Resuscitation by primary care doctors

BACKGROUND: Sudden cardiac arrest is a common mechanism of premature death in the community. Resuscitation is often possible, but no large study of resuscitation by doctors who practice there has been published. METHODS: General practitioners (GPs) equipped with defibrillators reported 555 patients with cardiac arrest in whom they attempted resuscitation. FINDINGS: Average age was 65.4, 75% male. Most arrests (49%) occurred at the patient's home but some (18%) occurred at or near the doctors' surgeries. Heart disease was responsible for 88% of the arrests: in these cases resuscitation to leave hospital alive was frequently successful (148 of 436 attempts, 34%). Success was rare (one of 59, <2%) when the arrest was due to non-cardiac disease. Resuscitation was most common when the first monitored rhythm was shockable (VF/VT) and defibrillated promptly: 144 out of 351 (41%) patients surviving. VF/VT was most common with early rhythm monitoring, particularly when the doctor was present (63% survival), or nearby (54%). When VF/VT complicated AMI, 72% of those defibrillated within 1min of onset survived. With delayed attendance, the frequency of VF/VT fell and asystole or Pulseless Electrical Activity (PEA) became more common. Survival after resuscitation was rare for patients presenting with these rhythms: five of 202 (2.5%). No such patient survived unless the rhythm could be converted to VF/VT with drugs or basic life support and subsequently shocked. CONCLUSION: Primary care doctors equipped with defibrillators attend patients with cardiac arrest under circumstances in which resuscitation is frequently successful. This presents a unique opportunity to reduce mortality from sudden cardiac arrest.     

Early defibrillation and the chain of survival in 'in-hospital' adult cardiac arrest; minutes count

OBJECTIVE: To report the outcomes from and the impact of the chain of survival in 'in-hospital' cardiac arrest where the presenting rhythm was VF/VT, the arrest was witnessed, defibrillation was conducted rapidly and no other resuscitation interventions were required. Outcome measures: Any return of spontaneous circulation and discharge from hospital. METHODS: A 2-year prospective resuscitation audit using the Utstein style was conducted within a major London NHS Hospital Group. RESULTS: There were 124 patients who had primary VF/VT arrest. Eight were excluded from the study and 14 had non-witnessed cardiac arrest. Twenty one patients had witnessed VF/VT arrest but with delayed defibrillation, 81 patients had witnessed VF/VT arrest with rapid defibrillation, 69 patients had witnessed VF/VT arrest with rapid defibrillation, CPR and other additional interventions. There were 15 patients that had witnessed cardiac arrest with a presenting rhythm of VF/VT, who received rapid defibrillation and had no ventilation or chest compression prior to or following defibrillation. All 15 patients achieved a return of spontaneous circulation, and 12 were discharged alive. CONCLUSIONS: Rapid defibrillation prior to any other resuscitation intervention is associated with increased survival from witnessed VF/VT arrest in in-hospital cardiac arrest victims, and that the time to first shock is critical in enhancing the prospects of long-term survival in these patients.     

An audit of cardiac arrest management by extended trained ambulance crew.

OBJECTIVE--To audit the use of extended skills by South Glamorgan Ambulance crew in attempted resuscitations from out-of-hospital cardio-respiratory arrest, in terms of successful discharge of patients from hospital and the accuracy with which agreed protocols were applied. Design-Retrospective analysis of ambulance report forms, electrocardiograph rhythm strips, casualty cards and discharge summaries during 26 months (1st May 1987-30th June 1989). SETTING--A mixed urban and semi-rural area of 187 square miles with a population of 396,000. RESULTS--There were 274 attempted resuscitations. Seven patients (2.5%) were managed for primary respiratory arrest and 3 were discharged. In 98 patients (35.8%) the initial resuscitation protocol was for ventricular fibrillation: 26 were admitted and 17 were discharged. In 169 patients (61.7%) the initial resuscitation protocol was for asystole or electromechanical dissociation: 11 were admitted and 1 discharged. The majority of patients who were successfully discharged from hospital were those in ventricular fibrillation who responded to defibrillation alone (13 survivors). Drug administration may have played a role in the successful resuscitation of the remainder. Endotracheal intubation was successful in 94.7% and vein cannulation in 87.7% of attempts. There were deviations from the ventricular fibrillation protocol in 27 cases (27.5%) and from the asystole protocol in 27 cases (16.0%). CONCLUSION--Survival rates for ventricular fibrillation managed by these personnel were satisfactory with early defibrillation. Defibrillation alone was responsible for the majority of successful resuscitations. The additional benefit of drug administration appears small, though potentially important. The majority of patients were in asystole by the time the ambulance arrived. IMPLICATIONS--Extended trained crews use their skills effectively. The most important skill is defibrillation. Further studies are required to explain the high proportion of patients found in asystole. The performance of individual ambulance personnel should be assessed prospectively, because agreed resuscitation protocols are not always followed.     

