# Knowledge of Nonmedical Individuals about Cardiopulmonary Resuscitation in Case of Cardiac Arrest: A Cross-Sectional Study in the Population of Jeddah, Saudi Arabia

Authors: Fadi Jandali Qara; Loui K. Alsulimani; Maged M. Fakeeh; Diyaa H. Bokhary
Journal: Emergency Medicine International
 (2019)

---

## Abstract

Introduction. In cardiac arrest victims, providing a high-quality cardiopulmonary resuscitation (CPR) is a fundamental component of initial care, especially in the out-of-hospital settings. In this study, we sought to assess the knowledge of nonmedical people regarding cardiopulmonary resuscitation in the case of out-of-hospital cardiac arrest.Methods. A cross-sectional survey containing 22 questions was administered to individuals aged ≥ 18 years, who were not health care providers. Sample included residents of Jeddah, Saudi Arabia. The survey included knowledge about cardiac arrest findings, previous experience with CPR, knowledge of basic life support (BLS), and concerns related to CPR.Results. The fully completed survey forms of 600 respondents were analysed. Out of these, 28.7% stated that they had previously received training in CPR. Regarding manifestations of cardiac arrest, 40.7% suggested loss of consciousness, 36.8% suggested cessation of breathing, and 24.7% suggested cessation of circulation. Only 11.7% among respondents were found to be able to perform chest compressions. Also, only 9.2% could perform mouth-to-mouth ventilation, and 29.5% were able to perform both. While 55.5% knew the location for performing chest compressions, 44.7% knew the correct depth, and only 18.5% knew the correct compression–ventilation rate. Bystander CPR had been performed by only 10.7%.Conclusion. In our sample, we found lack of knowledge regarding CPR. We advise for a coordinated national effort to improve the public awareness about CPR performance. This may include mass education, specialized training, and setting legislations.


---

## Body

## 1. Introduction

Sudden cardiac arrest is the main cause of death for millions of people worldwide every year [1, 2]. In cardiac arrest victims, cardiopulmonary resuscitation (CPR) is a fundamental component of initial care. The quality of delivered CPR improves the survival rate from cardiac arrest [3], especially when the incident happens out of the hospital.The incidence of adult out-of-hospital cardiac arrest (OHCA) is estimated to be 95.9 cases per 100,000 persons per year [4, 5]. In a survey performed in a busy street in a city of a western region of Turkey, 40.7% of people living in a highly educated region reported having received CPR training and 3.6% had previously performed bystander CPR [2]. This requires an improvement of community awareness about recognizing the signs of cardiac arrest and determining when to start performing CPR.There is a significant impact of having good public awareness about how to practice CPR. In the majority of cases, the first person to act in OHCA is a victim's relative, usually a nonmedical person. Approximately 70% to 75% of cases of OHCA are witnessed by nonmedical people [6–8]. The early recognition of OHCA, early activation of emergency medical services (EMS), and early provision of bystander basic life support (BLS) are the most important factors that determine the survival probability in patients with OHCA; these actions depend entirely on the knowledge, attitude, and actions of the bystanders [7, 9]. Survival after OHCA is low (3%–30%) but showed improvement after increased public education and increased use of automatic external defibrillators [7, 10]. Data collected on survival rates showed that OHCA patients who receive bystander CPR have a greater chance of survival versus those who do not [4].Unfortunately, there are scarce data available about OHCA and CPR performed by individuals who are not health care providers in Saudi Arabia [11]. One study looked at cases of OHCA and identified differences in clinical variables and survival rates in patients arresting out-of-hospital and in the emergency department at a single hospital in Riyadh, Saudi Arabia. The study found that a total of 61 adults arrested out of hospital, and the most prevalent reported presumed cause of arrest was of cardiac origin in 82.3% of patients [11]. Patients arrested at home composed 74% of the study population with an overall mortality rate of 95.8% and a low rate of bystander CPR being performed. A family member most often transported the patient to the hospital [11].We believe that the knowledge of nonmedical people (i.e., individuals who are not health care providers) to recognize and intervene by doing CPR in the kingdom of Saudi Arabia has not previously been evaluated. In the present study, we aimed to assess the knowledge of nonmedical people in Jeddah to recognize and intervene by doing CPR in the case of OHCA.


