Background: Traditional, instructor led, in-person training of CPR skills has become more challenging due to COVID-19 pandemic. We compared the learning outcomes of standard in-person CPR training (ST) with alternative methods of training such as hybrid or online-only training (AT) on CPR performance, quality, and knowledge among laypersons with no previous CPR training. Methods: We searched PubMed and Google Scholar for relevant articles from January 1995 to May 2020. Covidence was used to review articles by two independent researchers. Effective Public Health Practice Project (EPHPP) Quality Assessment Tool was used to assess quality of the manuscripts. Results: Of the 978 articles screened, twenty met the final inclusion criteria. All included studies had an experimental design and moderate to strong global quality rating. The trainees in ST group performed better on calling 911, time to initiate chest compressions, hand placement and chest compression depth. Trainees in AT group performed better in assessing scene safety, calling for help, response time including initiating first rescue breathing, adequate ventilation volume, compression rates, shorter hands-off time, confidence, willingness to perform CPR, ability to follow CPR algorithm, and equivalent or better knowledge retention than standard teaching methodology. Conclusion: AT methods of CPR training provide an effective alternative to the standard in-person CPR for large scale public training.

Pakistan's Emergency Medical Services (EMS) are a critical component of its healthcare system, providing pre-hospital emergency care across a nation with over 220 million people. This article explores the evolutionary journey of Pakistan's EMS, highlighting both the challenges it faces and the strides it has made, with a specific emphasis on patients experiencing out-of-hospital cardiac arrest (OHCA). To extract relevant information, we searched MEDLINE & Embase data bases using MeSH terms “Emergency Medical Services” OR “EMS” AND “Out-of-Hospital-Cardiac-Arrest” OR “OHCA” AND “Pakistan”. In addition, we also retrieved information from the EMS leadership in Pakistan through e-mails. We delve into the significance of key performance indicators for OHCA, advocate for the establishment of OHCA registries to improve patient outcomes, address regional disparities in pre-hospital care, and acknowledge the gradual progress of the EMS system.

Vital signs play a critical role in prioritizing patients in emergency departments (EDs), and are the foundation of most triage methods and disposition decisions. This study was conducted to determine the frequency of vital signs documentation anytime during emergency department treatment and to explore if abnormal vital signs were associated with the likelihood of admission for a set of common presenting complaints. Data were collected over a four-month period from the EDs of seven urban tertiary care hospitals in Pakistan. The variables included age, sex, hospital type (government run vs. private), presenting complaint, ED vital signs, and final disposition. Patients who were >12 years of age were included in the analysis. The data were analyzed to describe the proportion of patients with documented vitals signs, which was then crossed-tabulated with top the ten presenting complaints to identify high-acuity patients and correlation with their admission status. A total of 274,436 patients were captured in the Pakistan National Emergency Department Surveillance (Pak-NEDS), out of which 259,288 patients were included in our study. Vital signs information was available for 90,569 (34.9%) patients and the most commonly recorded vitals sign was pulse (25.7%). Important information such as level of consciousness was missing in the majority of patients with head injuries. Based on available information, only 13.3% with chest pain, 12.8% with fever and 12.8% patients with diarrhea could be classified as high-acuity. In addition, hospital admission rates were two- to four-times higher among patients with abnormal vital signs, compared with those with normal vital signs. Most patients seen in the EDs in Pakistan did not have any documented vital signs during their visit. Where available, the presence of abnormal vital signs were associated with higher chances of admission to the hospital for the most common presenting symptoms.

Given the critical disparities in survival for out-of-hospital-cardiac-arrest (OHCA) in resource limited countries and the lack of context-specific evidence to guide resuscitation practices, we aimed to systematically evaluate the effectiveness of the chain of survival components including bystander response, emergency medical services (EMS) response, advanced life support, and post-resuscitation care on outcomes such as return of spontaneous circulation, survival to admission, survival to hospital discharge, and neurological outcomes in these settings. This systematic review, following PRISMA guidelines, included observational and interventional studies on OHCA management from low, lower-middle, and upper-middle-income countries, published in English (2004–2023). PubMed, Embase, CINAHL, and Cochrane Library were searched using predefined terms. Two reviewers independently screened studies, extracted data using the Utstein template, and resolved conflicts with a third reviewer. Data included pre-hospital, patient, and post-resuscitation care factors, as well as short and long-term outcomes. Descriptive analysis and narrative synthesis were conducted, with return of spontaneous circulation (ROSC) rates compared across income groups using t-tests. Sixteen (16) eligible studies were included. No study was found from low-income countries. ROSC rates ranged from 0.7% to 44%, survival to discharge from 0.6% to 14.1%, and good neurological outcomes (CPC 1–2) from 0.6% to 53.8%. While upper-middle-income countries showed slightly higher ROSC rates, differences were not statistically significant. Risk of bias was moderate to high due to selection bias, inadequate confounding control, and inconsistent reporting. These findings emphasize the need for standardized reporting and further research to improve outcomes in resource limited countries. This review highlights low survival rates for OHCA in resource limited countries, with significant variability and gaps in evidence. Strengthening EMS systems, adopting context-specific strategies, and standardizing reporting are critical to improving outcomes.

