Elsevier

Resuscitation

Volume 68, Issue 3, March 2006, Pages 365-369
Resuscitation

CLINICAL PAPER
Quality of BLS decreases with increasing resuscitation complexity,☆☆

https://doi.org/10.1016/j.resuscitation.2005.07.019Get rights and content

Summary

Objective

Multiple procedures performed in parallel may cause each procedure to be performed less effectively than if performed in isolation. BLS performed by prehospital providers potentially includes artificial ventilations, chest compressions, and application of an automated external defibrillator (AED). This study examines the effectiveness of artificial ventilation and chest compressions both with and without an AED.

Methods

Thirty-six prehospital providers participated in a prospective observational study. Tested in pairs (n = 18), subjects randomly completed three, 6-min scenarios [apneic patient with a pulse (VENT), a pulseless patient (CPR), and a pulseless patient with an AED available (CPR + AED)]. A full-torso manikin capable of generating a carotid pulse was connected to a computer to record number of ventilations, tidal volume, flow rate, number of compressions, and compression depth. Data were analyzed by t-test, ANOVA, and Mann–Whitney U-test.

Results

Artificial ventilation performed in isolation provided more correct ventilations than during CPR or CPR + AED (25.7%, 14.2%, 13.7%, p = 0.02). Fewer ventilations were delivered during CPR and CPR + AED (p = 0.03). More compressions were delivered with CPR alone vs. CPR + AED (51.9, 35.7 min−1, p = 0.00). More correct compressions were delivered during CPR alone vs. CPR + AED (p = 0.05).

Conclusions

Both the quality and quantity of BLS decreases as the number of procedures performed simultaneously increases. Further decrements might occur when ALS skills enter into resuscitation. These results suggest a need to automate and/or prompt the performance of BLS to optimize resuscitation.

Introduction

Basic life support (BLS) resuscitation is a complex skill with individual elements often studied by isolated intervention. The distracters associated with complex situations are well described in the education literature but are largely ignored in medicine.1

The most recent addition to BLS resuscitation is the automated external defibrillator (AED). This device has been shown to improve resuscitation in out of hospital cardiac arrest (OOHCA) when the patient is in ventricular fibrillation (VF) but its operation reduces the time available for the delivery of chest compressions.2 However, studies have shown that the incidence of VF is declining and may not be the most common rhythm encountered by first responders.3, 4 The low incidence of VF encountered by EMS providers, combined with the time required for AED application and operation may contribute to the poor rate of return of spontaneous circulation (ROSC) in OOHCA.

This study examined various combinations of BLS skills to determine the effect of complex resuscitation scenarios on individual skills. Specifically, we examined the effectiveness of artificial ventilation when performed in isolation, when combined with chest compressions, and when combined with chest compressions and use of an AED. We also examined the quality of chest compressions during two-rescuer CPR both with and without an AED.

Section snippets

Materials and methods

Thirty-six paramedic students were enrolled in a prospective observational study (Table 1). Each subject volunteered and provided informed consent. The study was approved by the University of Pittsburgh Institutional Review Board. Subjects were not compensated for their time. They were tested in pairs (n = 18) and completed three 6-min scenarios: (1) an apneic patient with a pulse, (2) an apneic, pulseless patient without an AED available, and (3) an apneic, pulseless patient with an AED

Results

The number of ventilations delivered during the 6-min scenario was greater in the ventilation alone group than in the CPR or CPR + AED groups (Table 2). However, the number of ventilations delivered per minute was lower than the AHA recommendation of 10–12 min−1 in all three groups. Notably, eight of the groups failed to recognize a pulse in the apneic patient and incorrectly treated the patient with CPR. These groups were excluded from the ventilation analysis.

The number of correct ventilations

Discussion

These data show that the effectiveness of BLS resuscitation decreases as the resuscitation becomes more complex. Additionally, BLS skills did not meet current AHA guidelines for any of the scenarios used in this study. In general, the number of ventilations and compressions decrease as the number of skills delivered increases. Overall, the quality of skills provided was less than expected by current guidelines.

Bag-valve mask ventilation is a complex psychomotor skill. While studies have shown

Conclusions

BLS resuscitation skill performance decreases as complexity of the resuscitation increases. However, BLS interventions in all three scenarios do not meet current AHA guidelines. Future studies need to address methods to improve BLS interventions.

Acknowledgements

We acknowledge the help of Clifton Callaway (MD PhD) and Allan Wolfson (MD) for manuscript revision and the prehospital care providers at the Center for Emergency Medicine who participated in the study.

References (9)

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Presented at the American Heart Association Fellows’ Research Day, Pittsburgh, PA (13 February 2004 by Dr. Jon C. Rittenberger) and Presented at the Society for Academic Emergency Medicine 2004 Annual Meeting, Orlando, FL (19 May 2004 by Dr. Jon C. Rittenberger).

☆☆

A Spanish translated version of the summary of this article appears as Appendix in the online version at 10.1016/j.resuscitation.2005.07.019.

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