To our knowledge, this is the first study conducted in the U.S. to demonstrate that a high school-centered, CPR educational intervention with a “pay-it-forward” component can disseminate CPR knowledge beyond the classroom and reach into low income, minority neighborhoods. High school participants and subsequently trained friends and family demonstrated a statistically significant improvement in aggregate scores. Moreover, students trained an average of 4.9 additional people, demonstrating the potential for a multiplier effect. In a study from Denmark, mass distribution of similar video self-instruction kits resulted in dissemination to an average of 2.5 additional people per student.In another study from Norway with a better survey response rate of 78%, an additional 2.8 people were trained per student participant.Students in our training intervention outperformed their Denmark and Norway counterparts. Our survey response rate was 97% , and students taught on average an additional 4.9 people. Moreover, all participants, students and family and friends, demonstrated significant CPR and AED knowledge increase compared to baseline.However, an investment of one 45- to 60-minute period every school year is sufficient to ensure widespread CPR knowledge.In our study, training was completed in a 45-minute physical education class period, with minimum loss of standard curriculum time, and at low cost. With a retail price of $38.50,pots for cannabis plants the estimated cost per person trained in our pilot program was $6.54. By using video-based learning with an inflatable mannequin, schools can teach Hands-Only CPR skills in a single class period at low cost and with good knowledge acquisition.

Financially restricted schools and communities may not be able to invest in individual training kits for each high school student to take home or even for use in school. A more cost-effective model may include video-based training with use of shared CPR mannequins in the classroom setting. Instead of taking kits home for skills training, students can pay it forward and instruct others by using video and web-based learning platforms without skills practice. Previous research in Arizona has demonstrated that bystanders who learned CPR by watching a 60-second video without skills practice had significantly improved responsiveness, chest compression rate, and decreased hands-off intervals compared to no training.The “pay-it-forward” model also provides an opportunity for high school students to reinforce their knowledge of the chain of survival. Medical students in Germany demonstrated that their own CPR skills improved by teaching schoolchildren.Another study from Belgium demonstrated that instructing schoolchildren to teach Basic Life Support to their relatives and friends led to a more positive attitude of the adults towards bystander CPR.A CPR educational intervention in which high school students become teachers to friends and family can reinforce student knowledge while empowering youth to become community health advocates. As of the drafting of this study,states including Illinois have made CPR a mandatory component of the public high school curriculum.The widespread adoption of CPR training in schools represents a long-term investment to ensure that multiple generations are trained and ready to act.An immediate benefit is the potential impact of adolescents as lay rescuers. Another short-term benefit not well investigated is the potential for an immediate multiplier effect by reaching out of the classroom and into the communities served by the schools.

One successful example of health information flowing from child to parent is the Hip Hop for Stroke program, a school-based, multimedia, stroke-literacy intervention targeting children aged 8-12 in Central Harlem.HHS improved knowledge of stroke symptoms and intent to activate 9-1-1 in children participants while increasing parental stroke literacy.While the concept of child-mediated health education is not new, its application to OHCA remains novel and untested as a major strategy to address significant disparities in outcome by community. Because schools provide large-scale, centrally organized settings accessed by people from all ranges of the social spectrum, a high school-centered, community wide CPR training program has remarkable potential for reach into communities that would otherwise be hard to reach by traditional CPR education efforts. There is significant evidence regarding the high efficacy of child-mediated CPR education. Previous survey studies of witnesses to OCHA have demonstrated that any previous CPR training is a predictor of CPR performance.Moreover, parallel efforts in faith-based, community-based, and employment organizations to teach Hands-Only CPR and share that knowledge with their constituents may have a ripple effect in communities with low bystander-CPR rates.Multifaceted, community-based approaches aimed at strengthening the link in the chain of survival have been successful at increasing bystander-CPR rates and, subsequently, cardiac arrest survival.To eliminate disparities in bystander CPR provision, public education campaigns must prioritize neighborhoods with the highest need as identified using public health surveillance tools such as registries. The effect in communities found to have a high incidence of cardiac arrest and little-to-no incidence of bystander CPR could be exponential. A significant limitation of this study was the inability to determine individual knowledge acquisition given that surveys did not include personal, identifiable information. However, the marked and statistically significant improvement in aggregate scores suggest that a video self-instruction, CPR-training program with a “pay-it forward” component can increase understanding of the indications for and the steps to perform CPR.