Public access defibrillation in Helsinki--costs and potential benefits from a community-based pilot study

In cardiac arrest the interval between the collapse and defibrillation may be shortened by teaching lay people to use defibrillators. We conducted a 3-year prospective, community-based study on public access defibrillation (PAD) in an urban emergency medical services system. All public sites with a cardiac arrest incidence of at least one per year were equipped with automated external defibrillators. Twenty cardiac arrest patients were enrolled, seven in PAD and 13 in control group. Defibrillation was accomplished significantly earlier (P=0.01) in the PAD group. The direct costs were 110,270 Eur and only 13.5-16% of this figure would be related to the cost of defibrillators during their 8 years lifespan. This study showed that a community based model of PAD shortens the time to CPR and defibrillation significantly in an urban environment but various challenges have to be solved before wider implementation of PAD. In future projects the nature of the costs especially should be considered.     

Evaluation of the use of automatic external defibrillation in out-of-hospital cardiac arrest in Hong Kong.

A retrospective 6-month audit of out-of-hospital cardiac arrests in Hong Kong following the introduction of automatic external defibrillators is presented. During the 6-month period from 1 July 1995 to 31 December 1995, resuscitation was attempted on 754 patients. Of the 744 patients with cardiac arrest whose records were available, 53.6% had a witnessed arrest. Few cardiac arrest patients (8.9%) received bystander cardiopulmonary resuscitation (CPR) and the majority (80%) of arrests occurred at home. Six hundred and forty-three (86.4%) patients were declared dead on arrival at hospital or in the Accident and Emergency department; 89 (12%) died in hospital and only 12 (1.6%) were discharged alive. The average ambulance response interval (call receipt to arrival of ambulance at scene) was 6.42 min. The average arrest-to-first-shock interval was 23.77 min. Factors predicting survival included initial rhythm and arrest-to-first-shock interval. The survival rate of 1.6% is low by world standards. To improve the survival rates of people with out-of-hospital cardiac arrest, the arrest-to-call interval must be reduced and the frequency of bystander CPR assistance increased. Once these changes are in place, a beneficial effect from the use of pre-hospital defibrillation might be seen.     

Out of hospital cardiac arrests--the experience of one hospital in Singapore.

In Singapore, all public emergency ambulances are equipped with semi-automatic external defibrillators and the crew is trained in their use. This is the first paper from Singapore reporting the survival rate in patients presenting to an urban public hospital with acute coronary syndrome (ACS) who developed out-of-hospital cardiac arrest (OHCA). All consecutive patients who presented to the ED of a public hospital with OHCA or ACS were surveyed from 1 April 1999 to 30 September 1999. There were 392 patients among whom 115 (28.5%) had OHCA. There was no significant difference in age and gender distribution between the OHCA and non-OHCA patients. More than 2/3 of the OHCA patients had no report of chest pain or breathlessness before they collapsed. Forty five (39.1%) of the 115 OHCA patients were noted to have initial rhythms of ventricular tachycardia (VT) or ventricular fibrillation (VF) and received pre-hospital defibrillation. The mean time from collapse to first DC shock was 12.07+/-7.2 min. Twenty (17.4%) of the OHCA patients had return of spontaneous circulation after resuscitation in the ED. Four patients (3.5%), all with an initial rhythm of VF were discharged alive from the hospital. Much remains to be done to reduce the time interval to first DC shock for the OHCA group.     

