(SC) vs. 661 ± 64(Y) vs. 935 ± 42(DC); for honey-like viscosity it was 191 ± 21(SC) vs. 426 ± 34(Y) vs. 590 ± 68(DC); and for pudding-like viscosity 74 ± 13(SC) vs. 164 ± 6(Y) vs. 211 ± 8(DC). Conclusion Suctioning liquids of different viscosity, the new DuCanto catheter was more effective than the Yankauer catheter that was more effective than a standard suctioning catheter. The relative superiority of the DuCanto was highest in fluids with high viscosity.

Background: A victim’s gender is a known factor that influences the willingness of adult bystanders to perform cardiopulmonary resuscitation (CPR) if an out-of-hospital cardiac arrest (OHCA) occurs. This study aims to identify whether gender characteristics of OHCA victims are also relevant to schoolchildren, who are the key target group of CPR trainings worldwide. Methods: A prospective, educative intervention study was performed in schoolchildren (5th–7th grade). Schoolchildren’s willingness to perform CPR was assessed by means of questionnaires before (t0) and after (t1) standardized CPR training. Participants were asked how determined they were to perform CPR in male and female OHCA victims on a 5-point Likert scale (not being determined to being very determined). A data analysis was performed according to the gender characteristics of schoolchildren. Results: Overall, 342 schoolchildren aged 10–15 years were included, and 166 male (MG) and 176 female (FG) schoolchildren served as a comparison group. Before (t0) and after (t1) the intervention, females showed a significantly higher general willingness to perform CPR than males (t0: 97.1% vs. 89.0%; p < 0.003 and t1: 95.7% vs. 98.9%; p = 0.038). The general willingness to perform CPR after training had a stronger increase in males (8.0% vs. 2.3%; p = 0.017). In the case that the OHCA victim was female, male schoolchildren were less willing to perform CPR than females at baseline (MG: n = 101;60.8% vs. FG: n = 147;84.5%; p < 0.001) and after training (MG: n = 97;58.4% vs. FG: n = 138;79.3%; p < 0.001). At t1, CPR willingness for female victims was improved in males (MG: n = 36;21.7% vs. FG: n = 19;10.9%; p = 0.006). Conclusions: The gender characteristics of OHCA victims, as well as schoolchildren themselves, have a relevant impact on the willingness to perform CPR. Training concepts should effectively motivate male schoolchildren to reduce preexisting inhibitions, especially towards female OHCA patients. Trial registration: This study was registered at the German Clinical Trials Register (Registration number: DRKS00017707) on 2 August 2019.

Background Although not routinely established during cardiopulmonary resuscitation (CPR), video-assisted CPR has been described as beneficial in the communication with emergency medical service (EMS) authorities in out-of-hospital cardiac arrest scenarios. Since the influence of video quality has not been investigated systematically and due to variation of quality of a live-stream video during video-assisted CPR, we investigated the influence of different video quality levels during the evaluation of CPR performance in video sequences. Methods Seven video sequences of CPR performance were recorded in high quality and artificially reduced to medium and low quality afterwards. Video sequences showed either correct CPR performance or one of six typical errors: too low and too high compression rate, superficial and increased compression depth, wrong hand position and incomplete release. Video sequences were randomly assigned to the different quality levels. During the randomised and double-blinded evaluation process, 46 paramedics and 47 emergency physicians evaluated seven video sequences of CPR performance in different quality levels (high, medium and low resolution). Results Of 650 video sequences, CPR performance was evaluable in 98.2%. CPR performance was correctly evaluated in 71.5% at low quality, in 76.8% at medium quality, and in 77.3% at high quality level, showing no significant differences depending on video quality ( p = 0.306). In the subgroup analysis, correct classification of increased compression depth showed significant differences depending on video quality ( p = 0.006). Further, there were significant differences in correct CPR classification depending on the presented error ( p < 0.001). Allegedly errors, that were not shown in the video sequence, were classified in 28.3%, insignificantly depending on video quality. Correct evaluation did not show significant interprofessional differences ( p = 0.468). Conclusion Video quality has no significant impact on the evaluation of CPR in a video sequence. Even low video quality leads to an acceptable rate of correct evaluation of CPR performance. There is a significant difference in evaluation of CPR performance depending on the presented error in a video sequence. Trial registration German Clinical Trial Register (Registration number DRKS00015297) Registered on 2018-08-21.