## 2. Methods

This cross-sectional survey study was initiated after receiving ethics committee approval from the Unit of Biomedical Ethics at King Abdulaziz University (reference no. 181-18).Our sample size was 600 persons, which was calculated by the use of OpenEpi (Massachusetts Institute of Technology, Cambridge, MA, USA). All of the selected participants live in Jeddah, the second largest city after Riyadh and the most cosmopolitan city in the kingdom of Saudi Arabia. Prior to filling out the questionnaire, the purpose of the study was explained and verbal consent was obtained from all of the participants in the study. The inclusion criteria were an age of older than or equal to 18 years and not being a health care provider. Those who were younger than 18 years, health care providers, or who refused to participate were excluded.The questionnaire was distributed to residents of Jeddah, Saudi Arabia, between March 2018 and April 2018. The questionnaire survey used in the present study was taken from an investigation done in Izmir, Turkey [2], and translated into Arabic by an expert in translation and subsequently translated into English by another expert in translation. Both translated versions were reviewed for consistency and clarity. Both the Arabic and the English questionnaires were distributed at separate times to 30 participants who spoke both English and Arabic fluently. The results were the same on both occasions.The questionnaire included 22 questions in the Arabic language (which were adapted according to our practices and culture) on the demographic features of the participants; their knowledge regarding cardiac arrest manifestations (e.g., cyanosis, difficulty in breathing, nausea, and faintness of the skin); their previous CPR experiences (e.g., witnessing cardiac arrest, conducting CPR, and having a CPR certificate); whether or not they knew the national phone number for emergency situations; their BSL knowledge (e.g., compression location, number, and rate of ventilations/compressions); their concerns regarding CPR (e.g., possibility of making a mistake, contracting a contagious disease from blood and vomitus, and legal concerns); and their attitudes (i.e., who are the people to whom they will give CPR without hesitation) (Supplementary Materials (available here)).Correct cardiac arrest findings and algorithms of BLS were determined according to the 2015 European Resuscitation Council Resuscitation Guidelines [12], the 2017 American Heart Association Focused Update on Adult BLS and CPR Quality [13], and the 2010 Saudi Heart Association Guidelines on CPR.The data were analysed using the Statistical Package for the Social Sciences version 15.0 software package program (IBM Corp., Armonk, NY, USA). Categorical data were displayed as numbers (n) and percentages (%), while numerical data were displayed in the form of mean ± standard deviation (after testing for normality of distribution). The chi-squared test was used in the analysis of categorical data. A p value of < 0.05 in the statistical tests was accepted as being significant.


## 3. Results

### 3.1. Demographic Data

Out of 600 participants, 360 (60%) were females. The mean age of our population was 37.4 years ± 13.6 years. Two hundred forty-nine (41.8%) people were employees. The number of participants who stated that they had received CPR training was 172 (28.7%). Additional collected demographic data are presented in Table1.Table 1
Demographic data.
Variable Mean ± SD Range Age (years) 37.4 ± 13.6 (18–72)  Variable N %  Gender  Male 240 40.0  Female 360 60.0  Education  Elementary 5 0.8  Intermediate 26 4.4  High school 82 13.7  College 59 9.9  University 158 26.4  Postgraduate 268 44.8  Occupation  Unemployed 30 5  Worker 16 2.7  Employee 249 41.8  Housewife 117 19.7  Student 104 17.5  Retired 57 9.6


### 3.2. Regarding the Prodromal Symptoms and Signs of Sudden Cardiac Arrest

The main reported manifestation was chest pain (68.8%), followed by difficulty in breathing (50.8%), loss of consciousness (40.7%), and discontinuation of breathing (36.8%). The rest of the manifestations suggested by the respondents to indicate sudden cardiac arrest are presented in Table2.Table 2
Prodromal symptoms and signs of sudden cardiac arrest.
Variable N % Loss of consciousness 244 40.7  Discontinuation of breathing 221 36.8  Discontinuation of circulation 148 24.7  Cyanosis 185 30.8  Nausea 66 11  Difficulty in breathing 305 50.8  Chest pain 413 68.8  Faintness of the skin 137 22.8  The individual is not moving 142 23.7


### 3.3. Identification of Cardiac Arrest Findings

With respect to consciousness evaluation, the percentage of those who knew one of the procedures correctly was 44.8%, followed by those knowing two of the procedures correctly being 25.2%, and then those knowing three of the procedures correctly being 12.8%. Regarding respiration evaluation, the percentage of those knowing one of the procedures correctly was 39.2%, followed by those knowing two of the procedures correctly (31.2%), and then those knowing three of the procedures correctly (20.2%). Furthermore, for circulation evaluation, the percentage of those knowing one of the procedures correctly was 51.4%, followed by those knowing both of the procedures correctly (32.2%). More than half of the respondents (57.2%) knew the correct meaning of chest compression, that is, ‘to apply strong compressions to the chest at certain intervals (compression)’. These results are presented in Table3.Table 3
Identification of cardiac arrest findings.
Variable N % Consciousness evaluation  No response when called 373 62.2  No response when touched 221 36.8  Not moving at all 208 34.7  I do not know 114 19  Those knowing three of the procedures correctly 77 12.8  Those knowing two of the procedures correctly 151 25.2  Those knowing one of the procedures correctly 269 44.8  Those who do not know any of the procedures (I do not know) 103 17.2  Respiration evaluation  Not having any respiratory movement 360 60  Not having any respiratory sound 267 44.5  No coming air out of the mouth of an individual 310 51.7  No steaming up of a mirror placed in front of the mouth of an individual 135 22.5  I do not know 42 7  Those knowing three of the procedures correctly 115 20.2  Those knowing two of the procedures correctly 188 31.2  Those knowing one of the procedures correctly 235 39.2  Those who do not know any of the procedures (I do not know) 38 6.3  Circulation Evaluation  Not feeling a pulse in the vessels of the neck 121 20.2  Not feeling a pulse in the vessels of the arm 187 31.2  Both 193 32.2  I do not know 108 18  ‘Chest compression’ means  To scrub the chest at certain intervals 67 11.2  To apply strong compression to the chest at certain intervals (compression) 343 57.2  To scrub the heart directly by opening the chest wall 11 1.8  To apply compression directly to the heart by opening the chest wall 24 4.0  I have no idea 155 25.8