In-hospital cardiac resuscitation outside the ICU by nursing staff equipped with automated external defibrillators--the first 500 cases

BACKGROUND: Since nursing staff in the hospital are frequently the first to witness a cardiac arrest, they may play a central role in the effective management of in-hospital cardiac arrest. In this retrospective study the first 500 in-hospital cardiac arrests in non-monitored areas, which were treated initially by nursing staff equipped with automated external defibrillators (AEDs) are reported. METHODS AND RESULTS: Between April 2001 and December 2004, 500 in-hospital cardiac arrest calls were made: there were false arrests in 61 patients, so a total of 439 patients (88%) were evaluated using the Utstein style of data collection. ROSC occurred in 256 patients (58%), 125 (28%) were discharged from hospital and 95 (22%) were still alive 6 months after discharge. Among the 73 patients with VF/VT 63 (86%) had ROSC, 34 (47%) were discharged from hospital and 28 (38%) were alive after 6 months. The chance of survival was not influenced by the time between the call of the arrest team and the 1st defibrillation but was slightly higher with physicians as in-hospital first responders (p=0.078). In contrast, 366 patients with non-VF/VT, 193 (53%) had ROSC, but only 91 (25%) were discharged from hospital and 67 (18%) were alive after 6 months. The risk of dying was significantly higher in patients with non-VF/VT (p<0.001), and there was a trend to a higher risk ratio in patients older than 65 years and in patients with non-witnessed cardiac arrest (p=0.056 and 0.079, respectively). CONCLUSION: This observational study supports the concept of hospital-wide first responder resuscitation performed by nursing staff before the arrival of the CPR-team. Among these patients survival rate was higher in those with VF/VT defibrillated at an early stage. Consequently, it may be assumed that patients may die unnecessarily due to sudden cardiac arrest if proper in-hospital resuscitation programmes are not available.     

Influence of External Defibrillator Electrode Polarity on Cardiac Resuscitation

Eight hundred forty-seven consecutive patients discovered in cardiac arrest by first responding firefighters received initial defibrillation attempts using automatic external defibrillators. The effect of electrode polarity on defibrillation and resuscitation was delermined in the subset of 289 (34%) with ventricuiar fibrillation in a prospective, randomized trial. The ECG was recorded in 205 consecutive patients whose initial rhythm was ventricular fibrillation. Eighty-seven of 114 patients (76%) in whom the apex chest electrode was positive were defibrillated with the first 200-joule shock, compared to 70 of 91 patients (77%) in whom the apex eiectrode was negative. There was no difference in the type of rhythm established, e.g., organized versus brady-asystole following defibrillation with either electrode polarity. Resuscitation was possible in 56% of patients in whom the apex electrode was positive and 60% of those in whom the apex electrode was of negative polarity. Hospital survival rates (26% vs 27%) were also similar for both treatment groups, Unlike results during experimental external defibrillation of animals or those obtained using implantoble defibrillators, this randomized trial of external defibrillation conducted during attempted out-of-hospital resuscitation showed no difference in outcomes related to electrode polarity.     

Defibrillation

Defibrillation has emerged as the single most effective intervention for resuscitation of patients from cardiac arrest. This article reviews the electrophysiologic basis of defibrillation, and ways to increase the effectiveness of counter-shocks, particularly for refractory ventricular fibrillation. Automatic implantable and automatic external defibrillators have been developed and are being used in many locations. In future years they will be used increasingly in the homes of high-risk patients, in community settings with limited access to emergency care, and by minimally trained pre-hospital emergency personnel.     

Evaluation of the in-hospital Utstein template in cardiopulmonary resuscitation in secondary hospitals

INTRODUCTION: The in-hospital Utstein template for cardiopulmonary resuscitation (CPR) was assessed in four secondary hospitals (334-441 beds) which did not have systematic data collection. MATERIALS AND METHODS: The reports and outcome over a period of 12 months during the years 2000-2001 were evaluated. RESULTS: Of a total of 1690 patients that had a cardiac arrest (CA), 204 (12%) were resuscitated. Information on the collected Utstein parameters were available as follows: initial rhythm in 91%, time interval from collapse to defibrillation (in case of ventricular fibrillation or ventricular tachycardia as initial rhythm) in 90%, time interval to return of spontaneous circulation (ROSC) in 83% and duration of resuscitation in 83%. ROSC was achieved in 69 patients (34%, CI 27-41%) and 34 (17%, CI 11-23%) survived to hospital discharge. Twenty patients showed satisfactory neurological recovery (10%, CI 6-14%). Eighteen (9%, CI 5-13%) patients were alive at 12 months from the event. Factors associated with survival to hospital discharge were VF/VT (P=0.007) as the initial rhythm and shorter interval to defibrillation (P=0.046). CONCLUSION: The in-hospital Utstein template was logical but laborious and it provided tools for resuscitation management evaluation in the study hospitals. For continuous use, a slightly compressed model may be warranted. In the present material, the overall survival rate to hospital discharge was in line with previous reports but there were somewhat less neurologically satisfactory survivors. There is an evident need to improve the outcome of patients suffering CA on the wards. An important step is to reduce the time interval to defibrillation.     