Background In the recent years, an increasing number of patients with multiple comorbidities (e.g. coronary artery disease, diabetes, hypertension) presents to the operating room. The clinical risk factors are accompanied by underlying vascular-endothelial dysfunction, which impairs microcirculation and may predispose to end-organ dysfunction and impaired postoperative outcome. Whether preoperative endothelial dysfunction identifies patients at risk of postoperative complications remains unclear. In this prospective observational study, we tested the hypothesis that impaired flow-mediated dilation (FMD), a non-invasive surrogate marker of endothelial function, correlates with Days at Home within 30 days after surgery (DAH30). DAH30 is a patient-centric metric that captures postoperative complications and importantly also hospital re-admissions. Methods Seventy-one patients scheduled for major abdominal surgery were enrolled. FMD was performed pre-operatively prior to major abdominal surgery and patients were dichotomised at a threshold value of 10%. FMD was then correlated with DAH30 (primary endpoint) and postoperative complications (secondary endpoints). Results DAH30 did not differ between patients with reduced FMD and normal FMD (14 (4) (median (IQR)) vs. 15 (8), P = 0.8). Similary, no differences between both groups were found for CCI (normal FMD: 21 (30) (median (IQR)), reduced FMD: 26 (38), P = 0.4) or frequency of major complications (normal FMD: 7 (19%) (n (%)), reduced FMD: 12 (35%), P = 0.12). The regression analyses revealed that FMD in combination with ASA status and surgery duration had no additional significant predictive effect for DAH30, CCI or Clavien-Dindo score. Conclusion FMD does not add predictive value with regards to DAH30, CCI or Clavien-Dindo score within our study cohort of patients undergoing abdominal surgery. Trial registration The study was registered in the German Clinical Trials Register ( DRKS00005472 ), prospectively registered on 25/11/2013.

Background Endotracheal intubation continues to be the gold standard for securing the airway in emergency situations. Difficult intubation is still a dreadful situation when securing the airway. Objective To compare VieScope with Glidescope and conventional Macintosh laryngoscopy (MAC) in a simulated difficult airway situation. Methods In this randomized controlled simulation trial, 35 anesthesiologists performed endotracheal intubation using VieScope, GlideScope and MAC in a randomized order on a certified airway manikin with difficult airway. Results For the primary endpoint of correct tube position, no statistical difference was found ( p = 0.137). Time until intubation for GlideScope (27.5 ± 20.3 s) and MAC (20.8 ± 8.1 s) were shorter compared to the VieScope (36.3 ± 10.1 s). Time to first ventilation, GlideScope (39.3 ± 21.6 s) and MAC (31.9 ± 9.5 s) were also shorter compared to the VieScope (46.5 ± 12.4 s). There was no difference shown between handling time for VieScope (20.7 ± 7.0 s) and time until intubation with GlideScope or MAC. Participants stated a better Cormack & Lehane Score with VieScope, compared to direct laryngoscopy. Conclusion Rate of correct tracheal tube position was comparable between the three devices. Time to intubation and ventilation were shorter with MAC and Glidescope compared to VieScope. It did however show a comparable handling time to video laryngoscopy and MAC. It also did show a better visualization of the airway in the Cormack & Lehane Score compared to MAC. Trial registration The study was registered at the German Clinical Trials Register www.drks.de (Identifier: DRKS00024968 ) on March 31st 2021.