### 3.4. Witnessing a Sudden Death

Only 95 (15.8%) reported witnessing a sudden death before, while only 36 (21.1%) were able to perform CPR. The rest of these results are presented in Table4.Table 4
Witnessing a sudden death.
Variable N % Who was he/she?  Somebody from my family 63 10.5  Somebody from my friends or acquaintances 14 2.3  A stranger 23 3.8  I have not seen a sudden death happen 505 84.2  What did you do in the situation?  I began to give chest compressions 21 15  I conducted mouth-to-mouth ventilation 10 7.1  I both gave chest compressions and conducted mouth-to-mouth ventilation (i.e., I gave CPR) 36 22.1  I called an ambulance 57 40.7  I told somebody to call for help 42 30.7  I called for help by telephone 20 14.3  I just watched and left 25 17.9


### 3.5. CPR Attitudes

For the respondents who answered the question ‘to whom would you apply CPR without hesitation,’ 465 (94.2%) stated for a family member, followed by 397 who said for a friend (66.2%), and then 313 who said for a neighbour (52.2%). For the question ‘what would you do in the case of a family member,’ ‘call an ambulance’ was selected by 44.4% and ‘begin to give a chest compression’ was selected by 35.8%. For the question ‘what would you do regarding a stranger,’ ‘call an ambulance’ was reported by 54.7% and ‘begin to give a cardiac chest compression’ was stated by 24.5%. The main reason that may prevent someone from giving a chest compression to either a friend/relative or a stranger was reported as ‘making a mistake’ by 71.0% and 62.0%, respectively. The rest of these results are presented in Table5.Table 5
Taking action.
Variable N % If sudden death occurs in the following people, for whom would you conduct respiration and give chest compression?  Someone from the family 565 94.2  Friend 397 66.2  Neighbour 313 52.2  A youth in the sports hall 230 38.3  A stranger in the supermarket 220 36.7  A person who has poor personal hygiene at the bus stop 172 28.7  A gamin who is drug-dependent and uses glue, hashish, and/or heroin 154 25.7  If somebody from among your family members or friends felt faint (sudden death), what would you do?  I would begin to give chest compression 215 35.8  I would call an ambulance 264 44.4  I would call somebody or call for help 119 19.8  I would just watch and leave 2 0.3  If you witness a stranger feeling faint,what would you do?  I would begin to give chest compression 147 24.5  I would call an ambulance 328 54.7  I would call somebody or call for help 120 20.0  I would just watch and leave 2 0.5  What concerns may prevent you from giving chest compression to your friends or relatives?  Making a mistake 426 71.0  Causing bone fractures 27 4.5  Causing harm to organs 25 4.2  Stopping a working heart 19 3.2  Punishment due to legal reasons 26 4.3  Contamination by blood or vomiting 5 0.8  Contracting a contagious disease 12 2.0  Other 60 10.0  What concerns may prevent you from giving chest compression to a stranger?  Making a mistake 372 62.0  Causing bone fractures 19 3.2  Causing harm to organs 24 4.0  Stopping a working heart 17 2.8  Punishment due to legal reasons 59 9.8  Contamination by blood or vomiting 12 2.0  Contracting a contagious disease 31 5.2  Other 66 11.0


### 3.6. CPR Knowledge and Training Status

Only 196 (32.7%) of the participants reported knowing how to give a chest compression and only 172 (28.7%) had received formal training. Regarding where these individuals were trained, 46 (21.3%) reported receiving training ‘at a course given by the trainers of the ministry of health.’ The rest of these results are presented in Table6.Table 6
CPR training.
Variable N % Do you know how to give chest compression in the case of cardiac arrest and respiratory standstill?  No 404 67.3  Yes 196 32.7  Have you received any training?  No 428 71.3  Yes 172 28.7  Where (n = 172)?  At school 23 10.6  At university 32 14.8  During my military service 5 2.3  At a resuscitation society course 13 6.0  At a course given by the trainers of the ministry of health 46 21.3  In a sports club 6 2.8  At a course given in the workplace 37 17.1  Television/Internet/media 53 24.5


### 3.7. CPR Skills

Less than one-third (177; 29.5%) reported that they could ‘both ventilate and give a chest compression.’ Only 69 (11.5%) knew the proper rate of chest compression to artificial ventilation during CPR (30/2 compression/breath) and only 71 (11.8%) knew the proper rate of chest compressions (i.e., at least 100 times per minute). Of the total participant cohort, 333 (55.5%) knew the applying place of chest compression (middle of the chest) and 267 (44.5%) knew the appropriate force to apply (moderate force, such that the rib cage moves down 5 cm to 6 cm). Additionally, 428 (71.3%) knew about the defibrillator (a device that restarts a heart that has stopped working) and 132 (22.0%) knew where an automated external defibrillator or a pacemaker can be found. The rest of these results are presented in Table7.Table 7
Application of CPR.
Variable N % What BLS applications can you apply?  I can open the airway 58 9.7  I can control respiration 7 1.2  I can ventilate/conduct mouth-to-mouth ventilation 55 9.2  I can give chest compression 70 11.7  I can both ventilate and give chest compression 177 29.5  I do not know 233 38.8  What is the proper rate of chest compression /artificial ventilation during the chest compression (compressions/breaths)?  5/1 173 28.8  15/2 131 21.8  30/2 69 11.5  Other 227 37.8  Which of the following areas must chest compression be applied on?  An upper part of the chest 110 18.3  Middle of the chest 333 55.5  A lower part of the chest 83 13.8  Other 74 12.3  What must be the rate of the chest compression?  At least 150 times per minute 22 3.7  At least 100 times per minute 71 11.8  At least 50 times per minute 162 27.0  I don’t know 345 57.5  How much force must be applied during chest compression?  Enough that the rib cage moves down 1 cm to 2 cm 203 33.8  Moderate force, such that the rib cage moves down 5 to 6 cm 267 44.5  High force, such that the rib cage moves down 6 cm to 10 cm 42 7.0  As much force as possible 88 14.7  What do you know about the device defined as a defibrillator that is used during the chest compression when necessary?  I have never heard of it 75 12.5  I have heard of it before but not seen it 96 16  It is a device supporting respiration 55 9.2  It is a device used to restart a heart that has stopped working 428 71.3  Do you have any idea about where an ‘automated external defibrillator’ or a ‘pacemaker’ can be found?  I don’t know 468 78.0  Yes 132 22.0


