Disparities in cardiac arrest survival persist across gender, race, age, disability, socioeconomic status, and geographical location in part due to unequal access to life-saving interventions such as bystander cardiopulmonary resuscitation (CPR) and early defibrillation. Inequities in access to training, equipment, and local implementation may reinforce these disparities across the chain of survival. Current diversity, equity and inclusion (DEI) approaches to disparities in resuscitation research often examine inequities in isolation, limiting their ability to explain how structural, social, and institutional factors interact to influence outcomes. To address these limitations, this concept paper proposes examining the chain of survival through an intersectional lens which considers Justice at the forefront of Equity, Diversity, and Inclusion (JEDI). Adding justice as an ethical principle aims to target these broader factors, and when combined with DEI efforts, may lead to a more comprehensive approach on examining inequities in resuscitation. Within the European Resuscitation Council (ERC), this intersectional JEDI lens provides a support for identifying inequities and barriers across both the chain of survival and the formula of survival, including medical science, educational efficiency, and local implementation, so that giving and receiving high-quality resuscitation becomes realistically attainable for everyone.

Objective To evaluate the representation of sex pictograms displayed on automated external defibrillators (AEDs), pad packages, and defibrillation pads, assessing inclusivity and potential implications for real-life AED use. Methods Between May and October 2025, investigators from seven countries worldwide captured original photographs of AEDs, pad packages, and defibrillation pads from manufacturers, distributors, and institutional networks. Only adult, commercially available AEDs and defibrillation pads intended for real-life use were included; training or manual AEDs were excluded. Two independent researchers assessed each pictogram for sex representation, with consensus by a third reviewer when needed. Results Female pictograms were rare across all reviewed AEDs, pad packages, and defibrillation pad sets. Among 51 AEDs with pictograms, only two (3.9%) included any female pictograms, whereas most displayed only adult male pictograms (62.7%). In pad packages, female pictograms appeared on three packages (7.0%), while 48.8% showed only adult male pictograms. In defibrillation pad sets, female pictograms appeared in two sets (4.5%); most showed only adult male pictograms (56.8%). Neonatal and pediatric pictograms were uncommon overall, with pediatric boy pictograms representing the predominant across AEDs, pad packages, and defibrillation pad sets. Conclusions Instructional imagery on AEDs, pad packages, and defibrillation pads overwhelmingly represents male, with minimal or absent female depictions. This imbalance may reinforce gender bias, potentially leading to incorrect pad placement on women and reducing inclusivity in resuscitation. Manufacturers and resuscitation councils could promote accurate and balanced visual representations to ensure equitable and realistic AED use across sexes and body types during cardiac arrest management.

Basic life support (BLS) is crucial to improve cardiac arrest survival. Virtual reality (VR), a core aspect of extended reality, is increasingly utilized for immersive adult BLS training. However, the effectiveness of VR-based training varies significantly due to differences in target populations, implementation strategies, and the specific applications (apps) used. This study assesses how well VR apps for teaching adult BLS adhere to the 2021 adult BLS guidelines. In 2024, a comparative analysis was conducted using VR apps stores and the Google search engine. Three experts evaluated the identified VR apps using various VR headsets and a detailed adult BLS checklist. The findings were analyzed and documented using descriptive statistics. Of 911 identified VR adult BLS apps, 20 (2%) claimed to train adult BLS and were available for analysis. The common shortcomings identified were as follows: inadequate instruction to ensure the safety of the rescuer, the patient, and any bystanders before assisting out-of-hospital cardiac arrest (OHCA) patients (1/20; 5%), failure to recognize cardiac arrest (4/20; 20%), insufficient guidance on opening the OHCA patient's airway (3/20; 15%), and improper technique in performing high-quality chest compressions (3/20; 15%). While the majority of VR adult BLS apps included instructions on how to use an automated external defibrillator (AED) (17/20; 75%), many demonstrated deficiencies in the correct application of AED pads (11/17; 65%) and highlighted unsafe AED usage practices (3/17; 18%). This comparative analysis underscores the potential importance of evaluation and testing of VR BLS apps to ensure high-quality teaching tools in the domain of life-saving BLS education.