BACKGROUND Despite intensive research, cardiac arrest remains a leading cause of death. It is of paramount importance to undertake every possible effort to increase the overall quality of cardiopulmonary resuscitation (CPR) and improve patient outcome. CPR initiated by a bystander is one of the key factors in survival of such an incident. Telephone-assisted CPR (T-CPR) has proved to be an effective measure in improving layperson resuscitation. OBJECTIVE We hypothesised that adding video-telephony to the emergency call (video-CPR, V-CPR) enhances the quality of layperson resuscitation. DESIGN This randomised controlled simulation trial was performed from July to August 2018. Laypersons were randomly assigned to video-assisted (V-CPR), telephone-assisted (T-CPR) or control (unassisted CPR) groups. Participants were instructed to perform first aid on a mannequin during a simulated cardiac arrest. SETTING This study was conducted in the Skills Lab of the University Hospital of Cologne. PARTICIPANTS One hundred and fifty healthy adult volunteers. INTERVENTION The participants received a smartphone to call emergency services, with Emergency Eye video-call in V-CPR group, and normal telephone functionality in the other groups. T-CPR and V-CPR groups received standardised CPR assistance via phone. MAIN OUTCOME MEASURES Our primary endpoint was resuscitation quality, quantified by compression frequency and depth, and correct hand position. RESULTS Mean compression frequency of V-CPR group was 106.4 ± 11.7 min, T-CPR group 98.9 ± 12.3 min (NS), unassisted group 71.6 ± 32.3 min (P < 0.001). Mean compression depth was 55.4 ± 12.3 mm in V-CPR, 52.1 ± 13.3 mm in T-CPR (P < 0.001) and 52.9 ± 15.5 mm in unassisted (P < 0.001). Total percentage of correct chest compressions was significantly higher (P < 0.001) in V-CPR (82.6%), than T-CPR (75.4%) and unassisted (77.3%) groups. CONCLUSION V-CPR was shown to be superior to unassisted CPR, and was comparable to T-CPR. However, V-CPR leads to a significantly better hand position compared with the other study groups. V-CPR assistance resulted in volunteers performing chest compressions with more accurate compression depth. Despite reaching statistical significance, this may be of little clinical relevance. TRIAL REGISTRATION ClinicalTrials.gov (Identifier: NCT03527771)

Introduction: Widespread use of smartphones allows automatic geolocalization (i.e., transmission of location data) in countless apps. Until now, this technology has not been routinely used in connection with an emergency call in which location data play a decisive role This study evaluated a new software automatically providing emergency medical service (EMS) dispatchers with a caller's geolocation. We hypothesized that this technology will provide higher accuracy, faster dispatching of EMS and a faster beginning of thoracic compressions in a cardiac arrest scenario. Material and methods: Approval from the local Ethics Committee was obtained. 108 simulated emergency calls reporting a patient in cardiac arrest were conducted at 54 metropolitan locations, which were chosen according to a realistic pattern. At each location, a conventional emergency call, with an oral description of the location, was given first; subsequently, another call using an app with automatic geolocation was placed. Accuracy of localization, time to location, time to EMS dispatch and time to first thoracic compression were compared between both groups. Results: The conventional emergency call was always successful (n = 54). Emergency call via app worked successfully in n =46 cases (85.2%). Automatic geolocation was provided to EMS in all these n =46 cases (100%). Deviation from estimated position to actual position was 1173.5 +/- 4343.1 m for conventional and 65.6 +/- 320.5 m for automatic geolocalization (p <0.001). In addition, time to localization was significantly shorter using automatic geolocalization (34.7 vs. 71.7 s, p <0.001). Time to first thoracic compression was significantly faster in the geolocalization group (83.0 vs. 122.6 s; p< 0.001). Conclusions: This pilot study showed that automatic geolocalization leads to a significantly shorter duration of the emergency call, significantly shorter times until the beginning of thoracic compressions, and a higher precision in determining the location of an emergency.

BACKGROUND:Telephone-assisted cardiopulmonary resuscitation (CPR) is an effective and proven tool to improve patient survival and outcome after cardiac arrest, and is therefore recommended in international resuscitation guidelines. A new technology that provides the emergency medical services (EMS) dispatcher with a video livestream from a smartphone during telephone-assisted CPR was investigated to assess whether a correct judgment of CPR quality is feasible. MATERIAL AND METHODS:After Ethics Committee approval, we conducted this study from August to September 2018 in the University Hospital of Cologne and its metropolitan area. Our study team set up a full-scale resuscitation mannequin on 54 study sites. Video telephony between caller and EMS dispatcher was established, and CPR was initiated with randomized common quality issues concerning compression frequency, compression depth, and compression point. It was evaluated whether the dispatcher recognized correct and incorrect resuscitation performance. RESULTS:Forty-six video calls were established successfully. EMS dispatching staff identified correct compression frequency (100-120/min) in 87.5% of the cases, too low frequency (<80/min) was correctly identified in 92%, and too high frequency (>140/min) in 58.5%, respectively. Correct compression depth (5-6 cm) was identified in 70.6%, shallow compressions (<3cm) in 92.9% and a continuous decrease of depth in 100% of all cases. Correct compression point was identified in 87.5%, incorrect epigastric compression in 92.3%, incomplete release in 58.8%. CONCLUSION:A video livestream from a smartphone can support an EMS dispatcher's assistance in resuscitation. Typical resuscitation mistakes, like incorrect compression frequency or depth, and incorrect compression points could be recognized and corrected efficiently via video livestream.