### 3.8. Association between Identification of Cardiac Arrest Findings and CPR Training

The survey results revealed a significant difference in the identification of cardiac arrest findings between respondents with previous CPR training and those without. Those who had received training showed a higher rate of knowing the correct procedures of evaluation of consciousness, respiration, and circulation (p = 0.151, p = 0.018, and p = 0.026, respectively). For more details, see Table8.Table 8
Association between identification of cardiac arrest findings and CPR training.
Variable Those who have not received CPR training  N  % Those who have received CPR training  N  % Total  N  % p value a Consciousness evaluation  No response when called 126 42 168 0.151 29.4% 24.4% 28.0% No response when touched 25 13 38 5.8% 7.6% 6.3% Not moving at all 49 14 63 11.4% 8.1% 10.5% Those knowing three of the procedures correctly 48 29 77 11.2% 16.9% 12.8% Those knowing two of the procedures correctly 102 49 151 23.9% 28.5% 41.4% Those who do not know any of the procedures (I don’t know) 78 25 103 18.2% 14.5% 17.2%  Respiration evaluation  No respiratory movement 90 34 124 0.018∗ 21.0% 19.7% 20.7% No respiratory sound 35 7 42 8.2% 4.1% 7.0% No air coming out of the mouth of an individual 55 18 73 12.9% 10.5% 12.2% No steaming up of a mirror placed in front of the mouth of an individual 17 7 24 4.0% 4.1% 4.0% Those knowing three of the procedures correctly 66 49 115 15.4% 28.5% 20.2% Those knowing two of the procedures correctly 133 55 188 31% 32% 31.2% Those who do not know any of the procedures (I don’t know) 29 9 38 6.8% 5.2% 6.3%  Circulation evaluation  Not feeling a pulse in the vessels of the neck 91 30 121 0.026∗ 21.3% 17.4% 20.2% Not feeling a pulse in the vessels of the arm 135 52 187 31.5% 30.2% 31.2% Both 120 73 193 28.0% 42.4% 32.2% I don’t know 91 17 108 21.3% 9.9% 18% a: Respondents who chose ‘I do not know’ were excluded from the statistical test of significance


### 3.9. Association of Response to a Sudden Death with CPR Training

The results revealed no significant difference in the action of the witness of a sudden death between respondents with previous CPR training and those without. For more details, see Table9.Table 9
Association between the actions performed to a witnessed cardiac arrest with previous CPR training.
Variable Those who have not received CPR training  N  % Those who have received CPR training  N  % Total  N  % p value I both gave chest compressions and conducted mouth-to-mouth ventilation (i.e., I gave CPR) 15 21 36 0.568 16.3% 43.8% 22.1% I called emergency services 57 22 79 62.0% 45.8% 75.0% I just watched and left 20 5 25 21.7% 10.4% 17.9%


### 3.10. Association of CPR Application with CPR Training

The results revealed a significant association between the application of CPR and having CPR training. Those who received training showed a higher rate of knowing the correct answers regarding proper rate of chest compression /artificial ventilation during CPR, where the chest compression must be applied, the rate of chest compressions, and the force that must be applied during chest compression (p < 0.0001, p < 0.0001, p < 0.0001, and p = 0.004, respectively). For more details, see Table10.Table 10
Association of CPR application with previous CRP training.
Variable Those who have not received CPR training  N  % Those who have received CPR training  N  % Total  N  % p value What BLS applications can you apply?  I can open the airway 39 19 58 0.0001∗∗ 9.1% 11.0% 9.7% I can control respiration 6 1 7 1.4% 0.6% 1.2% I can ventilate/conduct mouth-to-mouth ventilation 32 23 55 7.5% 13.3% 9.2% I can give chest compression 43 27 70 10.0% 15.7% 11.7% I can both ventilate and give chest compression 95 82 177 22.2% 47.7% 29.5% I do not know 215 18 233 50.2% 10.5% 38.8%  What is the proper rate of chest compression /artificial ventilation during the CPR (compressions/breaths)?  5/1 122 51 173 0.0001∗∗ 28.5% 29.6% 28.8% 15/2 79 50 131 18.4% 29% 21.8% 30/2 23 46 69 5.3% 26.7% 11.5%  Where must chest compression be applied?  An upper part of the chest 82 28 110 0.0001∗∗ 19.2% 16.3% 18.3% Middle of the chest 222 111 333 51.9% 64.5% 55.5% A lower part of the chest 52 31 83 12.1% 18.0% 13.8% Other 72 2 74 16.8% 1.2% 12.3%  What must be the rate of the chest compression?  At least 150 times per minute 12 10 22 0.0001∗∗ 2.8% 5.8% 3.7% At least 100 times per minute 32 39 71 7.5% 22.7% 11.8% At least 50 times per minute 90 72 162 21.0% 41.9% 27.0% I do not know 294 51 345 68.7% 29.7% 57.5%  How much force must be applied during chest compression?  Enough that the rib cage moves down 1 cm to 2 cm 133 68 203 0.004 ∗ 31.0% 39.5% 33.8% Moderate force, such that the rib cage moves down 5 cm to 6 cm 185 84 267 43.3% 48.8% 44.5% High force, such that the rib cage moves down 6 cm to 10 cm 35 7 42 8.2% 4.1% 7.0% As much force as possible 75 13 88 17.5% 7.6% 14.7%