Background Virtual reality (VR) and gamification are increasingly recommended as adjuncts in resuscitation education, but their integration into undergraduate medical curricula and data on usability and learner acceptance remain limited. We evaluated a newly developed, gamified VR training application for medical students during their preparation for an Objective Structured Clinical Examination (OSCE). Methods In this single-centre observational questionnaire study, fourth-year medical students completed VR-based advanced life support (ALS) training with randomized electrocardiogram (ECG) rhythms and gamified decision tasks. The primary outcome was usability measured with the Virtual Reality System Usability Questionnaire (VRSUQ; 0–100 points). Secondary outcomes included VR-induced symptoms (VRSQ; 0–100 points), self-rated rhythm-analysis competence before and after training (1–10), self-rated in-app performance (0–10), and trainer-reported feasibility. Continuous variables are presented as median (interquartile range [IQR]). Associations between outcomes were assessed using Spearman rank correlation coefficients. Results Of 660 eligible students, 294 (44.5%) participated in the VR-study and completed the questionnaires. Usability was high (VRSUQ 83.3 [IQR 72.2–91.7]). VR-induced symptoms were low (VRSQ 8.3 [IQR 0.0–16.7]). Self-rated competence increased from 5.0 (IQR 4.0–7.0) before training to 8.0 (IQR 7.0–8.0) after training ( p < 0.001), corresponding to a competence gain of 2.0 points (IQR 1.0–3.0). Self-rated performance was 7.0 (IQR 5.0–8.0) and correlated with usability ( ρ = 0.44, p < 0.001). Overall training quality was rated 9.0 (IQR 8.0–10.0), and 91.9% would participate again. Usability did not differ between genders but was higher among students with prior VR experience. Trainers reported short setup times, manageable supervision ratios, and occasional technical support needs. Conclusion Gamified VR-based ALS training for medical students is feasible, demonstrates high usability and low symptom burden, and improves self-assessed competence. VR appears to be a well-accepted adjunct to undergraduate resuscitation education.

Background Out-of-hospital cardiac arrests are associated with high mortality. Despite lay rescuer automated external defibrillator (AEDs) use being crucial for improving outcomes, public utilization of AEDs remains low. Signage characteristics directing lay rescuers to AEDs in public areas vary. We describe AED signage variability across six continents, focusing on shape, color, text, and symbols. Methods A convenience sample of 120 publicly available online AED signage, collected between December 2024 and May 2025, was analyzed. Six continents were included: Europe (38.3%), North America (23.3%), Africa (14.2%), Australia (12.5%), Asia (7.5%), and South America (4.2%). Separately, 90 crowd-sourced images of airport AED signage were collected from 71 airports across six continents between January and November 2025: Europe (37.8%), North America (36.7%), Africa (1.1%), Australia (6.7%), Asia (15.6%), and South America (5.6%). We reported frequencies and proportions of signage characteristics for the samples and stratified by continent. Results The distribution of signage characteristics in the publicly available signage varied across six continents (p<0.05). In the airport sample, the distribution of sign shape; cross symbol color; and the presence of heart, lightning bolt, and arrow symbols did not differ across continents. However, background color, text color, presence of the cross symbol, and colors of the heart and lightning bolt symbols differed across continents (p<0.05). Over 90% of all signs analyzed contained a heart and lightning bolt symbol. Conclusions There appears to be significant variation in public AED signage globally. Further research is needed to determine if specific signage characteristics improve AED recognition and utilization.