RECTILINEAR BIPHASIC WAVEFORM DEFIBRILLATION OF OUT-OF-HOSPITAL CARDIAC ARREST

Objective. The rectilinear biphasic (RLB) waveform has been shown to effectively defibrillate short-duration ventricular fibrillation (VF) at significantly lower energies than a mono-phasic damped sine (MDS) waveform. This article reports RLB waveform defibrillation effectiveness for patients presenting in VF during out-of-hospital cardiac arrest when compared with historical MDS effectiveness. Methods. External RLB defibrillators were deployed in the Omaha Fire Department's emergency medical services (EMS) system. The RLB defibrillators delivered an escalating three-shock sequence of 120, 150, and 200?J. The results observed during the first year of full deployment were compared with the results observed during the previous year when only MDS defibrillators were deployed in the system. The MDS defibrillators delivered an escalating three-shock sequence of 200, 300, and 360?J. Defibrillation was defined as termination of VF for at least 5 seconds after a defibrillation shock. Results. There were 141 adult patients presenting in VF without trauma during the first year using RLB defibrillators. By comparison, there were 153 adult patients during the comparable year using MDS defibrillators. The 120-J RLB shocks had a significantly higher first-shock rate of successful VF termination (67%, 95% CI: 59%–75%) compared with the initial 200-J MDS shocks (48%, 95% CI: 40%–57%, p < 0.0025; odds ratio 2.14 [1.33–3.42]). The number of patients who were defibrillated to a return of spontaneous circulation with a sinus rhythm was significantly greater (25%, 95% CI: 18%–33%) when using the RLB defibrillator compared with using the MDS defibrillator (15%, 95% CI: 10%–22%, p = 0.05; odds ratio 1.85 [1.04–3.31]). Conclusion. The RLB defibrillator terminated the VF of patients in out-of-hospital cardiac arrest with superior rates using significantly less energy compared with historical rates for a higher-energy MDS defibrillator.     

The potential use of automatic defibrillators in the home for management of cardiac arrest

Ventricular fibrillation, an abnormal cardiac rhythm, occurs in at least two-thirds of the 400,000 people who die out of the hospital from sudden cardiac arrest. This rhythm can be treated successfully by electric countershock, a procedure known as defibrillation. The survival rate following such cardiac arrest is directly related to the rapidity of response; the shorter the time from collapse to defibrillation, the more patients will survive. There are two basic options to shorten the time from collapse to defibrillatory shock. The first is to upgrade the emergency medical system. The second is to provide spouses and family members of potential cardiac arrest patients with automatic home defibrillators. This article considers the effectiveness of the second option, home defibrillation, compared with that of an equally costly upgrade in existing emergency medical service systems. The comparisons depend on the existing level of emergency medical service system, the cost of the home defibrillator, and the rate at which a home defibrillator would be used appropriately. The comparisons suggest that in many circumstances home defibrillation is an appropriate option to be considered.     

Electrical therapies in cardiac arrest

Recognition and appropriate treatment of ventricular fibrillation or pulseless ventricular tachycardia is an essential skill for healthcare providers. Appropriate defibrillation can improve survival and benefit patient outcome. Similarly, increased public access to automatic electronic defibrillators has been shown to improve out-of-hospital survival for cardiac arrest. When combined with high-quality cardiopulmonary resuscitation, electrical therapies are an important aspect of resuscitation in the patient with cardiac arrest. This article focuses on the use of electrical therapies, including defibrillation, cardiac pacing, and automated external defibrillators, in cardiac arrest.     

Waveforms of external defibrillators: analysis and energy contribution.

BACKGROUND AND OBJECTIVE: Defibrillation is the most important therapy for terminating ventricular fibrillation in cardiac arrest patients. In addition to performing defibrillation at the earliest possible time, appropriate pulse energy and optimal waveform seem to be crucial for success. Emergency medical service personnel use different defibrillators and rely on their similarity of energy content. This study examined the true pulse energy content and waveform of 17 commonly used defibrillators. METHODS AND RESULTS: Defibrillation energies were selected to be 30, 200 or 360 J and defibrillators were discharged into test resistors, simulating transthoracic impedances of 25, 50 or 100 Ohms. Pulse energy deviated by up to +23% or -29% from the selected energy. Pulse energy within the initial 8 ms ranged from 90 to 30% of total pulse energy. Fourteen defibrillators utilising damped sinusoidal waveforms produced a monophasic pulse when discharged into resistances of 50 Ohms and 100 Ohms. CONCLUSIONS: Defibrillators used at the same energy settings do not necessarily produce the same defibrillation pulse energy. All but one defibrillator actually use monophasic waveforms, leaving the potential advantage of biphasic waveforms unused. Energy accuracy of defibrillators needs to be improved, and biphasic waveforms should be used more.     