## 3.1. Demographic Data

Out of 600 participants, 360 (60%) were females. The mean age of our population was 37.4 years ± 13.6 years. Two hundred forty-nine (41.8%) people were employees. The number of participants who stated that they had received CPR training was 172 (28.7%). Additional collected demographic data are presented in Table1.Table 1
Demographic data.
Variable Mean ± SD Range Age (years) 37.4 ± 13.6 (18–72)  Variable N %  Gender  Male 240 40.0  Female 360 60.0  Education  Elementary 5 0.8  Intermediate 26 4.4  High school 82 13.7  College 59 9.9  University 158 26.4  Postgraduate 268 44.8  Occupation  Unemployed 30 5  Worker 16 2.7  Employee 249 41.8  Housewife 117 19.7  Student 104 17.5  Retired 57 9.6


## 3.2. Regarding the Prodromal Symptoms and Signs of Sudden Cardiac Arrest

The main reported manifestation was chest pain (68.8%), followed by difficulty in breathing (50.8%), loss of consciousness (40.7%), and discontinuation of breathing (36.8%). The rest of the manifestations suggested by the respondents to indicate sudden cardiac arrest are presented in Table2.Table 2
Prodromal symptoms and signs of sudden cardiac arrest.
Variable N % Loss of consciousness 244 40.7  Discontinuation of breathing 221 36.8  Discontinuation of circulation 148 24.7  Cyanosis 185 30.8  Nausea 66 11  Difficulty in breathing 305 50.8  Chest pain 413 68.8  Faintness of the skin 137 22.8  The individual is not moving 142 23.7


## 3.3. Identification of Cardiac Arrest Findings

With respect to consciousness evaluation, the percentage of those who knew one of the procedures correctly was 44.8%, followed by those knowing two of the procedures correctly being 25.2%, and then those knowing three of the procedures correctly being 12.8%. Regarding respiration evaluation, the percentage of those knowing one of the procedures correctly was 39.2%, followed by those knowing two of the procedures correctly (31.2%), and then those knowing three of the procedures correctly (20.2%). Furthermore, for circulation evaluation, the percentage of those knowing one of the procedures correctly was 51.4%, followed by those knowing both of the procedures correctly (32.2%). More than half of the respondents (57.2%) knew the correct meaning of chest compression, that is, ‘to apply strong compressions to the chest at certain intervals (compression)’. These results are presented in Table3.Table 3
Identification of cardiac arrest findings.
Variable N % Consciousness evaluation  No response when called 373 62.2  No response when touched 221 36.8  Not moving at all 208 34.7  I do not know 114 19  Those knowing three of the procedures correctly 77 12.8  Those knowing two of the procedures correctly 151 25.2  Those knowing one of the procedures correctly 269 44.8  Those who do not know any of the procedures (I do not know) 103 17.2  Respiration evaluation  Not having any respiratory movement 360 60  Not having any respiratory sound 267 44.5  No coming air out of the mouth of an individual 310 51.7  No steaming up of a mirror placed in front of the mouth of an individual 135 22.5  I do not know 42 7  Those knowing three of the procedures correctly 115 20.2  Those knowing two of the procedures correctly 188 31.2  Those knowing one of the procedures correctly 235 39.2  Those who do not know any of the procedures (I do not know) 38 6.3  Circulation Evaluation  Not feeling a pulse in the vessels of the neck 121 20.2  Not feeling a pulse in the vessels of the arm 187 31.2  Both 193 32.2  I do not know 108 18  ‘Chest compression’ means  To scrub the chest at certain intervals 67 11.2  To apply strong compression to the chest at certain intervals (compression) 343 57.2  To scrub the heart directly by opening the chest wall 11 1.8  To apply compression directly to the heart by opening the chest wall 24 4.0  I have no idea 155 25.8


## 3.4. Witnessing a Sudden Death

Only 95 (15.8%) reported witnessing a sudden death before, while only 36 (21.1%) were able to perform CPR. The rest of these results are presented in Table4.Table 4
Witnessing a sudden death.
Variable N % Who was he/she?  Somebody from my family 63 10.5  Somebody from my friends or acquaintances 14 2.3  A stranger 23 3.8  I have not seen a sudden death happen 505 84.2  What did you do in the situation?  I began to give chest compressions 21 15  I conducted mouth-to-mouth ventilation 10 7.1  I both gave chest compressions and conducted mouth-to-mouth ventilation (i.e., I gave CPR) 36 22.1  I called an ambulance 57 40.7  I told somebody to call for help 42 30.7  I called for help by telephone 20 14.3  I just watched and left 25 17.9