Another limitation was the inability to ensure quality control of the pay-it-forward component. It is uncertain whether students provided the answers to the people that they trained or if the increase in the post-intervention scores truly reflected knowledge increase. It is also unclear whether knowledge will translate into adequate technique or increased bystander CPR and AED use. Despite these limitations, our “pay-it-forward” model is an inexpensive,cannabis flood table novel strategy to disseminate CPR and AED knowledge in priority neighborhoods with limited access to traditional CPR training courses.Procedural sedation and analgesia is the use of sedative, analgesic, or dissociative drugs to relieve pain and anxiety associated with diagnostic and therapeutic procedures, while maintaining continuous and independent ventilation.Many procedures that were formerly performed under general anesthesia in the operating room are now successfully completed using PSA in locations outside the OR, including the emergency department.As a result, PSAs are now being performed more frequently by non-anesthesiologists , such as emergency physicians, and it is estimated that roughly a quarter of a million pediatric patients will receive PSA in the ED alone each year.Therefore, it is paramount that emergency physicians be prepared not only to administer proper PSA to children, but also to manage any complications or adverse events that may arise when PSA takes place in the pediatric ED. Adverse event rates during pediatric PSA in non-OR settings are reported between 2.3%-17.6%.6, 7 The definition of adverse events during PSA varies in the literature and has included the following: oxygen desaturation less than 90-93%; apnea; stridor; laryngospasm; bronchospasm; cardiovascular instability; paradoxical reactions; emergence reactions; emesis; and aspiration.Of these, the adverse events that pose the most significant risk to the safety of the patient are those that compromise the airway.Smaller studies have found rates of airway compromise during PSA ranging from 5-6%.Medications used for PSA varied in these studies and included chloral hydrate, propofol, ketamine, midazolam and fentanyl. Larger studies have also found significant but lower rates of airway compromise among pediatric patients undergoing PSA. The Pediatric Sedation Research Consortium found that among nearly 30,000 PSAs performed outside the OR, oxygen desaturation occurred 157 times per 10,000 sedations; stridor and laryngospasm both occurred in 4.3 per 10,000 sedations; and unexpected apnea occurred in 24 per 10,000 sedations.Finally, similar adverse event rates with oxygen desaturations were reported in a systematic meta-analysis of studies involving PSA in the ED.Thus, evidence shows that despite various medications used in pediatric PSAs in different settings, the risk of airway compromise remains. Because of the universal risk for airway compromise among PSA medications, further research has sought to identify patient factors that predict higher risk for adverse events during PSA. For example, studies have shown that patients of younger age or with higher American Society of Anesthesiologists classification may experience more adverse respiratory events during PSA.In light of the inherent airway risks of PSA and the potential ability to identify predisposing factors for adverse events prior to PSA, professional medical governing bodies have proposed guidelines and recommendations specifically for PSA performed by NAs.

The guidelines encompass risk assessment prior to PSA by performing a complete history and physical exam and determining ASA classification and nil per os status. They also stress the importance of appropriate monitoring during PSA and access to airway rescue equipment and pharmacological reversal agents. When implemented, these guidelines have proven to decrease the rate of respiratory adverse events.It is notable, however, that the guidelines cursorily, if at all, suggest using Mallampati scores in pre-PSA evaluations. Mallampati scores are obtained by visualizing a patient’s posterior oropharynx while the patient is seated and opening his mouth with his tongue protruded. The modified Mallampati classification scheme scores adequacy of visualization from I to IV, with I being full visualization and IV being visualization of only the hard palate. The Mallampati score is used to predict difficulty with intubation, with those who score III or IV being more difficult to intubate, and has been validated in children.Given that a higher Mallampati score may indirectly indicate children who have potentially difficult or anatomically different airways, this classification scheme may add important risk information to pediatric pre-PSA assessments. Thus, the objective of this study was to assess whether pre-PSA Mallampati score can predict adverse events during pediatric PSA. Our study found that there was not a significant difference in the proportion of adverse events between those individuals with Mallampati scores of III/IV vs. those with Mallampati scores of I/II. In fact, post-hoc power analysis showed that this study had a 95% power to detect a 15% difference in the proportion of adverse events between these two groups. Notably, a greater proportion of patients with Mallampati scores of III/IV compared with those of Mallampati scores of I/II required repositioning during PSA. This is not surprising since those with higher Mallampati scores likely have the body habitus, particularly increased neck girth and larger facies, that could predispose a patient to obstructive respiratory events during PSA. Hirsch et al. found that children who were obese and undergoing PSA experienced a greater desaturation rate compared with children who were not obese.Furthermore, Mallampati scores have also been shown to be an independent predictor of obstructive sleep apnea, thus highlighting the fact that these scores may be an indirect measurement of anatomical factors that should be considered in pre-PSA assessments.In this study, nearly 20% of the patients did not have a documented Mallampati score or the physician administering PSA was unable to obtain a score. Although the physicians who did not document a Mallampati score were not required to provide information on why these scores were not reported, we surmise that the primary reason for scores not obtained was secondary to patient compliance. The median age of those whose scores were either not obtained or unable to be obtained was 2.6 years, thus suggesting that age may limit the physician’s ability to obtain a Mallampati score. Mallampati scoring requires the patient to sit upright, voluntarily open his mouth and refrain from saying “ahh”. Koop et al. showed that children under the age of four are less likely to be able to cooperate with such maneuvers and may not have the cognitive ability to follow through with multi-step tasks that require greater attention.Similarly, other studies comparing Mallampati scores to other indirect methods predicting difficult endotracheal intubations, such as the Cormack and Lehane grading system, have also encountered difficulty in obtaining Mallampati scores for children ages 1-3 years.Furthermore, pediatric patients presenting to the PED for PSA are often suffering from painful injuries, and under these circumstances physical examinations, particularly oropharyngeal exams, can be viewed as distressing from the patient and parent perspectives.Thus, age, physical pain, and distress or anxiety may hinder the physician’s ability to obtain a Mallampati score. While this study was powered to detect differences in adverse events between those with Mallampati scores of III/IV vs. those with Mallampati scores of I/II, it is still rare for adverse, sedation-related events to occur, particularly with the use of ketamine. The adverse event rate during the study period was 11.6%, which is similar to previously reported PSA adverse event rates at this institution.