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KIDS SAVE LIVES: School children education in resuscitation for Europe and the world

Böttiger, Bernd W.; Semeraro, Federico; Altemeyer, Karl-Heinz; Breckwoldt, Jan; Kreimeier, Uwe; Rücker, Gernot; Andres, Janusz; Lockey, Andrew; Lippert, Freddy K.; Georgiou, Marios; Wingen, Sabine

European Journal of Anaesthesiology (EJA): December 2017 - Volume 34 - Issue 12 - p 792–796
doi: 10.1097/EJA.0000000000000713

From the Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany (BWB, SW), Department of Anaesthesia and Intensive Care Medicine, Maggiore Hospital, Bologna, Italy (FS), Saarbrücken, Germany (KHA), Faculty of Medicine, University of Zürich, Zürich, Switzerland (JB), Department of Anaesthesiology, University Hospital of Munich (LMU), Munich, Germany (UK), Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Rostock, Rostock, Germany (GR), Department of Anaesthesiology and Intensive Therapy, Jagiellonian University Hospital, Krakow, Poland (JA), Emergency Department, Calderdale Royal Hospital, Halifax, UK (AL), Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark (FL) and American Medical Center Cyprus, Nicosia, Cyprus (MG)

Correspondence to Bernd W. Böttiger, MD, ML, DEAA, FESC, FERC, Department of Anaesthesiology and Intensive Care Medicine, European Resuscitation Council (ERC), German Resuscitation Council (GRC), University Hospital of Cologne, Kerpener Straße 62, D-50937 Cologne, Germany Tel: +49 221 478 82054, 478 82052; fax: +49 221 478 87811; e-mail:

Sudden cardiac death is the third leading cause of death in industrialised nations. It is estimated that in Europe and in the United States, more than 700 000 patients die annually following sudden cardiac death, even when the emergency medical service has been activated and started cardiopulmonary resuscitation.1,2 The same applies to all other developed regions of the world. Despite many improvements in emergency medical services and hospital treatment of sudden cardiac death patients, the survival rates remain low. The key problem is that it can take a long time for an emergency medical service to arrive after the victim's collapse. The brain, however, starts to die some 3 to 5 min after circulatory arrest. Thus, the treatments that emergency medical services deliver arrive too late for most sudden cardiac arrest patients.

One of the most effective ways to increase survival in sudden cardiac arrest is swift onset of cardiopulmonary resuscitation by bystanders (who we know observe the victim collapse in at least 60% of cases3) and by educated and trained ‘first responders’ who are dispatched in parallel with the emergency medical services. Lay bystander resuscitation rates differ significantly across Europe, ranging from 10 to 20% in many countries, and higher than 60 to 80% in a few other countries.4 Some countries have made remarkable progress with increasing bystander resuscitation rates over the last decade. Denmark in particular can serve as a blue print for national initiatives to successfully and markedly increase bystander resuscitation rates. In Denmark, over a period of more than 10 years, bystander resuscitation rates following sudden cardiac arrest increased from less than 20% in 2001 to more than 50% in 2012. This was not only associated with a tripling in survival of patients following sudden cardiac arrest, but also – and most interestingly – with lower rates of brain damage, nursing home admission and death from any cause within the first year after sudden cardiac arrest as compared with no bystander resuscitation.5 Furthermore, the majority of survivors went back to work.6 This success is because of nationwide initiatives including mandatory education in resuscitation in elementary schools since 2005 in Denmark.7 In the years before, Norway and some states in the United States and Germany successfully established similar programs. To save the lives of hundreds of thousands of sudden cardiac arrest patients, it is, therefore, important to focus efforts on increasing bystander resuscitation. This is also one of the 10 recommendations emphasised by the Global Resuscitation Alliance as the most important to improve survival from out-of-hospital cardiac arrest.8

Educating school children in cardiopulmonary resuscitation is an effective and long-lasting way to increase bystander efforts.9 This was recognised in 2015 by the WHO when they endorsed the KIDS SAVE LIVES statement.10,11 Following such training, school children can also serve as multipliers,11 and all this will have a significant positive influence on survival after sudden cardiac arrest.