## 3.5. CPR Attitudes

For the respondents who answered the question ‘to whom would you apply CPR without hesitation,’ 465 (94.2%) stated for a family member, followed by 397 who said for a friend (66.2%), and then 313 who said for a neighbour (52.2%). For the question ‘what would you do in the case of a family member,’ ‘call an ambulance’ was selected by 44.4% and ‘begin to give a chest compression’ was selected by 35.8%. For the question ‘what would you do regarding a stranger,’ ‘call an ambulance’ was reported by 54.7% and ‘begin to give a cardiac chest compression’ was stated by 24.5%. The main reason that may prevent someone from giving a chest compression to either a friend/relative or a stranger was reported as ‘making a mistake’ by 71.0% and 62.0%, respectively. The rest of these results are presented in Table5.Table 5
Taking action.
Variable N % If sudden death occurs in the following people, for whom would you conduct respiration and give chest compression?  Someone from the family 565 94.2  Friend 397 66.2  Neighbour 313 52.2  A youth in the sports hall 230 38.3  A stranger in the supermarket 220 36.7  A person who has poor personal hygiene at the bus stop 172 28.7  A gamin who is drug-dependent and uses glue, hashish, and/or heroin 154 25.7  If somebody from among your family members or friends felt faint (sudden death), what would you do?  I would begin to give chest compression 215 35.8  I would call an ambulance 264 44.4  I would call somebody or call for help 119 19.8  I would just watch and leave 2 0.3  If you witness a stranger feeling faint,what would you do?  I would begin to give chest compression 147 24.5  I would call an ambulance 328 54.7  I would call somebody or call for help 120 20.0  I would just watch and leave 2 0.5  What concerns may prevent you from giving chest compression to your friends or relatives?  Making a mistake 426 71.0  Causing bone fractures 27 4.5  Causing harm to organs 25 4.2  Stopping a working heart 19 3.2  Punishment due to legal reasons 26 4.3  Contamination by blood or vomiting 5 0.8  Contracting a contagious disease 12 2.0  Other 60 10.0  What concerns may prevent you from giving chest compression to a stranger?  Making a mistake 372 62.0  Causing bone fractures 19 3.2  Causing harm to organs 24 4.0  Stopping a working heart 17 2.8  Punishment due to legal reasons 59 9.8  Contamination by blood or vomiting 12 2.0  Contracting a contagious disease 31 5.2  Other 66 11.0


## 3.6. CPR Knowledge and Training Status

Only 196 (32.7%) of the participants reported knowing how to give a chest compression and only 172 (28.7%) had received formal training. Regarding where these individuals were trained, 46 (21.3%) reported receiving training ‘at a course given by the trainers of the ministry of health.’ The rest of these results are presented in Table6.Table 6
CPR training.
Variable N % Do you know how to give chest compression in the case of cardiac arrest and respiratory standstill?  No 404 67.3  Yes 196 32.7  Have you received any training?  No 428 71.3  Yes 172 28.7  Where (n = 172)?  At school 23 10.6  At university 32 14.8  During my military service 5 2.3  At a resuscitation society course 13 6.0  At a course given by the trainers of the ministry of health 46 21.3  In a sports club 6 2.8  At a course given in the workplace 37 17.1  Television/Internet/media 53 24.5


## 3.7. CPR Skills

Less than one-third (177; 29.5%) reported that they could ‘both ventilate and give a chest compression.’ Only 69 (11.5%) knew the proper rate of chest compression to artificial ventilation during CPR (30/2 compression/breath) and only 71 (11.8%) knew the proper rate of chest compressions (i.e., at least 100 times per minute). Of the total participant cohort, 333 (55.5%) knew the applying place of chest compression (middle of the chest) and 267 (44.5%) knew the appropriate force to apply (moderate force, such that the rib cage moves down 5 cm to 6 cm). Additionally, 428 (71.3%) knew about the defibrillator (a device that restarts a heart that has stopped working) and 132 (22.0%) knew where an automated external defibrillator or a pacemaker can be found. The rest of these results are presented in Table7.Table 7
Application of CPR.
Variable N % What BLS applications can you apply?  I can open the airway 58 9.7  I can control respiration 7 1.2  I can ventilate/conduct mouth-to-mouth ventilation 55 9.2  I can give chest compression 70 11.7  I can both ventilate and give chest compression 177 29.5  I do not know 233 38.8  What is the proper rate of chest compression /artificial ventilation during the chest compression (compressions/breaths)?  5/1 173 28.8  15/2 131 21.8  30/2 69 11.5  Other 227 37.8  Which of the following areas must chest compression be applied on?  An upper part of the chest 110 18.3  Middle of the chest 333 55.5  A lower part of the chest 83 13.8  Other 74 12.3  What must be the rate of the chest compression?  At least 150 times per minute 22 3.7  At least 100 times per minute 71 11.8  At least 50 times per minute 162 27.0  I don’t know 345 57.5  How much force must be applied during chest compression?  Enough that the rib cage moves down 1 cm to 2 cm 203 33.8  Moderate force, such that the rib cage moves down 5 to 6 cm 267 44.5  High force, such that the rib cage moves down 6 cm to 10 cm 42 7.0  As much force as possible 88 14.7  What do you know about the device defined as a defibrillator that is used during the chest compression when necessary?  I have never heard of it 75 12.5  I have heard of it before but not seen it 96 16  It is a device supporting respiration 55 9.2  It is a device used to restart a heart that has stopped working 428 71.3  Do you have any idea about where an ‘automated external defibrillator’ or a ‘pacemaker’ can be found?  I don’t know 468 78.0  Yes 132 22.0


