Challenges in treatment of cardiac arrest in low- and low middle-income countries

Thank you, I won’t give up. I feel better now—but I want to understand what’s happened. I want to say thank you all for what you did for me—Christian Eriksen Sudden cardiac death is the third leading cause of death in Europe. Although there have been developments in education and treatment of cardiac arrest in recent years, the survival with good neurological outcome remains poor, especially in the setting of out-of-hospital cardiac arrest (OHCA) with survival rate 0%–18%.1 Outside of Europe, multiple studies of OHCA incidence and outcome have been published reporting survival rates between 3% and 6% in Asia, 11% in USA, and 12% in Australia and New Zealand.1 Having in mind those statistics and that the survival of OHCA is low even in one of the most developed countries like USA with highest level of care, there are few questions arising: What are we doing wrong? Maybe the answer is not in the income? How can we, as a community, help to beat the odds? Low-income countries like Nicaragua lack the well-established pre-hospital resources in comparison with middle- and high-income countries. Emergency Medical Services (EMS) in those countries consist of, at most, a vehicle, stretcher, and emergency lights and siren; also, most patients arrive by foot or personal transportation, and in many situations, especially in low-income countries where adequate EMS resources and personnel are lacking, there are extended response times and transport times. In those countries, the implementation of basic life support (BLS) cardiopulmonary resuscitation (CPR) education to the community and health care professionals could have a positive impact on cardiac arrest patient outcomes.2 The main problem in low-income countries is the lack of funding, so the usual proposed protocol for developed middle- and high-income countries (Figure 1) cannot be implemented in real time. Obtaining an automatic external defibrillator (AED) and its dispersion through the community as well as organization of cardiac arrest centres and EMS requires a lot of money and an assessment of cost-effectiveness. Cardiac arrest network. Proposed management of out-of-hospital cardiac arrest. So, in developing countries, it is all about lay response and effective CPR training to improve patients’ outcomes. The importance of lay responders has been supported by several studies.3 As stated before, cardiac arrest is a global community problem. Through the years, the European Resuscitation Council and International Liaison Committee on Resuscitation have addressed the issue by providing continuous education and training and by publishing guidelines for management of cardiac arrest patients. In countries with limited resources, the main goal is to provide continuous education programmes. First, all health care professionals should get certified in advance life support (ALS) and non-medical personnel working in hospital in BLS. Having in mind that education in ALS is more expensive than one in BLS, for people who come from those countries, there should be discounts, sometimes even few courses provided for free for ones who are the most interested and best in their field. After all health care providers have been certified, the next step is to engage the lay community until at least 80% of general population is certified in BLS and immediate life support. CPR educational programmes should also be included in primary and high school in collaboration with Kids Save Lives organization. Studies have shown that most OHCAs happen at home. Often those are elderly who are watching after their grandchildren. In those circumstances, timely and effective CPR and EMS call can provide better outcomes. Furthermore, since in low-income countries, there is limited number of ambulances, which are often delayed; work should be done on implementing dispatcher-assisted CPR until the ambulance comes along. Studies have shown that dispatcher-assisted CPR improves its quality and could affect later outcome. When in-hospital cardiac arrest occurs, they should be handled by emergency response cardiac arrest team. But, this is an issue in low-income countries, because of lack of resources, defibrillators, AEDs, and hospital staff. Limited resources magnifies even more the importance of lay response. Sometimes cardiac arrest can occur in the bathroom, in the waiting room, in front of the janitor, or a doorman, and until medical team arrives, everyone should be able to recognize cardiac arrest and start CPR. In the future, artificial intelligence will have many influences on our education. For example, recently, the first cardiology congress was held in Metaverse organized by Global Society of Cardiology.4 In area of cardiac arrest, virtual reality training of lay persons in CPR will be the future. There are some papers already published on this matter.5,6 This type of training can be very useful in countries with limited resources and lack of simulation centres, and it should be implemented in order to provide better care and outcomes for those suffering from cardiac arrest. The incidence of cardiac arrest is still high, and despite of new developments in the area of pre-hospital and in-hospital resuscitation, the overall survival is low, even in the most developed countries. The mortality is higher in those suffering from unwitnessed OHCA. In those who have witnessed cardiac arrest, the survival is better and with favourable neurological outcome when the initial rhythm is shockable. The main impact on survival has early initiated high-quality CPR performed by bystanders. In countries that do not have cardiac arrest centres due to limited resources and lack of funding, engaging bystanders might be the only way to provide favourable outcomes for those suffering from cardiac arrest. I hereby express my gratitude to Sofija Vukajlovic, a graphical designer for helping me make the figure included in publication. All authors declare no funding, research grants or personal relationship with authors whose work was cited in this manuscript. The article is based on authors personal opinion on management of cardiac arrest.