Carolina Malta Hansen

KrychtiukAmerican Heart Journal

RAndomized Cluster Evaluation of Cardiac ARrest Systems (RACE-CARS) trial: Study rationale and design

Out-of-hospital cardiac arrest (OHCA) occurs in nearly 350,000 people each year in the United States (US). Despite advances in pre- and in-hospital care, OHCA survival remains low and is highly variable across systems and regions. The critical barrier to improving cardiac arrest outcomes is not a lack of knowledge about effective interventions, but rather the widespread lack of systems of care to deliver interventions known to be successful. The RAndomized Cluster Evaluation of Cardiac ARrest Systems (RACE-CARS) trial is a 7-year pragmatic, cluster-randomized trial of 60 counties (57 clusters) in North Carolina using an established registry and is testing whether implementation of a customized set of strategically targeted community-based interventions improves survival to hospital discharge with good neurologic function in OHCA relative to control/standard care. The multi-faceted intervention comprises rapid cardiac arrest recognition and systematic bystander CPR instructions by 9–1-1 telecommunicators, comprehensive community CPR training and enhanced early automated external defibrillator (AED) use prior to emergency medical systems (EMS) arrival. Approximately 20,000 patients are expected to be enrolled in the RACE CARS Trial over 4 years of the assessment period. The primary endpoint is survival to hospital discharge with good neurologic outcome defined as a cerebral performance category (CPC) of 1 or 2. Secondary outcomes include the rate of bystander CPR, defibrillation prior to arrival of EMS, and quality of life. We aim to identify successful community- and systems-based strategies to improve outcomes of OHCA using a cluster randomized-controlled trial design that aims to provide a high level of evidence for future application.

Female sex is linked to ~13% lower odds of receiving public bystander CPR.

BrayCirculation

2026 International Liaison Committee on Resuscitation Consensus on Science With Treatment Recommendations: Summary from the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

Bag Size for Manual Ventilation During Cardiopulmonary Resuscitation in Adult Cardiac Arrest: A Systematic Review

Background Smaller-capacity self-inflating bags have been proposed to limit delivered tidal volume during adult cardiopulmonary resuscitation (CPR). This review evaluates whether using smaller-capacity self-inflating bags, compared with standard-size adult bags, for manual ventilation during CPR affects patient and ventilation outcomes. Methods We conducted a systematic review using the ILCOR Continuous Evidence Evaluation approach, searching MEDLINE, Embase, Web of Science, and CENTRAL from inception to May 7, 2026 (PROSPERO CRD420251266387). Eligible studies included randomised and non-randomised designs in humans and simulation. Critical outcomes were survival to discharge or 30 days with and without favourable neurological outcome. Important outcomes included survived event, return of spontaneous circulation (ROSC), tidal volume, ventilation rate, and adverse events. Certainty of evidence was assessed using GRADE. Results No randomised trials were identified. Evidence comprised one before-and-after observational study (n=1,994 out-of-hospital cardiac arrest patients with advanced airways) and two cross-over simulation studies. The observational study compared periods using smaller ventilation bags (450–700 mL) with standard adult bags (1000–1685 mL). Compared with the standard-bag period, the smaller-bag period was associated with lower survival with favourable neurological outcome (AOR 0.65, 95% CI 0.43–0.99) and lower event survival (adjusted odds ratio [AOR] 0.73, 95% CI 0.60–0.90). Survival to discharge and ROSC did not differ significantly. Simulation studies demonstrated inconsistent effects of bag size on guideline-consistent tidal volume delivery. The certainty of evidence was very low for all outcomes. Conclusions Although evidence is very limited and of very-low certainty, smaller bags may influence delivered tidal volume and worsen patient outcomes. Routine substitution of standard adult bags with small bags during CPR is not supported.

In Denmark, the diagnosed prevalence of hypertrophic cardiomyopathy varied significantly by geography, being highest in Zealand (prevalence ratio 1.31 vs Capital Region) and thinly populated areas.

Help-seeking and barriers to emergency care during out-of-hospital cardiac arrests in public housing areas: a qualitative study

Airway management with a supraglottic airway device during resuscitation by basic life support providers: a systematic review

Anticipatory charging cuts pre-shock and peri-shock pauses versus standard charging but survival benefits remain uncertain.

Automated external defibrillators provide safe and effective public defibrillation, though further strategies are needed to improve public understanding and utilization.

