To the Editor,
Immediate basic life support (BLS) and early defibrillation are two of the links of the chain of survival, being crucial to restore the spontaneous circulation of a person in cardiac arrest.1, 2 Most cardiac arrest events occur in the out-of-hospital setting, hence BLS and defibrillation training are recommended for all citizens.3 Taking into account the importance of the automated external defibrillator (AED) and the recommendation to be used by the general population (public access defibrillation initiatives), they must be designed for those with minimal training.
This is part of a study (unpublished results) with the aim to reduce the no-flow time during AED use, in which 79 participants with (n = 53) and without BLS training (n = 26) were compared in an out-of-hospital cardiac arrest (OOHCA) simulated scenario. They were told that a casualty in a crosswalk collapsed and requested to apply the BLS algorithm including AED use. The Laerdal AED Trainer 2 (Laerdal Medical, Stavanger, Norway) had been configured to recommend two shocks. Following two shocks, the casualty regained spontaneous circulation and respirations. The scenario was considered finished if the participant completed all required tasks for BLS and AED use.
Twelve untrained BLS participants (46.2 %) were not able to finish the scenario due to difficulties during AED use. Regarding BLS trained ones, only two did not complete the scenario (3.8 %) (p < 0.001). Specifically, we wanted to focus on the 14 participants (12 without BLS training) who did not finish the scenario. Three were not able to put the pads on the victim’s chest (they did not find the sticky part of the pads) and 4 decided to remove the pads just after initiating the first shock. The remaining 7 prematurely turned off the AED during the 2-min between the first and second heart rhythm analysis, interrupting the scenario. Interestingly, these 7 participants explained that they were attempting to turn on the AED one more time; they became concerned that the AED turned itself off because it had remained silent. The participants also perceived the time duration to be far longer than 2-min, further making the silence more uncomfortable.
Even with no BLS training, verbal assistance from telephone dispatchers or even by some “intelligent” devices improve citizen bystanders’ BLS performance for OOHCA.4 Although the AED is designed for the public with no prior instruction, our results suggest that the use of the AED may be less intuitive than previously assumed, pointing out to the need of some AED familiarity5 and strategies to improve AED software and displays to improve bystander performance. Therefore, we recommend that manufacturers require the following additions to AEDs: 1) prompts related to “Do not turn off the AED at any time,” 2) an audible metronome to guide the correct chest compression rate, 3) or coaching reminders at regular intervals like: “Please maintain chest compressions and avoid any interruption until the next new message” (Fig. 1 and Supplementary Table). We believe that citizen bystander use of the AED would benefit from reducing “The Sound of Silence” that may generate doubts about next actions or AED failure.
Fig. 1.
Proposal of prompts to optimize AED use.
Declaration of Competing Interest
Cristian Abelairas-Gómez and Nino Fijačko are members of the ERC BLS Science and Education Committee and mentees of ILCOR Task Force Education Implementation and Team..
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.resplu.2022.100323.
Appendix A. Supplementary material
The following are the Supplementary data to this article:
References
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