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Original Research
Basic Life Support and Advanced Cardiac Life Support: Knowledge
of Medical Students in New Delhi
Sinha Akritia, Mehrotra Mayankb, DevganArushic

Abstract
Background: The chain of survival includes basic life support (BLS) as an important element. Knowledge
of CPR is an important part of medical students training but there is still no routine training included in
medical undergraduate teaching in developing countries like India, thus, medical graduates often face
difficulty in emergency situations.
Aim: To assess BLS/ACLS knowledge among medical students from different professional years in New Delhi.
Methodology: A multi-centric study was planned as an analytical cross-sectional study with study sample
drawn from medical students enrolled in various professional years and interns during the session 20122013 at 5 medical colleges of New Delhi. The sample was randomly drawn from each professional year
and interns of 5 teaching hospitals of New Delhi. The study was conducted from May to August 2013.A
predesigned self-administered objective questionnaire was distributed and15 minutes were given to each
participant. Twenty questions were based on BLS while ten on ACLS.
Results: The data from 288 responders was analyzed using Microsoft Excel 2010 and Stata S.E 9.0.The
mean scores of first-year students in BLS and ACLS were the lowest, 4.56 + 2.76 and 1.65 + 1.35
respectively while the mean scores of second-,third- and final-year students in BLS and ACLS were 6.28
+3.03 and 2.6 + 1.68, 7.75 + 3.34 and 3.62 + 2.47, 10.17 + 2.4 and 6.1 + 2.04 respectively. The
mean scores of interns were the highest, 10.85 +1.83 in BLS and 6.35 + 2.59 respectively(p<0.001). The
mean score of study sample was 7.416 + 3.55 in BLS and 3.7 + 2.66 in ACLS.
Those who received a formal training in BLS/ACLS had a mean score of 11.07+ 1.86 compared to those
who had not received formal training and had a score of 6.99 + 3.43(p<0.001).
Conclusion: The study revealed that the medical undergraduates (UGs) had inadequate knowledge in
BLS and ACLS. Most of them support the idea of training in BLS/ACLS to be a part of the UG curriculum.
Those who were performing CPR (interns) had a significantly higher knowledge than those who didnt. The
knowledge of formally trained students is significantly higher than untrained students.
Key words: Basic life support(BLS), advanced cardiac life support(ACLS), CPR, training, knowledge.
Department of Anaesthesia and Intensive Care, VardhmanMahavir Medical College and Safdarjung Hospital,New Delhi-110029
a
Intern,VMMC and Safdarjung Hospital, New Delhi.
b
MD, Department of Anaesthesia and Intensive Care, VMMC and Safdurjung Hospital, New Delhi.
c
Final year Medical Student, VMMC and Safdarjung Hospital, New Delhi.
Correspondence and Reprint Requests: Dr. Akriti Sinha, 401, MBBS Girls Hostel, VMMC and Safdarjung Hospital, New Delhi-110029
E-mail: akriti.him@gmail.com
Received: January 19, 2014 | Accepted: February 27, 2014 | Published Online: April 27, 2014
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (creativecommons.org/licenses/by/3.0)
Conflict of interest: None declared | Source of funding: Nil

Journal of Young Medical Researchers, Vol. 1, Issue 2, January - July 2014

Sinha Akritia and others

Introduction
Despite important advances in prevention, cardiac
arrest remains a substantial public health problem
and a leading cause of death in many parts of
the world.[1]In the United States and Canada,
approximately 3,50,000 people per year
(approximately half of them admitted in-hospitals)
suffer a cardiac arrest and receive attempted
resuscitation. This estimate does not include the
substantial number of victims who suffer an arrest
without attempted resuscitation. While attempted
resuscitation is not always appropriate, there are
many lives and life-years lost because appropriate
resuscitation is not attempted.[2]
Cardiopulmonary resuscitation (CPR) is a series
of life-saving actions that improve the chances
of survival, following cardiac arrest.[3] Successful
resuscitation, following cardiac arrest, requires an
integrated set of coordinated actions represented
by the links in the Chain of Survival. The links
include the following: immediate recognition of
cardiac arrest and activation of the emergency
response system, early CPR with an emphasis on
chest compressions, rapid defibrillation, effective
advanced life support (ALS), and integrated
post-cardiac arrest care.[4] The likelihood to
achieveROSC increases with drug therapy,
advanced airway management and physiological
monitoring.
Return to a prior quality of life and functional state
of health is the ultimate goal of a resuscitation
system of care.In 1966 the AHA developed the
first CPR guidelines which have been followed by
periodic updates, the latest one being of 2010.[5]
Knowledge of CPR is an important part of medical
students training but there is still no routine training
included in the medical UG teaching in developing
countries like India, thus, medical graduates when
they become interns and post graduates often face
difficulty in emergency situations. In this study we