We recommend that resuscitation training for school children should start at the age of 12 years or earlier, with 2 h of theoretical and practical training per year, and as long as the children go to school. Educated teachers and medical personnel are both equally effective in training school children in cardiopulmonary resuscitation.

Following several initiatives, school children education in cardiopulmonary resuscitation is already mandatory in five countries in Europe, and it is a recommendation in 16 additional countries (Fig. 1).12 Our aim is to have school children educated in resuscitation all over Europe and the rest of the world. To support this goal, we have summarised what we have experienced and, in part, actively initiated with regard to historical facts and milestones (Table 1 ).13 Many of those have been initiated by anaesthesiologists,13 and this editorial wants to motivate and activate as many colleagues as possible from all kinds of emergency medical disciplines.

Fig. 1

Fig. 1

Table 1

Table 1

Table 1

Table 1

What can be done to support the movement KIDS SAVE LIVES? There are different concepts, curricula and methods available to educate school children in resuscitation14–25:

  1. Small and relatively cheap manikins that can also be taken home by the school children (school children as multipliers);
  2. ‘High-fidelity’ manikins with feedback systems for group education;
  3. Serious games and apps dedicated to school children;
  4. School children education by medical personnel (doctors, nurses and paramedics);
  5. School children education by educated school teachers;
  6. School children education by other school children (peers)

The focus of the first steps of school children education in resuscitation is on chest compression resuscitation only (hands only).19 In case of out-of-hospital cardiac arrest, ‘hands only’ resuscitation is sufficient in most adult patients until arrival of the emergency medical service. This is because following sudden cardiac arrest there is still remaining oxygen in the blood and in the whole body outside the brain. Usually, we do not train ventilation or the use of automated external defibrillators before the age of 16 to 18 years.18

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What is most important?

It is well known that early commencement of resuscitation by laypersons is the most effective way to increase survival and improve neurological outcome following out-of-hospital cardiac arrest.24–28 Education of school children and using them as multipliers plays a central role in increasing lay resuscitation rates and, thus, survival.18 Therefore, we suggest implementation of mandatory education of school children in resuscitation nationwide and to support and secure this by national law.

Until this important goal is reached – which will save hundreds of thousands of lives annually – we all have to do our part. Society conferences are an excellent forum to spread the message and also to organise mass training events. Please, just start, help others and you will see it is effective – and it is also a lot of fun.

Further information, videos, presentations, curricula and concepts on school children education in resuscitation can be found here:

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Acknowledgements related to this article

Assistance with the Editorial: none.

Financial support and sponsorship: we cordially thank all colleagues, ministers, politicians, teachers, women and men, children, organizations, medical societies and business entities who have supported and will support the very important and positive impact of our ‘KIDS SAVE LIVES’ initiative in Europe and in other parts of the world. BWB is supported by the ERC Research NET.

Conflicts of interest: BWB is European Resuscitation Council (ERC) Board Director Science and Research; has received Speakers honorarium from Medupdate, FoMF, Baxalta, Bayer Vital, Bard; is Chairman of the German Resuscitation Council (GRC); is a Board Member of the German Society of Interdisciplinary Intensive Care and Emergency Medicine (DIVI); and is an Associated Editor of Resuscitation. FS is Chairman of the Italian Resuscitation Council (IRC). AL is Honorary Secretary of the Resuscitation Council (UK). FL is Board Member of Global Resuscitation Alliance, and Board member of Danish Resuscitation Council, and has received unrestricted research grants from the Danish TrygFonden and The Laerdal Foundation. MG is ERC Board Director of External Affairs and a board member of the Cyprus Resuscitation Council (CyRC).

Comment from the Editor: this Editorial was checked by the editors but was not sent for external peer review. BWB is an Associate Editor of the European Journal of Anaesthesiology.

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