Objetivo La parada cardiorrespiratoria extrahospitalaria es la principal causa de muerte súbita. La formación en soporte vital básico (SVB) es una competencia esencial en Enfermería. Las metodologías de enseñanza activa como el blended learning podrían mejorar los resultados formativos. Diseño Ensayo controlado aleatorizado con 4 grupos paralelos (n=160). Participantes: estudiantes de primer curso del Grado en Enfermería. Lugar: en una universidad de la Región de Mucia, España. Intervenciones: se compararon 4 metodologías: formación tradicional, realidad virtual (RV), aprendizaje mixto (blended) y grupo control sin intervención. Se evaluó la competencia práctica mediante una escala de 8 ítems de los pasos clave de la cadena de supervivencia y se analizaron parámetros técnicos con maniquíes Laerdal QCPR®, midiendo porcentaje de calidad, profundidad, ritmo, compresión y descompresión. Se emplearon ANOVA, chi-cuadrado y modelos de correlación (p<0,05). Resultados Los resultados de la competencia práctica fueron significativamente diferentes entre grupos (p<0,001). Mediciones principales: los grupos mixto (blended) y tradicional alcanzaron las puntuaciones más altas (6,6±1,7 y 6,6±1,5, respectivamente), seguidos por el grupo RV (6,3±1,5) y el grupo control (3,1±1,5). La calidad media de la RCP también mostró diferencias significativas (p=0,0045), siendo mayor en el grupo blended (72,3%), seguido por el grupo tradicional (65,4%), RV (63,4%) y control (46,9%). En cuanto a la profundidad media de las compresiones (p=0,0011), los grupos blended y RV obtuvieron resultados similares (6,1cm), superiores al tradicional (5,5cm) y control (4,8cm). La percepción de usabilidad del sistema de RV fue alta (78/100). Conclusiones El aprendizaje mixto mostró un rendimiento global más favorable en la mayoría de las variables analizadas, con puntuaciones superiores en calidad de la RCP y resultados igualados o mejores en competencia práctica y profundidad de compresiones, en comparación con los modelos tradicional o inmersivo. Estos hallazgos respaldan su utilidad como estrategia docente eficaz para la adquisición de competencias en SVB.

Background:Critical Events in Anaesthetised Kids undergoing Tracheal Intubation (CRICKET) is a prospective, international multicentre observational study with the objective of capturing, assessing, and analysing critical events associated with tracheal intubation in children. Methods:CRICKET involves paediatric patients aged 0-16 yr, requiring tracheal intubation, performed by the anaesthesia team for procedures or interventions requiring general anaesthesia, either planned or unplanned. Patient characteristics and airway management techniques are recorded using a dedicated electronic case report form. If one or more critical events associated with airway management occur, a second, more detailed questionnaire will be completed for the follow-up until the patient is discharged or up to a maximum of 30 days. We aim to include 105 000 patients from participating centres disseminated worldwide. Every participating centre collects data over a consecutive observational period of 3 months. The primary outcome is the incidence of critical events associated with tracheal intubation in children. Results:The CRICKET study started in January 2024 and is currently ongoing. By May 2025, around 25 000 patients were entered into the database, with an estimated 50 000 patients by the end of 2025. Because of the observational nature of the study and the extensive international involvement and effort, continuing the study or analysing the existing data will depend on available resources and exact incidence of critical events. Funding:This work was supported by the Italian Ministry of Health (Ricerca Corrente 2025). Clinical trial registration:ClinicalTrials.gov (NCT05804188).

OBJECTIVE:Out-of-hospital cardiac arrest is the leading cause of sudden death. Basic Life Support (BLS) training is an essential competency in Nursing. Active learning methodologies such as blended learning may improve educational outcomes. DESIGN:A randomized controlled trial with four parallel groups (n=160). PARTICIPANTS:was conducted among first-year undergraduate nursing students. Site: At a university in the Region of Murcia, Spain. INTERVENTIONS:Four methodologies were compared: traditional training, virtual reality (VR), blended learning, and a control group with no intervention. Practical competence was assessed using an 8-item checklist covering key steps in the chain of survival. Technical parameters were measured using Laerdal QCPR® manikins, including percentage of high-quality CPR, compression depth, rate, and full chest recoil. ANOVA, chi-square tests, and correlation models were applied (p<0.05). RESULTS:Practical competence differed significantly between groups (p<0.001). MAIN MEASUREMENTS:The blended and traditional groups achieved the highest scores (6.6±1.7 and 6.6±1.5, respectively), followed by the VR group (6.3±1.5) and the control group (3.1±1.5). Mean CPR quality also differed significantly (p=0.0045), with the blended group showing the highest percentage (72.3%), followed by traditional (65.4%), VR (63.4%), and control (46.9%). Regarding compression depth (p=0.0011), the blended and VR groups achieved similar results (6.1cm), outperforming the traditional (5.5cm) and control (4.8cm) groups. Perceived usability of the VR system was high (78/100). CONCLUSIONS:Blended learning showed overall better performance in most variables analyzed, with higher CPR quality and equal or superior results in practical competence and compression depth compared to the traditional and immersive models. These findings support its effectiveness as a teaching strategy for acquiring BLS competencies.