Despite extensive research on OHCA in urban centres worldwide, there is a significant gap in knowledge regarding these events in less urbanized regions, especially in Low-Middle-Income Countries (LMICs). To determine the characteristics and outcomes of adult out-of-hospital cardiac arrest (OHCA) in rural and suburban districts of Sindh, Pakistan. Data of OHCA patients (>18 years) was collected retrospectively from January 2020 to December 2022, from the medical records of district and tehsil hospitals of the province of Sindh. Data analysis was performed using the Statistical Package Software for the Social Sciences (SPSS) Statistics 29. Out of 139 OHCA patients, 75.5 % were males, and 24.5 % were females, with a mean age of 52.78 ± 13.1 years. Most cardiac arrests occurred at home (54.75 %). Only 0.7 % of patients were transported by emergency medical services (EMS), while 59 % arrived via private transport, such as cars or vans. An additional 4.3 % were brought by other ambulance services, including private and philanthropic organizations, and for 36 % of patients, the mode of transportation was undocumented. Cardiac arrests were witnessed in 43.2 % of cases. CPR (either in-hospital or pre-hospital) was performed on 59 % of patients, but only 6.1 % received pre-hospital CPR (Bystander: 1.22 %, Ambulance Staff: 2.44 %, Family Member: 2.44 %). Return of spontaneous circulation (ROSC) was achieved in 14.63 % of patients, while 4.88 % were alive at hospital admission. This study highlights significant gaps in the chain of survival for OHCA patients in rural and suburban Sindh, Pakistan, including inadequate EMS utilization, low bystander CPR rates, and delayed hospital care, contributing to poor outcomes. The findings may underestimate true rates due to missing and inconsistent data, emphasizing the need for improved documentation and prospective studies.

Background: Uraemic cardiomyopathy (UCM), the cardiac manifestation of chronic kidney disease, represents a significant clinical challenge that is often underdiagnosed despite being one of the strongest predictors of mortality in the chronic kidney disease (CKD) population. It develops through pathophysiological mechanisms unique to the uraemic state—left ventricular hypertrophy, myocardial fibrosis, and diastolic dysfunction—that often progress silently, sometimes even without traditional cardiovascular risk factors. Purpose: This review synthesises nephrology-centric mechanisms with clinical phenotypes and contemporary imaging (including CMR T1/T2 mapping and ECV), and proposes a CKD-stage–tailored diagnostic–therapeutic framework. It offers a distinct perspective by integrating the complex pathophysiology of UCM with practical diagnostic approaches and evolving management strategies, differentiating it from prior cardiology-focused overviews. Methods: A comprehensive literature search was conducted across Ovid MEDLINE, Embase, PubMed, Google Scholar, BMJ Best Practice, and UpToDate for studies published up to March 2025. Key findings were extracted from the final evidence set and manually verified for relevance. This review introduces a patho-mechanical cascade model of uraemic cardiomyopathy, integrating toxin-driven, metabolic, and haemodynamic axes. Nephrology-led screening protocols are proposed, leveraging proteomics and strain echo, and advocate mineralocorticoid receptor antagonists with sodium–glucose co-transporter-2 (SGLT2) inhibitor initiation at CKD Stage 3a. Cardiorenal clinics are essential for improved outcomes. Key Insights: UCM develops from a multifactorial process. This involves neurohormonal activation, oxidative stress, chronic inflammation, and exposure to toxins such as indoxyl sulfate and p-cresyl sulfate, arising from uraemia. Diagnosis is challenging, masked by overlapping features of fluid overload and anaemia. SGLT2 inhibitors, non-steroidal mineralocorticoid antagonists, and renin–angiotensin–aldosterone system modulation offer promising interventions. The effect of the dialysis modality, its timing, and renal transplantation on cardiac remodelling also emerging from recent studies. Conclusions: UCM sits at the intersection of two failing organ systems. Managing it effectively requires a paradigm shift to incorporate pharmacological and early diagnostic interventions and the integration of cardiology and nephrology care, and the timely implementation of interventions.