aimed at finding the awareness of medical students

of various professional years and interns regarding
BLS and ACLSwhich can be provided by either
trained medical personnels,emergency medical
technicians or by ordinarypeopletrained in BLS.
This ability to recognize and treat a respiratory or
cardiac arrest is a basic skill that all doctors are
expected to have mastered. However,not many
junior doctors are competent to carry out effective
CPR.[6] Theres a lack of structured pattern of BLS/
ACLS training in medical curriculum.[7]Thus, they
are not completely confident when they suddenly
face a situation of resuscitation.There are not
many studies to assess the knowledge of medical
students regarding resuscitation, especially in
India. Hence this study was conducted to assess
BLS/ACLS knowledge among them.
AIM:To assess BLS/ACLSknowledge among medical
students from different professional years inNew
Delhi.

Methodology
Study Design: A multi-centric study was planned as
an analytical cross-sectional study.
Study sample: It included medical students enrolled
in various professional years and interns during the
session of 2012-2013 at 5 medical colleges of
New Delhi. The samplewas randomly drawn from
each professional year and interns of 5 teaching
hospitals of New Delhi. Permission was taken from
the head of institutions (Table 1).
Study Time:The study was conducted over a
4-month period from May to August 2013.
Study Tool: A predesigned self-administered
objective questionnaire was given to each
participant. Twenty questions were based on BLS
while ten were based on ACLS.A questionnaire
was prepared by the authors that encompassed

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Basic Life Support and Advanced Cardiac Life Support

Table 1: Demographic details of the participants (n=288)

First Year Medical Students

58(20%)

Second Year Medical Students

56(19.4%)

Third Year Medical Students

60(20.8%)

Final Year Medical Students

57(19.8%)

Interns

57(19.8%)

GENDER
Male

165(57%)

Female

123(43%)

TRAINING
Formally BLS Trained

26(9%)

Formally ACLS Trained

10(3.4%)

3 domains:

Results

1. Demography and formal training of the

participants in BLS/ACLS

Out of 300 questionnaires filled,12 were excluded

as they were incomplete and remaining 288
were included in the study. Table 1 gives us the
demographic details of the participants.

2. Theoretical and practical knowledge of the

participants related to BLS,a set of self-prepared
20 MCQs with 4 options based on BLS For
Healthcare Providers Student Manual,2010.
3.Theoretical and practical knowledge of the
participants related to ACLS,a set of 10 MCQs
with 4 options based on Advanced Cardiovascular
Life Support (ACLS) Provider Manual,
2010American Heart Association Guidelines for
CPR and ECC.
Each student was given 15 minutes for 30 questions.
Data Analysis: The collected data were calculated
using Microsoft Excel and then statistical analysis
was made by Stata S.E 9.0. Students independent
t test was applied and p value <0.05 was
considered statistically significant.

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Participants (96%) felt BLS and ACLS training should

be a part of routine training in UG curriculum.
The mean scores of first-year students in BLS and
ACLS were the lowest, 4.56 + 2.76 and 1.65 +
1.35 respectively while the mean scores of second,third- and final years in BLS and ACLS were 6.28
+3.03 and 2.6 + 1.68, 7.75 + 3.34 and 3.62 +
2.47, 10.17 + 2.4 and 6.1 +2.04, respectively.
The mean scores of interns were the highest, 10.85
+ 1.83 in BLS and 6.35 + 2.59, respectively. The
mean score of study sample was 7.416 + 3.55 in
BLS and 3.7 + 2.66 in ACLS(Table 2).
An association was seen between the qualification
of medical students/internsand their knowledge in
3

Sinha Akritia and others

BLS (p value <0.005) (Table 2).