Ventilation parameters during adult cardiopulmonary resuscitation: a systematic review

Background: Effective ventilation during cardiopulmonary resuscitation (CPR) is challenging, with limited evidence to guide optimal rates, volumes, and other parameters. This systematic review, part of the continuous evidence evaluation process for the International Liaison Committee on Resuscitation, examined whether specific tidal volumes, respiratory rates, inspiratory times, or positive end-expiratory pressure (PEEP) improve outcomes. Methods: Studies of adults in any setting (in-hospital or out-of-hospital cardiac arrest) receiving ventilation were included if they compared specific tidal volumes, respiratory rates, inspiratory times, or PEEP. MEDLINE, EMBASE, and CENTRAL were searched from inception to November 10, 2025. Risk of bias was assessed using RoB 2.0 and ROBINS-I; certainty of evidence was evaluated with GRADE. Registered in PROSPERO (CRD420251070065). Results: Of 3021 records, 11 studies (3 randomized trials, 8 observational) met eligibility criteria. Certainty of evidence was very low, limited by bias, inconsistency, indirectness, and imprecision. Due to heterogeneity, results were reported narratively using Synthesis Without Meta-Analysis (SWiM) guidelines. Ventilation rates showed mixed associations with neurological, survival, and return of spontaneous circulation (ROSC) outcomes; some studies indicated harm with lower ventilation rates. Most found no differences between higher and lower tidal volumes, although very low tidal volumes were associated with worse outcomes in some studies. When impedance-detected ventilations occurred in ≥50% of chest compression pauses during 30:2 CPR, survival and ROSC were higher. Conclusion: Evidence on optimal ventilation during CPR is inconsistent and of very low certainty. Very low ventilation rates and tidal volumes may be harmful. Future research should use robust designs to define evidence-based ventilation targets.

BrayResuscitation

Basic Life Support: 2025 International Liaison Committee on Resuscitation Consensus on Science With Treatment Recommendations

The International Liaison Committee on Resuscitation conducts continuous review of new, peer-reviewed published cardiopulmonary resuscitation science, and publishes more comprehensive reviews every 5 years. The Basic Life Support Task Force chapter of the 2025 International Liaison Committee on Resuscitation Consensus on Science With Treatment Recommendations addressed all published resuscitation evidence reviewed by the Basic Life Support Task Force science experts since 2020. Topics addressed by systematic reviews in the last year include chest compression-only cardiopulmonary resuscitation, starting cardiopulmonary resuscitation with compressions or airway and breathing, chest compression and ventilation ratios, durations of cardiopulmonary resuscitation cycles, hand positioning during compressions, head-up cardiopulmonary resuscitation, ventilation feedback devices, and pad and paddle size and placement. Members from the Basic Life Support Task Force have assessed, discussed, and debated the quality of the evidence, based on Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task force are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task force lists priority knowledge gaps for further research.

European Resuscitation Council Guidelines 2025 Adult Basic Life Support

The European Resuscitation Council has produced these ERC Guidelines 2025 Basic Life Support for adults based on the ILCOR Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations published since 2021. The topics addressed include how to recognise cardiac arrest, alerting the emergency services, delivering chest compressions, performing rescue breaths, how to use an automated external defibrillator (AED) and safety considerations for rescuers. Quality of cardiopulmonary resuscitation (CPR) and the use of technology has been embedded into the relevant sections, rather than reported separately. The management of cardiac arrests in children, infants and neonates are described in the ERC guidelines 2025 Neonatal Life Support and Paediatric Life Support.

Cardiopulmonary resuscitation training in schools following 19 years of mandating legislation in Denmark: a nationwide survey

Background: Supporting the 'Kids Save Lives' initiative, cardiopulmonary resuscitation (CPR) training has been mandatory in elementary schools since 2005 in Denmark, but a study in 2013 found <one-third of school classes received CPR training. Since there have been no targeted initiatives to improve implementation, we investigated the current prevalence, and examined factors associated with CPR training in Danish elementary schools. Methods: Nationwide survey of Danish elementary schools with 9th grade classes targeting all school leadership and one 9th grade homeroom teacher at each school in 2024. The primary outcome was CPR training during 6th-9th grade. Logistic regression models were used to compare the prevalence of CPR training between 2023/24 and 2013 and to identify factors associated with CPR training. Results: Almost half (47 %, n = 629) of eligible schools were represented, with reports from 31 % (n = 418) of leadership and 28 % (n = 378) of teachers. Overall, 48.8 % of leadership reported CPR training the last three years, and 35.7 % of teachers reported their class had received CPR training. According to leadership, schools were less likely to have completed training in 2023/2024 vs 2013 (OR 0.60, 95 % CI: 0.50-0.80). Factors positively associated with CPR training included the perception that CPR training was expected (OR 3.03, 95 % CI: 1.93-4.78) and the presence of guidelines and responsibilities (OR 2.94, 95 % CI: 1.87-4.62). Conclusions: Despite mandating legislation, the prevalence of CPR training in Danish elementary schools declined over the past decade. Our results highlight the need for strategies beyond legislation to implement CPR training in schools.