BACKGROUND Education of schoolchildren in cardiopulmonary resuscitation (CPR) is a strategic goal for improvement of bystander CPR in society. OBJECTIVE(S) The primary objective was to analyse the impact of CPR training on the resuscitation knowledge and self-confidence of secondary schoolchildren. In addition, independent predictors of improved CPR knowledge and self-confidence were investigated. DESIGN Randomised-interventional controlled study. SETTING Four secondary schools in Germany. PARTICIPANTS Four hundred and twenty-four schoolchildren aged from 14 to 18 years were included into the study. Fifty-one percent were female, and 33% had an immigrant background. INTERVENTION The intervention group received a 90-min CPR training session, whereas controls had no intervention. Levels of knowledge and self-confidence in initiating CPR were analysed by a study questionnaire before (t(0)), 90 min after (t(1)) and 6 months after training (t(2)). MAIN OUTCOME MEASURES Based on the evaluation of study questionnaires, the primary endpoint was to determine the development of resuscitation knowledge and self- confidence in initiating cardiopulmonary resuscitation at survey time-points t(0), t(1) and t(2). RESULTS Schoolchildren in the intervention group (n=207) showed a significantly higher level of knowledge (P < 0.001) and self-confidence (P< 0.001) at t(1) and t(2) compared with controls (n=217). Age was a predictor for long-term self-confidence [odds ratio (OR), 1.20; 95% confidence interval (95% CI), 1.02 to 1.41; P=0.032]. The long-term benefit in the level of knowledge and self-confidence were significantly higher in native compared with immigrant schoolchildren: (OR, 1.79; 95% CI, 1.14 to 2.82; P= 0.011) and (OR, 1.67; 95% CI, 1.07 to 2.60; P= 0.024), respectively. CONCLUSION Guideline compliant (90 min) theoretical and practical CPR training improves the level of knowledge and self-confidence in 14 to 18-year-old schoolchildren. Older schoolchildren are more likely to have increased self-confidence with respect to initiating CPR. Schoolchildren with an immigrant background showed a significantly lower increase in their level of knowledge and self-confidence compared with native children. Adaptation and simplification of teaching materials and further research on educational methods for CPR are urgently needed to enable a sustainable approach to teaching CPR, which also produces a long-lasting effect in the entire population.

AIM:Bystander CPR-rates are embarrassingly low in some European countries. To increase bystander CPR-rates, many different approaches are used; one of them is training of schoolchildren in CPR. Multiple authors investigated practical and theoretical CPR performance and demonstrated gender differences related to schoolchildren CPR. The objective was to elaborate gender aspects in practical and theoretical CPR-performance from the current literature to better address female and male students. METHODS:A systematic search in PubMed-database with different search terms was performed for controlled and uncontrolled prospective investigations. Altogether, n = 2360 articles were identified and checked for aptitude. From n = 97 appropriated articles, n = 24 met the inclusion criteria and were finally included for full review and incorporated in the manuscript. RESULTS:Female students demonstrated higher motivation to attend CPR-training (p < 0.001), to respond to cardiac arrest (CA) (p < 0.01), scored higher in a CPR-questionnaire (p < 0.025), revealed better remembrance of the national emergency phone-number (p < 0.05) and showed a higher multiplier effect (p < 0.0001). Male students showed higher confidence in CPR-proficiency (p < 0.05), revealed deeper chest compressions (CC) (p < 0.001; p < 0.0015; p < 0.01), a higher CC-fraction (p < 0.01) and a higher arbitrary cardiac output simulated equivalent index (p < 0.05). Male gender could not be detected to be a predictor for higher tidal volume (p = 0.70; p = 0.0212). CONCLUSION:In context of schoolchildren CPR, gender aspects are underestimated. Female students seem to be more motivated to attend CPR-training, reach more people in the role of a multiplier and need to be individually addressed in intensified practical training. Male students achieve a more sufficient chest compression depth and -fraction and could benefit from individual motivation.

