Public CPR education can improve the behavior of bystanders significantly when a cardiac emergency occurs in the community. Availability of the simple three-digit 911 emergency number in the United States can reduce confusion and decrease delay in activating the EMS system. There are a number of problems associated with training the public to perform CPR. For example, it can be argued that the wrong rescuers have been trained. The typical cardiac arrest victim is male, is 50 to 75 years old, and usually arrests at home, often in the presence of a spouse of similar age. Most citizens who have taken CPR training are under 30 years of age; typically, fewer than 10 percent live with family members known to have heart disease. Most citizens who have received CPR training never actually witness or participate in managing a cardiac arrest; conversely, bystanders who witness a cardiac arrest usually do not know how to perform cPr. The majority of laypersons who attempt to perform CPR out of hospital are actually employed or volunteer their services as health professionals. The best solution to the problem is to target CPR training to "high-risk" individuals, such as middle-aged persons, senior center residents and staff, and family members (particularly the spouse) of patients who are survivors of AMI or cardiac arrest or who have other risk factors for SCD.
Skill retention is also a problem because CPR is a psychomotor technique that deteriorates rapidly over time unless practiced or used. In Belgium, 46 percent of bystanders who performed CPR forgot to perform mouth-to-mouth breathing; chest compressions were not done 17 percent of the time.31 It is important for laypersons or health care professionals who perform CPR infrequently to receive at least annual reinforcement. However, only about 20 percent of trainees return for annual training in the United States. Irrational fear of communicable disease, particularly infection with the human immunodeficiency virus (HIV), that is disproportionate to the known minimal risk of disease transmission may decrease the likelihood that trained rescuers will actually perform mouth-to-mouth ventilation on strangers. 32
Although the value of bystander CPR was once debatable, virtually all recent studies have shown that early initiation of CPR by a bystander improves survival from cardiac arrest significantly, and it also results in improved neurologic outcome of survivors. 8 The presumed mechanism by which CPR by a bystander improves outcome is the preservation of flow to the heart, brain, and other vital organs, providing a "holding action" until other therapies (e.g., defibrillation) can result in restoration of spontaneous circulation.
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