1% (3) studentsscored>80% (see Figure 1). Similar

results were shown by ShantaChandrasekaran et al
where none of the participants scored above 85%
while 85% of participants scored less than 50%.
[8]Only (48.1%) of the students from Switzerland
could give correct answers on knowledge based
questions.[9] Similarly low levels (54.3%, 25%)
of knowledge have been reported from medical
students in Poland and interns from southern India,
respectively.[10],[11]

Also an association was observed between the

trained participants in BLS/ACLS and their mean
scores(p<0.001) (Table 3).
Figures 1 and 2 show us the percentage score
of the study group in BLS and ACLS respectively.
Tables 4 and 5 show us theoretical and practical
knowledge of the participants in BLS and ACLS
respectively.

Early institution of CPR can double or triple the

victims chances of survival fromsudden cardiac
arrest.[12]However in our study only 41% had
knowledge about the AED usage (see Table 5).In
other study by Avabratha KS et al 37.4% of
medical interns were aware of the AED usage.[13]

Discussion
The study results showed that medical students in
Delhi failed to show adequate knowledge in both
BLS and ACLS (see Tables 4 and 5). Percentageof
students who scored less than 50% in BLS was 65,
only 2%(6) students scored 70%-79% and only

The newest development in the 2010 AHA

Table 2: Comparison of scores of the participants belonging to different professional years

Qualification

Mean
Standard
Mean
Standard
Score(BLS) Deviation Score(ACLS) Deviation

1stYear

4.56

2.76

1.65

1.1.35

2nd Year

6.28

3.03

2.6

1.68

3rd Year

7.75

3.34

3.62

2.47

Final Year

10.17

2.4

6.1

2.04

Interns

10.85

1.83

6.35

2.59

TOTAL SAMPLE

7.416

3.55

3.7

2.66

Table 3: Comparison of training and knowledge of the participants in BLS and ACLS

TRAINING
MEAN
STANDARD MEAN
(BLS OR ACLS)
SCORE(BLS)
DEVIATION
SCORE(ACLS)

(BLS)

STANDARD
DEVIATION
(ACLS)

Formally Trained (36)

11.07

1.86

6.6

2.81

Not Trained Formally (252)

6.99

3.43

3.47

2.53

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Basic Life Support and Advanced Cardiac Life Support

Figure 1: Pie chart showing percentage score of

the study sample in BLS

Figure 2: Pie chart showing percentage score of

study sample in ACLS

Guidelines for CPR and ECC is a change in the BLS

sequence ofsteps from airway, breathing, chest
compressions (ABC) tochest compressions, airway,
breathing (CAB) for adultsand pediatric patients
(children and infants, excluding newborns) as the
highest survival rates from cardiac arrest are
reported among patients of all ages with witnessed
arrest and a rhythm of VF or pulseless ventricular
tachycardia (VT). In these patients the critical initial
elements of CPR are chest compressions and early
defibrillation.[5] However, in our study only 4% of
the participants were able to answer all questions
regarding chest compressions correctly.

their knowledge in both BLS and ACLS(see Table

3).Shrestha Roshana et al. also showed that CPR
training significantly influenced BLS knowledge of
the participants as those who had received some
CPR training within 5 years obtained the highest
mean score of 8.622.49.[17]Other studies have
also concluded that the knowledge of trained
personnels was better than those of untrained
ones.[18]

Very few participants (9%) had undergone formal

training in BLS and only 3.6% in ACLS. HN Harsha
Kumar et al have also shown poor level of training
among the UG medical students.[14]Low levels of
training have been reported from Pakistan and the
UK.[15],[16]

Also a significant correlation was observed

between the qualification of medical students and
their knowledge (see Table 2).Interns who get
training in BLS in their anaesthesia rotations had
a significantly higher knowledge than the medical
UGs who had no such exposure. Chaudhari A et al
showed improvement in knowledge and skill of CPR
followinga BLS training.[19]Elif et al also observed
that past experience in real life resuscitation
improved the awareness.[20]

Statistically significant correlation was seen

between the formal training of the participants and

According to the General Medical Council of the

UK, preregistration house officers shouldhave

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Sinha Akritia and others

Table 4: Knowledge of the participants in BLS

QUESTIONS Score
1.Last update for BLS and ACLS was published by AHA in which year?