Pad size, orientation, and placement for defibrillation during basic life support: A systematic review

Aim: To evaluate the impact of defibrillation pad size, orientation, and position on clinical outcomes in adult and paediatric cardiac arrest with a shockable rhythm through a systematic review of available evidence. Methods: A systematic review was registered with PROSPERO (CRD42024512443). Searches were performed across PubMed, EMBASE, and the Cochrane Library up to March 31st, 2025. Studies involving adults or children with cardiac arrest and comparing pad sizes or positions were included. Risk of bias was assessed using the RoB 2.0 and ROBINS-I tools, and the certainty of evidence was evaluated using GRADE methodology. Results: Of 7855 screened studies, four met inclusion criteria, e.g. 1 randomized clinical trial (RCT) and 3 observational studies in adults, covering 1334 adult cardiac arrest patients. Evidence on pad size, deriving from an observational study enrolling 314 patients, was sparse and inconclusive, with no significant differences in defibrillation success between large and small pads (OR 0.82[0.42-1.60]). For pad orientation, no evidence was found. For pad placement, one RCT including 280 patients suggested a potential survival benefit from vector-change defibrillation using anterior-posterior (AP) pad placement in refractory ventricular fibrillation (VF), compared to the standard anterior-lateral (AL) placement (adj. RR 1.71[1.01-2.88]). Data from two observational studies including 739 patients were conflicting and limited by high risk of bias. Conclusion: Evidence remains inconclusive to support the superiority of any specific pad size, orientation or position for improving survival or neurological outcomes in cardiac arrest. However, vector-change to the AP position may offer benefit in cases of refractory VF. High-quality RCTs are needed to further inform clinical practice.

Family screening after sudden cardiac death yields inherited heart disease in ~12%, mostly within 5 years.

Smartphone-based alert of community first responders: A multinational survey to characterise contemporary systems

Several countries worldwide have implemented systems to alert community first responders (CFR) via smartphone applications to increase likelihood of survival after out-of-hospital cardiac arrest (OHCA). Substantial heterogeneity across CFR systems has been reported but recent reports are lacking. The European Resuscitation Council (ERC) conducted a survey to characterise and compare CFR systems focusing on requirements for joining CFR programs. An online survey with 28 questions regarding general system description, CFR qualification and training) was conducted using SurveyMonkey between October 2024 and January 2025. The survey was shared via QR-code at the ERC Congress 2024, e-mail invitations to all ERC national resuscitation councils, the ERC Guidelines 2025 webpage, ERC social media, ERC newsletter, and personal e-mail invitations to research groups and CFR systems. Thirty-five CFR systems from 19 countries participated in the survey. The majority of CFR systems (69%, n=24) require some kind of Basic Life Support (BLS) training as a minimum qualification. In 80% (n=28) the minimum age for participation is 18 years. App-specific training is offered by 51% (n=18) and in 11% (n=4) of CFR systems no dispatch centre is involved in the alert, 43% (n=15) of systems alert exclusively to OHCA, and 17% (n=6) of CFR systems only alert CFR to adult OHCAs. There are multiple CFR systems with a high degree of heterogeneity regarding minimum required CFR qualification and training as well as alerting modalities. Understanding these differences across systems is paramount to design studies to test the effect of CFR on patient outcomes.

Volunteer Responder Recruitment, Voluntary Deployment of Automated External Defibrillators, and Coverage of Out‐of‐Hospital Cardiac Arrest in Denmark

BACKGROUND: A volunteer responder program to out-of-hospital cardiac arrest (OHCA) was implemented stepwise in Denmark (2017-2020). This study assessed automated external defibrillator (AED) and volunteer responder coverage of historical OHCAs in Denmark. METHODS: Non-emergency medical services witnessed OHCAs (2016-2020) from the Danish Cardiac Arrest Registry with known location and AEDs from the Danish AED network were included. Volunteer responders with an exact location were identified using the volunteer responder server. A historical OHCA was defined as covered when ≥4 volunteer responders and ≥1 AED were <500 m range. Coverage was examined according to location (public or home), time of day (noon or midnight), and volunteer responder background (lay people or health care professionals). RESULTS: A total of 22 330 OHCAs and 22 418 AEDs (387 AEDs/100 000 inhabitants) were included. At noon, 34 180 volunteer responders (589 volunteer responders/100 000 inhabitants) were identified as available. During daytime, OHCA coverage was 56% (95% CI, 55.9-57.2, n=12 625) decreasing to 30% (95% CI, 29.8-31.0, n=6793) when including only volunteer responders with a health care background. There was no significant difference in coverage according to time of day or location of arrest. OHCA coverage was 85% (95% CI, 84.2-86.0, n=6153) 4 years after implementation (first area included). CONCLUSION: Regardless of time of day, more than half of all OHCAs were covered by volunteer responders and AEDs in Denmark. Excluding lay volunteers would almost halve the coverage. Our results indicate successful recruitment of volunteer responders and deployment of AEDs with great potential for improving bystander defibrillation.