## 3.8. Association between Identification of Cardiac Arrest Findings and CPR Training

The survey results revealed a significant difference in the identification of cardiac arrest findings between respondents with previous CPR training and those without. Those who had received training showed a higher rate of knowing the correct procedures of evaluation of consciousness, respiration, and circulation (p = 0.151, p = 0.018, and p = 0.026, respectively). For more details, see Table8.Table 8
Association between identification of cardiac arrest findings and CPR training.
Variable Those who have not received CPR training  N  % Those who have received CPR training  N  % Total  N  % p value a Consciousness evaluation  No response when called 126 42 168 0.151 29.4% 24.4% 28.0% No response when touched 25 13 38 5.8% 7.6% 6.3% Not moving at all 49 14 63 11.4% 8.1% 10.5% Those knowing three of the procedures correctly 48 29 77 11.2% 16.9% 12.8% Those knowing two of the procedures correctly 102 49 151 23.9% 28.5% 41.4% Those who do not know any of the procedures (I don’t know) 78 25 103 18.2% 14.5% 17.2%  Respiration evaluation  No respiratory movement 90 34 124 0.018∗ 21.0% 19.7% 20.7% No respiratory sound 35 7 42 8.2% 4.1% 7.0% No air coming out of the mouth of an individual 55 18 73 12.9% 10.5% 12.2% No steaming up of a mirror placed in front of the mouth of an individual 17 7 24 4.0% 4.1% 4.0% Those knowing three of the procedures correctly 66 49 115 15.4% 28.5% 20.2% Those knowing two of the procedures correctly 133 55 188 31% 32% 31.2% Those who do not know any of the procedures (I don’t know) 29 9 38 6.8% 5.2% 6.3%  Circulation evaluation  Not feeling a pulse in the vessels of the neck 91 30 121 0.026∗ 21.3% 17.4% 20.2% Not feeling a pulse in the vessels of the arm 135 52 187 31.5% 30.2% 31.2% Both 120 73 193 28.0% 42.4% 32.2% I don’t know 91 17 108 21.3% 9.9% 18% a: Respondents who chose ‘I do not know’ were excluded from the statistical test of significance


## 3.9. Association of Response to a Sudden Death with CPR Training

The results revealed no significant difference in the action of the witness of a sudden death between respondents with previous CPR training and those without. For more details, see Table9.Table 9
Association between the actions performed to a witnessed cardiac arrest with previous CPR training.
Variable Those who have not received CPR training  N  % Those who have received CPR training  N  % Total  N  % p value I both gave chest compressions and conducted mouth-to-mouth ventilation (i.e., I gave CPR) 15 21 36 0.568 16.3% 43.8% 22.1% I called emergency services 57 22 79 62.0% 45.8% 75.0% I just watched and left 20 5 25 21.7% 10.4% 17.9%


## 3.10. Association of CPR Application with CPR Training

The results revealed a significant association between the application of CPR and having CPR training. Those who received training showed a higher rate of knowing the correct answers regarding proper rate of chest compression /artificial ventilation during CPR, where the chest compression must be applied, the rate of chest compressions, and the force that must be applied during chest compression (p < 0.0001, p < 0.0001, p < 0.0001, and p = 0.004, respectively). For more details, see Table10.Table 10
Association of CPR application with previous CRP training.
Variable Those who have not received CPR training  N  % Those who have received CPR training  N  % Total  N  % p value What BLS applications can you apply?  I can open the airway 39 19 58 0.0001∗∗ 9.1% 11.0% 9.7% I can control respiration 6 1 7 1.4% 0.6% 1.2% I can ventilate/conduct mouth-to-mouth ventilation 32 23 55 7.5% 13.3% 9.2% I can give chest compression 43 27 70 10.0% 15.7% 11.7% I can both ventilate and give chest compression 95 82 177 22.2% 47.7% 29.5% I do not know 215 18 233 50.2% 10.5% 38.8%  What is the proper rate of chest compression /artificial ventilation during the CPR (compressions/breaths)?  5/1 122 51 173 0.0001∗∗ 28.5% 29.6% 28.8% 15/2 79 50 131 18.4% 29% 21.8% 30/2 23 46 69 5.3% 26.7% 11.5%  Where must chest compression be applied?  An upper part of the chest 82 28 110 0.0001∗∗ 19.2% 16.3% 18.3% Middle of the chest 222 111 333 51.9% 64.5% 55.5% A lower part of the chest 52 31 83 12.1% 18.0% 13.8% Other 72 2 74 16.8% 1.2% 12.3%  What must be the rate of the chest compression?  At least 150 times per minute 12 10 22 0.0001∗∗ 2.8% 5.8% 3.7% At least 100 times per minute 32 39 71 7.5% 22.7% 11.8% At least 50 times per minute 90 72 162 21.0% 41.9% 27.0% I do not know 294 51 345 68.7% 29.7% 57.5%  How much force must be applied during chest compression?  Enough that the rib cage moves down 1 cm to 2 cm 133 68 203 0.004 ∗ 31.0% 39.5% 33.8% Moderate force, such that the rib cage moves down 5 cm to 6 cm 185 84 267 43.3% 48.8% 44.5% High force, such that the rib cage moves down 6 cm to 10 cm 35 7 42 8.2% 4.1% 7.0% As much force as possible 75 13 88 17.5% 7.6% 14.7%