Correct:46%(132)

2.PULSE:
(a)Which pulse should be checked in a patient with suspected
cardiac arrest?

All correct (100%):1% (3)

3/4 correct (75%):11% (32)

(b)Pulse should be checked for how long in BLS?

2/4 correct (50%):34% (98)

(c)Which pulse should be checked in a child?

1/4 correct (25%):32%(92)

(d)Which pulse should be checked in an infant?

None (0%): 22%(63)

3.CPR

(a)Ratio of compressions and breaths in each cycle of CPR

All correct (100%):4% (12)

(b)Site of hand placement for delivery of chest compressions

4/5 correct (80%):8% (23)

(c)Chest compression depth in an adult and a child respectively?

3/5 correct (60%):19%(55)

(d)Chest compression to breath ratio in 1 rescuer and 2 rescuers

in an infants CPR?

2/5 correct (40%):25%(72)

1/5 correct (20%):26%(74)

(e)Ratio of Chest compressions to rescue breaths in ACLS

None (0%):18%(52)

4.Choking on foreign body

All correct (100%): 8% (23)

(a)Maneuver recommended in a patient who is choking?

2/3 correct (66%): 35%(101)

(b)Maneuver recommended in a pregnant patient whos choking?

1/3 correct (33%):34%(98)

(c)Maneuver recommended in an infant whos choking?

None (0%): 23%(66)

(5)Which one is not a part of key changes in BLS made by AHA

in its latest guidelines?

Correct: 28%(81)

(6)Technique to be preferred in patients with suspected spinal injury?

Correct: 34%(98)

(7)AED stands for?

Correct:43%(124)

(8)Recommendation in a patient who is drowning?

Correct:38%(109)

(9)Time lag between delivery of shock and resumption of chest

compressions?

Correct:26%(75)

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Basic Life Support and Advanced Cardiac Life Support

Table 5: Knowledge of the participants in ACLS

(1) Rhythm/ECG

Both correct(100%):31%(89)

(a) Which ones are shockable rhythms?

One correct (50%):24%(69)

(b) Which ones are non-shockable rhythms?

None: 45%(230)

(2) Recommended energy for defibrillation?

Monophasic and Biphasic

Correct: 41%(118)

(3) Drugs:

Both Correct:25%(72)

(a) Drug no longer administered in pulseless rhythm in ACLS

One correct:35%(100)

(b) Dose of Epinephrine used in ACLS?

None: 40%(116%)

(4) An ideal team of ACLS consists of how many members?

Correct: 26%(75)

(5) Ratio of chest compressions to breaths in ACLS

Correct:36%(103)

training in BLS before they join their post and that

theyshould receive ACLS training during the first
year.[21]The royalcollege of physicians has also
stated that ALS should be taught in theUG courses
and the preregistration house officers should be
capable ofinstituting ALS.[22]Participants (96%)
felt BLS and ACLS training should be a part of
routine training in the UG curriculum which is similar
to other study, thus, reflecting that these are felt
needs of the students.[14]
Training of resuscitation skills is poor due to lack
of resources in developing countries like India.
[23],[24]Moreover, as the guidelines are updated
every 5 years, the need for repetitive training
is a must so as to ensure that these changes are
implemented. Medical schools are expected to
produce well-trained doctors who are competent
in clinical practice which include the techniques
ofbasic resuscitation, thus, it is time that we
standardize training in BLS and ACLS and make
it a mandatory component of all medical UG
curricula. The Medical Council of India has already
incorporated emergency medicine as a separate
speciality. Spreading awareness and teaching the

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basics of ALS to the medical and paramedical

team as well as teaching BLS and first aid to the
community will be the prime responsibility of this
new emergency specialty.[13]
In conclusion, this study has revealed a critical issue
that medical students in New Delhi lack adequate
knowledge in BLS and ACLS which should be
addressed promptly. Since prior CPR training and
clinical exposure influence the retention of
knowledge, standard BLS/ACLS training should
be incorporated in the UG curriculum and should
be repeated periodically. It is also necessary to
evaluate and update the knowledge of medical
students in BLS and ACLS for better patient outcome
and bringing about uniformity in healthcare
delivery.

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