Long-term prognosis following resuscitation from out-of-hospital cardiac arrest: role of aetiology and presenting arrest rhythm

ObjectiveLittle is known about long-term prognosis following resuscitation from out-of-hospital cardiac arrest, especially as it relates to the presenting rhythm or arrest aetiology. We investigated long-term survival among those discharged alive following resuscitation according to presenting rhythm and arrest aetiology.MethodsWe conducted a cohort investigation of all non-traumatic adult out-of-hospital cardiac arrest patients resuscitated and discharged alive from hospital between January 1, 2001 and December 31, 2009 in a large metropolitan emergency medical service system. Information about demographics, circumstances, presenting arrest rhythm and aetiology was collected using the dispatch, EMS, and hospital records. Long-term vital status was ascertained using state death records and the Social Security Death Index through 31st December 2010. We used Kaplan Meier to evaluate survival.ResultsDuring the study period, a total of 1001/5958 (17%) persons were resuscitated and discharged alive, of whom 313/1001 (31%) presented with a non-shockable rhythm and 210/1001 (21%) had a non-cardiac aetiology. Overall median survival was 9.8 years with 64% surviving >5 years. Five-year survival was 43% for non-shockable rhythms compared to 73% for shockable rhythms, and 45% for non-cardiac aetiology compared to 69% for cardiac aetiology (p < 0.001 respectively).ConclusionCardiac arrest due to non-shockable rhythm or non-cardiac aetiology comprises a substantial proportion of those who survive to hospital discharge. Although long-term survival in these groups is less than their shockable or cardiac aetiology counterparts, nearly half are alive 5 years following discharge. The findings support efforts to improve resuscitation care for those with non-shockable rhythms or non-cardiac cause.     

Flying squad response to out-of-hospital cardiac arrest--a decade of experience.

The Flying Squad (MEDIC I) based at the Royal Infirmary, Edinburgh, commenced operation in 1980. The MEDIC I response to out of hospital non-traumatic cardiac arrest over the past decade is reported. On-scene resuscitation was attempted in 384 patients. A total of 149 (39%) patients were successfully resuscitated and transferred to hospital. Thirty-six (9.4%) patients survived to discharge from hospital. Patients receiving basic life support prior to the arrival of MEDIC I and in ventricular fibrillation had a survival rate of 14.5% (25/174). During 1988-89, 21 patients were initially attended by ambulance crews equipped with semi-automatic external defibrillators and eight (38%) of these patients survived. The response of a hospital-based flying squad to support trained ambulance crews, especially when equipped with a defibrillator may provide an economically and operationally feasible alternative to training all first responders in the full range of paramedic skills.     

Double Sequential External Defibrillation and Survival from Out-of-Hospital Cardiac Arrest: A Case Report

Background: Patients who present in ventricular fibrillation are typically treated with cardiopulmonary resuscitation (CPR), epinephrine, antiarrhythmic medications, and defibrillation. Although these therapies have shown to be effective, some patients remain in a shockable rhythm. Double sequential external defibrillation has been described as a viable option for patients in refractory ventricular fibrillation. Objective: To describe the innovative use of two defibrillators used to deliver double sequential external defibrillation by paramedics in a case of refractory ventricular fibrillation resulting in prehospital return of spontaneous circulation and survival to hospital discharge with good neurologic function. Case: A 28-year-old female sustained a witnessed out-of-hospital cardiac arrest (OHCA). Bystander CPR was performed by her husband followed by paramedics providing high-quality CPR, antiarrhythmic medication, and 6 biphasic defibrillations using standard energy levels. Double sequential external defibrillation was applied and a return of spontaneous circulation was attained on scene and maintained through to arrival to the emergency department. Following admission to hospital the patient was diagnosed with long QT syndrome. An implantable cardioverter defibrillator was placed and the patient was discharged with a Cerebral Performance Category of 2 as well as a modified Rankin Scale of 2 after an 18-day hospital stay. The patient's functional status continued to improve post discharge. Conclusion: The addition of double sequential external defibrillation as part of a well-organized resuscitation effort may be a valid treatment option for OHCA patients who present in refractory ventricular fibrillation.     