Background:Favourable neurological outcome in patients with out-of-hospital cardiac arrest (OHCA) vary across countries. Different advanced resuscitation strategies such as extracorporeal cardiopulmonary resuscitation (ECPR) might have impact on long-term neurological outcome. However, this remains unclear in Switzerland. Methods:This retrospective single-centre observational study included all patients with OHCA transported by the local emergency medical services to a large Swiss academic hospital between 1 January 2015 and 31 December 2023. Data were collected before and after the implementation of the local ECPR programme for patients with refractory OHCA on 01 May 2018. The primary outcome was 1-year favourable neurological outcome, defined as Cerebral Performance Categories 1 and 2. Secondary outcomes included 30-day favourable neurological outcome, characteristics and survival of patients treated with ECPR, and factors associated with non-survival among all OHCA patients. Results:A total of 578 patients with OHCA were transported to the hospital. Favourable neurological survival at 1 year was 16.8% (95%-CI, 12.1-22.4%) before and 21.5% (95%-CI, 17.4-26.1%) after the ECPR programme implementation. Hazard ratios for overall survival were 2.19 for patients with a non-shockable initial rhythm, 1.02 for older age and 1.68 for unwitnessed OHCA. Of all transported patients, 16.8% (n = 97, n = 31 before vs. n = 66 after) met local ECPR criteria. In total 34 patients with refractory OHCA were treated with ECPR, all assessable survivors had favourable 1-year neurological outcomes. Conclusion:This observational study on patients sustaining OHCA transferred to a large Swiss hospital showed 1 year favourable outcome in 19.7% (95%-CI: 16.6-23.2%). Among ECPR patients, all five survivors had a favourable neurological outcome at 1 year. No association was found between implementing an ECPR programme for patients with refractory OHCA and 1 year favourable neurological outcome. However, the effect might be underestimated given the low incidence of ECPR. Clinical trial registration:https://www.clinicaltrials.gov, identifier NCT03759210.

INTRODUCTION:Risk evaluation, strategy formulation and preparation are important to decreasing the incidence of adverse events associated with tracheal extubation. The focus of this guideline is tracheal extubation, but many of the principles outlined are relevant to all forms of discontinuation of airway management (tracheal extubation; removal of a supraglottic airway; cessation of facemask support; and tracheostomy removal) and conversion between upper airway lifelines (facemask; supraglottic airway; and tracheal tube) or a neck airway. METHODS:An international, multidisciplinary working group reviewed existing airway guidelines and published literature. A structured process for generating expert consensus statements was undertaken, which included consultation with an international advisory group comprising both airway operators and assistants, as well as human factors experts. Discrepancies between the results of these two processes were analysed and reconciled. Guidelines were generated and recommendations were categorised according to the American Heart Association classification system. RESULTS:Risk evaluation for tracheal extubation includes assessing the risk of hypoxaemia, pulmonary aspiration and harm from airway stimulation. The patient's baseline risk as well as any potential changes since tracheal intubation should be considered. In addition to patient risks, team and situation risk factors should be considered when formulating the extubation strategy. Planned extubation is always elective, maximising ability to control the timing, environment and resources available. Deferring extubation is recommended if this will significantly decrease risk. When substituting one lifeline for another, 'conversion procedures', characterised by the presence of a continuous guide to maintain or facilitate rapid restoration of alveolar ventilation, are safer and preferred over airway 'replacement procedures', particularly when airway management is regarded as 'at risk'. DISCUSSION:These guidelines assist airway practitioners from any discipline to evaluate whether tracheal extubation is 'at risk' and link this to formulating a safe and effective strategy that addresses the specific challenges identified.