## 4. Discussion

It is agreed largely that CPR is one of the most essential methods available to save a cardiac patient’s life. As such, we think that it is very important to evaluate the level of knowledge in our society. In the present study, we sought to assess the knowledge of nonmedical people in Jeddah to recognize and intervene by doing CPR in the case of OHCA.At the beginning of our analysis, we calculated the percentage of nonmedical people who had participated in a CPR course in the past. Unfortunately, we found that only 172 (28.7%) individuals undertook a CPR course, despite the excellent education level that our people generally have. This finding was almost similar to those of two studies conducted in Ireland and New Zealand, respectively, which revealed percentages of 28% and 27%. However, other previous studies showed higher rates of CPR training. Specifically, 79% were reported to have CPR training by a study conducted in Washington [14], 75% in Poland [15], 69.4% in Slovenia [7], 64% in Australia [16], and 40.3% in Turkey [2]. These disparate findings can be explained by the fact that BLS courses are a mandatory requirement before getting a driver’s license or before enrolment in some jobs in certain countries like Turkey and Slovenia [2, 7]. In our country, at this time, it is not a mandatory requirement, except in a very few number of workplaces. One-quarter of trained nonmedical people in the present study got their CPR experience through the Internet, television, or media, which could explain the huge gap between us and the aforementioned countries.The methods of assessing for cardiac arrest varied between respondents who received BLS course and those who did not in a statistically significant manner. Among those who previously received CPR training, 16.9%, 28.5%, and 17.4% can properly assess consciousness, breathing, and circulation, respectively. Our findings were almost equal to those of the Slovenian study, in which the authors found that 22%, 29.4%, and 9.5% of the trained people could properly assess consciousness, breathing, and circulation, respectively [7]. On the other hand, our results were much better than those reported in a Turkish study in which the investigators found that only 5%, 5.2%, and 7.1% of the trained people could properly assess consciousness, breathing, and circulation, respectively [2]. These findings assert the good quality of the CPR training that nonmedical people in our study received.Regarding BLS application, 29.5% can perform both breathing and cardiac compression, which was similar to the results of the Turkish study (28.7%) but less than the results of the Slovenian study (38%). In comparison, 38.8% reported that they do not know how to do either one of these actions, a finding which was similar to the Turkish study (38.6%) and lower than the Slovenian study (45.4%) [2, 7]. Additionally, when our study population was asked about the details of breathing and cardiac compression (for example, compression place, compression force, compression rate, and compression to breathing ratio), our population showed the same level of knowledge as did those participants in previous studies of other countries, which was very low in general with a clear significant difference between people who received training versus those who did not receive training. This raises the importance of the introduction of an urgent intervention to boost the level of knowledge in order to save as many cardiac arrest patients as possible.According to our results, 15.8% of our population has witnessed a sudden death, with the majority of those patients being family members (70%). Unfortunately, only 22.1% started CPR in these cases. Similarly, in the Turkish study, 18.6% of the participants reported having witnessed a sudden death and 22% said they started CPR, with the main reason behind not conducting CPR being fear to make a mistake, which could be explained by the low level of knowledge among their population [2]. However, much lower rates of conducting CPR were reported by a study in Japan, in which 19% of participants witnessed a sudden death but only 4% of them started CPR [17]. Thankfully, a good number of people in Saudi Arabia report feeling comfortable regarding giving CPR to a member of their family (94.2%) and to a stranger (36.7%). Similarly, in a study conducted in Arizona, 80% of 750 participants reported feeling fine to perform CPR on a member of their family and 50% reported the same regarding a stranger [18].When we put our participants in a situation of sudden cardiac arrest of one of their family members or friends, nearly one-third of participants (35.8%) would begin CPR. The most common reason for not conducting CPR was reportedly to be the fear to make a mistake (71.0%). A study conducted in Japan found that the scare of disease transmission was the most common cause (28%) [17].On the other hand, when we asked our participants about the same situation occurring to strangers, the percentage of those willing to begin CPR decreased to 24.5%, though the most common cause remained a fear of performing it the wrong way (62%). However, the scare of disease transmission and legal issues increased to become 5.2% and 9.85%, respectively. In the study in Arizona, concerns about making a mistake was the most common cause of unwillingness to perform CPR (22.8%), while 17.7% reported hesitation due to potential legal issues [18]. In Japan, the most common cause was scare of transmission of diseases in 63% [17]. Again, these findings raise the value of finding a solution to increase the knowledge about CPR and correct existing mistaken beliefs.


## 5. Conclusion and Recommendations

The level of knowledge of our community regarding CPR is limited and very shallow compared to the knowledge levels of other neighbouring countries. Furthermore, some mistaken beliefs do exist. For that reason, we have some recommendations that we expect will increase the knowledge regarding CPR in Saudi Arabia. First of all, we highly recommend undertaking huge efforts to increase the awareness and knowledge of CPR. For example, we advise high-grade schools and universities to conduct a BLS course every year and to make it a routine requirement. We additionally advise our government to designate a BLS course as an obligatory requirement before getting a driver’s license or prior to enrolment in some jobs that include contact with other people. Second, we suggest establishing a routine examination of CPR awareness and knowledge, which will assess the benefits of the conduction of BLS courses and attempt to elucidate the weak points so as to further improve the courses in the future. Finally, we believe it is also very important to assess the quality of CPR that has been performed, as this is a very important element in the success of resuscitation [5].



---

*Source: 3686202-2019-01-16.xml*