Rectilinear biphasic waveform defibrillation of out-of-hospital cardiac arrest

Objective

The rectilinear biphasic (RLB) waveform has been shown to effectively defibrillate short-duration ventricular fibrillation (VF) at significantly lower energies than a monophasic damped sine (MDS) waveform. This article reports RLB waveform defibrillation effectiveness for patients presenting in VF during out-of-hospital cardiac arrest when compared with historical MDS effectiveness.

Methods

External RLB defibrillators were deployed in the Omaha Fire Department's emergency medical services (EMS) system. The RLB defibrillators delivered an escalating three-shock sequence of 120, 150, and 200 J. The results observed during the first year of full deployment were compared with the results observed during the previous year when only MDS defibrillators were deployed in the system. The MDS defibrillators delivered an escalating three-shock sequence of 200, 300, and 360 J. Defibrillation was defined as termination of VF for at least 5 seconds after a defibrillation shock.

Results

There were 141 adult patients presenting in VF without trauma during the first year using RLB defibrillators. By comparison, there were 153 adult patients during the comparable year using MDS defibrillators. The 120-J RLB shocks had a significantly higher first-shock rate of successful VF termination (67%, 95% CI: 59%-75%) compared with the initial 200-J MDS shocks (48%, 95% CI: 40%-57%, p < 0.0025; odds ratio 2.14 [1.33-3.42]). The number of patients who were defibrillated to a return of spontaneous circulation with a sinus rhythm was significantly greater (25%, 95% CI: 18%-33%) when using the RLB defibrillator compared with using the MDS defibrillator (15%, 95% CI: 10%-22%, p = 0.05; odds ratio 1.85 [1.04-3.31]).

Conclusion

The RLB defibrillator terminated the VF of patients in out-of-hospital cardiac arrest with superior rates using significantly less energy compared with historical rates for a higher-energy MDS defibrillator.     

241例心跳骤停与心肺脑复苏的回顾性分析

目的 探讨心跳骤停患者的临床特点及救治经验，以提高心肺脑复苏成功率。方法 回顾性分析我科1990年10月至2002年10月十二年间院内及院外急救的241例心跳骤停患者的临床资料，初步分析治疗与预后的关系。结果 241例心跳骤停患者中，初步复苏成功10例，最终复苏成功(心肺脑均复苏)仅4例，复苏率分别为4．62％、1．82％。1990至1998年间复苏成功率较低，初步复苏成功率1．38％，最终复苏成功率0。1999至2002年间复苏成功率明显提高，初步复苏成功率8．24％，最终复苏成功率4．12％。自1998年我科开展院外急救以来，尚无一例院外心跳骤停者复苏成功。结论 心跳骤停患者抢救成功与否与抢救人员专业水平、抢救开始时间、抢救措施正确与否、对室颤患者能否早期除颤及患者原发病是否可逆等因素密切相关。     

A strategy for nurse defibrillation in general wards

Reducing the delay to defibrillation has a major impact on chance of survival from cardiac arrest. A high proportion of cardiac arrests occur in general ward areas, and the teaching and application of defibrillation is as much a priority there as in high dependency areas. The patients most likely to survive in-hospital cardiac arrests are those whom return of spontaneous circulation had been achieved by the first responder. In most clinical areas the first responder is likely to be a nurse. Nurses in Brighton had been taught manual defibrillation for many years, but were often reluctant to use their skills. We introduced a course specifically designed for ward nurses, covering rhythm recognition and defibrillation, with the objective of training large numbers and making the skill so prevalent that it would become an accepted nurse procedure. RESULTS: Ninety-eight nurses were trained during 1996. By the end of that year, nurses in general ward areas performed defibrillation in 80% of all cases where a shock was required at any time during the resuscitation attempt. However, only 3/25 (12%) of patients in a primary shockable rhythm were defibrillated before a member of the cardiac arrest team arrived. One hundred and forty-nine additional nurses were trained during 1997/8. By the end of this two year period there was no increase in the overall percentage of nurse defibrillations, but the number of patients in primary VF/VT defibrillated before the arrival of the cardiac arrest team had markedly increased to 17/37 (46%, P < 0.02). During this period the overall hospital survival to discharge from primary VF/VT showed a non significant improvement from 41 to 55%. CONCLUSION: We believe that it is not sufficient simply to permit nurse defibrillation, it must be perceived as a routine skill within the environment of an acute hospital.