To evaluate clinical performance and user perception after advanced life support training through immersive virtual reality (VR) simulation, focused on decision-making in a hypothermia scenario involving a helicopter evacuation. Cross-sectional observational study with an analytical component. Update Course on Ultrasound and Emergencies organized by the semFYC, held in Las Palmas de Gran Canaria from February 6 to 8, 2025. 101 healthcare professionals who fully completed the simulation experience and assessment questionnaires. Immersive VR clinical simulation using a 360° video recorded at a ski station, presented through Meta Quest 3® headsets. The scenario included 16 clinical decisions related to the management of a hypothermic patient during air transport. Percentage of correct clinical decisions, subjective perception (satisfaction, realism, confidence), and system usability assessed using the System Usability Scale (SUS). The mean score for correct decisions was 69.4% (SD = 15.2). Participants rated the experience very positively, highlighting realism (8.87/10), training usefulness (M > 4.7/5), and increased clinical confidence. The mean SUS score was 76.7, indicating "good" usability. A lower performance was identified in specific advanced hypothermia decision-making items. Immersive VR simulation proved to be a feasible, well-accepted, and useful strategy for training in clinical decision-making in complex, low-frequency scenarios. The results support its integration as a complementary tool in continuing emergency training programs.

Objectives To evaluate the feasibility and acceptability of an immersive virtual reality (VR) scenario for assessing decision-making in accidental hypothermia resuscitation within a civil–military disaster-management exercise, and to explore neurophysiological signals as hypothesis-generating correlates of decision-making.Design Cross-sectional observational study.Setting A multinational civil–military disaster-management exercise in Bulgaria (September 2025).Participants Convenience sample of first responders who completed the VR scenario and post-experience questionnaire (n=62; mean age 30.6 years (SD 7.8); 59/62 male (95.2%) and 3/62 female (4.8%); 43/62 civilian (69.4%) and 19/62 military (30.6%)).Interventions Participants completed an interactive 360° immersive VR scenario with multiple-choice decision points covering key steps in accidental hypothermia management. A subsample underwent exploratory neurophysiological monitoring (electroencephalogram (EEG)/ECG) during the scenario.Primary and secondary outcome measures Primary outcome was decision accuracy across scenario decision points. Secondary outcomes included perceived usefulness, ease of use, presence and physical discomfort. Exploratory outcomes (subsample) included EEG-derived engagement index and frontal alpha asymmetry.Results Sixty-two participants completed the simulation. Perceived usefulness and ease of use reached the highest median score (7.0 (IQR 6–7.0)), with >95% agreement across items. Decision accuracy across decision points ranged from 37.5% to 85.7%, with lower accuracy in hypothermia-specific algorithm steps compared with general resuscitation actions. In a very small exploratory EEG/ECG subsample, illustrative case-level, event-locked individual traces suggested possible differences preceding incorrect responses (hypothesis-generating only).Conclusions Immersive VR was feasible and well accepted for assessing hypothermia resuscitation decision-making in a civil–military exercise. Observed performance highlighted hypothermia-specific decision gaps. Controlled and longitudinal studies are needed to evaluate learning gain and training effectiveness.

Resuscitation education is central to improving resuscitation performance and survival outcomes after cardiac arrest, yet no guidance exists for the standardization of reporting outcomes for cardiac arrest resuscitation education research. Standardization of reporting outcomes will allow the comparison of studies and collation of results, thus strengthening the conclusions that can be drawn from systematic reviews. Here, we aim to guide researchers by providing a list of quantitative outcome measures for resuscitation education research. The Utstein working group conducted 3 rounds of a Delphi process to identify outcome categories for educational research for health care professionals and laypeople. Sixteen outcome categories with 60 specific outcomes were identified for resuscitation education research involving health care providers, and 16 outcome categories with 51 specific outcomes were identified for research involving laypeople. Definitions are provided for all specific outcomes. The Resuscitation Education Outcomes Pyramid provides a summary of all potential outcome categories in a tiered fashion, with outcome categories further grouped into instructor outcomes, learner outcomes, patient outcomes, or systems- and population-level outcomes. Implementation of these standardized outcomes for resuscitation education research will support knowledge synthesis efforts through systematic reviews of the literature, leading to more impactful educational guidelines and improved clinical practice in the future.