The frame of survival for cardiopulmonary resuscitation in lower-resource settings
Authors: Gayathri Devi Nadarajan, Marcus Eng Hock Ong
Journal: The Lancet Global Health (2024)

Inequitable access to emergency care has resulted in global disparities in survival for out-of-hospital cardiac arrest (OHCA) and other time-sensitive conditions. The implementation of cardiac arrest standards originating from high-income countries and the delivery of prehospital emergency care are affected by socioeconomic and geopolitical differences. The sharing of various programmes in the Health Policy paper by Sebastian Schnaubelt and colleagues (September, 2023)1Schnaubelt S Garg R Atiq H et al.Cardiopulmonary resuscitation in low-resource settings: a statement by the International Liaison Committee on Resuscitation, supported by the AFEM, EUSEM, IFEM, and IFRC.Lancet Glob Health. 2023; 11: e1444-e1453Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar is helpful for prehospital systems starting development. It is also commendable that the team has representatives from low-income and middle-income countries (LMICs). However, there could have been better global representation—eg, from countries in southeast Asia where the prehospital system infrastructure has developed rapidly over the past decade. These countries have emergency medicine recognised as a specialty (except for Laos and Cambodia), have established OHCA data collection through the Pan Asian Resuscitation Outcomes Study (PAROS),2Doctor NE Ahmad NSB Pek PP Yap S Ong MEH The Pan-Asian Resuscitation Outcomes Study (PAROS) clinical research network: what, where, why and how.Singapore Med J. 2017; 58: 456-458Crossref PubMed Scopus (32) Google Scholar and are working on quality improvement by use of baseline data. This progress is important because the broad sharing of narratives at each stage of development can be a strong enabler for prehospital emergency care (PEC) systems. Although Schnaubelt and colleagues' chainmail of survival is an interesting concept, it should perhaps include dispatchers and first responders, because in low-resource settings with challenging geographical terrain or traffic conditions, there is a need to depend on first responders in an innovative way. For example, in Bangkok, Thailand, motorcycle taxi drivers can navigate small lanes and are used as first responders.3Riyapan S Saengsung P Chantanakomes J Nakornchai T Limsuwat C Impact of the motorcycle-taxi cardiopulmonary resuscitation (CPR) project on bystander CPR in the Bangkoknoi district of Bangkok, Thailand.Resuscitation. 2021; 162: 180-181Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar Our Global Resuscitation Alliance (GRA) consensus findings on cardiopulmonary resuscitation in low-resource settings4Nadarajan GD Tiah L Ho AFW et al.Global Resuscitation Alliance Utstein recommendations for developing emergency care systems to improve cardiac arrest survival.Resuscitation. 2018; 132: 85-89Summary Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 5Chong SL Laerdal T Cordero J et al.Global Resuscitation Alliance consensus recommendations for developing emergency care systems: reducing perinatal mortality.Resuscitation. 2018; 133: 71-74Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar depict similar issues, but as a frame of survival influencing the chain of survival (figure). The inner frame depicts the country's internal PEC organisation, and the outer frame depicts the country's geopolitical and socioeconomic factors. Differentiating between these two layers can help stakeholders visualise the role they play and help PEC leaders plan their actions, which is what we hope to achieve through such policy papers. The outer and inner frames must be addressed to enable improvement in OHCA outcomes in LMIC settings. For example, a culture of helping others or acceptance of death should be promoted to implement initiatives to improve OHCA survival.By not addressing the frames, there may be resistance at the public and bystander levels to recognise or be first responders to cardiac arrest, preventing prompt recognition and management of OHCA. The consensus also discussed barriers and potential solutions, and prioritised 11 fundamental elements. We believe our findings can complement Schnaubelt and colleagues' Health Policy paper in improving global OHCA survival. We suggest that future research could consider incorporating this frame of survival when addressing cardiopulmonary resuscitation in low-resource settings. MEHO reports grants from the Laerdal Foundation, Laerdal Medical, and the Ramsey Social Justice Foundation for the Pan-Asian Resuscitation Outcomes Study; an advisory relationship with Global Healthcare; a licensing agreement with ZOLL Medical Corporation and a patent filed (application number 13/047,348); and is the co-founder and scientific adviser of TIIM Healthcare. GDN reports no competing interests. Cardiopulmonary resuscitation in low-resource settings: a statement by the International Liaison Committee on Resuscitation, supported by the AFEM, EUSEM, IFEM, and IFRCMost recommendations on cardiopulmonary resuscitation were developed from the perspective of high-resource settings with the aim of applying them in these settings. These so-called international guidelines are often not applicable in low-resource settings. Organisations including the International Liaison Committee on Resuscitation (ILCOR) have not sufficiently addressed this problem. We formed a collaborative group of experts from various settings including low-income, middle-income, and high-income countries, and conducted a prospective, multiphase consensus process to formulate this ILCOR Task Force statement. Full-Text PDF Open Access