Under the umbrella of the ERC Research NET, we conducted a second survey on key principles of CPR training implementation in school-curricula, known as KIDS SAVE LIVES (KSL) program. In 2015 the World Health Organization (WHO) has endorsed KSL, a joint statement from the European Resuscitation Council (ERC), the European Patient Safety Foundation (EPSF), the International Liaison Committee on Resuscitation (ILCOR) and the World Federation of Societies of Anesthesiologists (WFSA) [[1]Böttiger B.W. Van Aken H. Kids save lives – training school children in cardiopulmonary resuscitation worldwide is now endorsed by the World Health Organization (WHO).Resuscitation. 2015; 94: A5-A7Google Scholar]. This statement recommends two hours of CPR training annually from the age of 12 years in all schools worldwide. The 10 ERC principles – “Increasing survival with KSL” – described in the ERC Position Statement are considered to be the best way to implement nationwide campaigns [[2]Böttiger B.W. Bossaert L.L. Castrén M. Cimpoesu D. Georgiou M. Greif R. et al.Wingen S; Board of European Resuscitation Council (ERC). Kids save Lives - ERC position statement on school children education in CPR: "Hands that help - training children is training for life".Resuscitation. 2016; Google Scholar]. In order to evaluate the implementation of the KSL program throughout Europe after three years, a second survey was launched online on November 8th 2017 with the support of ERC, National Resuscitation Councils (NRCs) and ERC Research NET members [[3]Böttiger B.W. members of the ERC Research NET ERC Research NET-The network for sudden cardiac arrest and resuscitation research in Europe.Resuscitation. 2017; 117: e21-e22Google Scholar]. The survey covered the same topics as the previous [[4]Semeraro F. Wingen S. Schroeder D.C. Ecker H. Scapigliati A. Ristagno G. et al.KIDS SAVE LIVES implementation in Europe: a survey through the ERC research NET.Resuscitation. 2016; 107: e7-e9Google Scholar]. Until June 28th, 2018, we received 31 responses from 34 countries (91%), which represented an improvement compared to the first survey (79%; 27 over 34 countries). Among the responders, 97% knew that the WHO has endorsed the KSL statement, and 84% the statement details; 74% declared that education of schoolchildren was a recent topic in their country. Education in CPR is a legislation in 5 countries and a suggestion in twenty-three countries (74%; which reflects an improvement of 5 new countries). Fifty-four percent of responders declared that 12 years of age was the starting age for CPR training, with a median of 2 h per years. Seven nations have established CPR training annually (only 2 in the previous survey). In countries with legislation, main topic of education is cardiac arrest (CA). In countries without an established legislation, CA is the suggested topic. The main focus for education in countries with legislation is: primary schools in 20%, secondary schools in 40% and primary/secondary schools in 40%. In countries without legislation the preferred target are primary schools in 45%, secondary schools in 32%, primary/secondary schools in 14% and no answer 9% of cases. The equipment used for practical CPR-training is mainly a low-fidelity manikin (25%), an inflatable manikin (22%) and an AED trainer (21%). Our survey gives a new photograph of KSL in Europe (Fig. 1) three years after the most important cultural implementation of schoolchildren education in CPR. We are very thankful to all supporters. In October 2018, the very first global edition of “World Restart a Heart (WRAH)” will take place [[5]Böttiger B.W. Lockey A. Aickin R. Castren M. de Caen A. Escalante R. et al."All citizens of the world can save a life" - the World restart a Heart (WRAH) initiative starts in 2018.Resuscitation. 2018; 128: 188-190Google Scholar]. Under the motto “All Citizens of the World Can Save A Life”, ERC will join forces with all NRCs in Europe, ILCOR and resuscitation organisations all across the world to create further awareness and to teach CPR everywhere. Our KSL initiative will be part of this new campaign; #LLAP to KSL campaign. Federico Semeraro is Past President, Italian Resuscitation Council (IRC). Sabine Wingen, Daniel C. Schroeder, Hannes Ecker and Diana Cimpoesu have no conflict of interest. Andrea Scapigliati is President, Italian Resuscitation Council (IRC). Giuseppe Ristagno is member of Scientific Commitee, Italian Resuscitation Council (IRC). Bernd W. Böttiger is ERC Board Director Science and Research; Associated Editor, European Journal of Anaesthesiology; Speakers honorarium from Medupdate, FoMF, Baxalta, Bayer Vital; Chairman, German Resuscitation Council (GRC); Board Member, German Society of Anaesthesiology and Intensive Care Medicine (DGAI); Board Member, German Society of interdisciplinary Intensive Care and Emssergency Medicine (DIVI); Associated Editor, Resuscitation, Professor and Head of the Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Germany. This survey was supported by the ERC Research NET.