JMIR Publications

ABSTRACT

Background:

Cardiorespiratory arrest ranks among the leading causes of mortality in the pre-hospital setting, defined as the absence of a central pulse and breathing. Studies indicate that 70% of cases are witnessed by a family member and may result in sudden death. This fact underscores the need for all individuals to acquire the knowledge and skills required to recognize the condition and initiate care for the victim. European countries launched a project known as Kids Save Lives in 2015, which was subsequently replicated in Brazil by the University of São Paulo, with the aim of training children to respond to cardiorespiratory arrest.

Objective:

to develop a prototype of a serious game for schoolchildren aged nine to fifteen years, focused on the recognition of cardiorespiratory arrest and cardiopulmonary resuscitation maneuvers.

Methods:

A technological development study, guided by the methodological framework proposed by Jeannine Novak (2010), comprising five phases: concept, pre-production, prototype, production, and post-production. The present study was carried out through the third phase.

Results:

The pre-production of the serious game was conducted through the synthesis of content extracted from the manuals of the American Heart Association, the International Liaison Committee on Resuscitation, and printed materials pertaining to the Advanced Cardiovascular Life Support course. Based on the Game Design Document developed by the interdisciplinary team, the structure of the product was established. The prototype development process was conducted iteratively, with continuous testing cycles performed to achieve the final outcome. It is noteworthy that the core mechanics of the serious game were developed using the Game Maker engine; consequently, the animations are basic and provisional. The design and aesthetic refinement of the product will be addressed in the subsequent phase of the study. At present, the prototype is available for access on both desktop and mobile platforms.

Conclusions:

The prototype demonstrated adherence to the cardiorespiratory arrest care algorithm sequence, incorporating interactive and intuitive visual and auditory elements, thereby enabling the recognition of the event and the initiation of cardiopulmonary resuscitation maneuvers. The educational technology developed may be relevant, given its considerable potential to disseminate knowledge for the training of school-aged children, enabling them to be active agents in the rapid recognition of cardiorespiratory arrest and, consequently, strengthening the chain of survival, particularly in domestic settings. The need to advance through the remaining stages of the serious game proposed in this study is emphasized, so that it may be applied, evaluated, and implemented within educational and healthcare services. To develop a prototype of a serious game for schoolchildren aged nine to fifteen years, centered on the recognition of CRA and cardiopulmonary resuscitation maneuvers. Technological development study involving the production of an educational technology in the format of a SG. The methodological framework adopted was the meaningful learning method based on Jeannine Novak, which comprises five stages: concept, pre-production, prototype, production, and post-production. The present study addresses the third stage exclusively: prototype [13]. Methodological Procedures: The study had a duration of 18 months, with the prototyping phase taking place between April and August 2025. It was conducted at the Amazonas State University (UEA), involving an interdisciplinary team composed of nurses, a software engineer, and undergraduate students in information systems. For the development of the prototype, it was necessary to address the concept and pre-production phases of the SG, corresponding respectively to: 1st phase: Definition of the general objective — to train school-aged children to recognize CRA and perform CPR maneuvers. Prior to prototype development, and given the nature of the SG, it was necessary to establish a theoretical foundation to support the guidelines to be conveyed throughout the game. Accordingly, the AHA Manuals, the ILCOR, the 2025 AHA Guidelines, and the printed manual of the Advanced Cardiovascular Life Support (ACLS) course were consulted as primary references [1,8]. 2nd phase: Development of the Game Design Document (GDD) - encompassing critical information such as: objective and purpose; player motivation, addressed through win and loss conditions; the distinguishing features of the game; definition of the target audience, which is also linked to the game genre; target platforms; story synopsis; character descriptions; scenarios; game engine; and interface design [14-16]. 3rd phase: Production of the Minimum Viable Product (MVP), that is, the prototype. This version corresponds solely to the core concept of the game. The SG will comprise: character introduction; a tutorial; and phases with distinct scenarios for the application of acquired knowledge, in which the player will be tested and assessed [13, 14, 17-19]. As in the preceding stages of the study, the entire prototype creation process was carried out collaboratively. The technology team was responsible for developing the core mechanics in accordance with the guidelines provided by the health team: for each screen developed, iterative testing cycles were performed, along with the necessary adjustments [13, 20]. GameMaker Studio 2 was used as the game engine for prototype development, with GameMaker Language (GML) as the programming language. The tool was selected based on its available resources for digital game development and its applicability to the creation of interactive educational resources, as described in the literature [21,22]. Prototype of the Technical Development Aspect Category Description Objective and composition To interactively and playfully simulate the basic steps of CPR (cardiopulmonary resuscitation) Development Environment GameMaker Studio 2. Interaction Flow Initial tutorial; Interactive actions (active player participation); Rhythm phase Evaluation and feedback. Objects and Instances Each object represents visual, logical, and interactive elements. Animation and Visual Feedback The victim and the mobile phone were programmed with a tremor system to indicate interactivity. Rhythm Mechanic with Music The bass drum beat in the music serves as a temporal marker for chest compressions. Includes an ECG trace with QRS complex and a heart graphic as visual references. Synchronization Technology Rhythmic note system based on a global variable Beat (formula: delta_time / BPM). Music manager controls volume and transitions (fade-in). Judgment System (Rhythm) Object evaluates compression accuracy in relation to the QRS complex. Textual feedback: "Perfect", "Good", "Poor", or "Failed". Prototype of the Player Aspect: The game is classified as a rhythm game, comprising an explanatory tutorial covering the stages of CRA recognition and management. Subsequently, the knowledge acquired by the user will be put to the test in the following phases, with the core mechanic centered on achieving the appropriate rhythm and depth for chest compressions. The MVP was designed primarily to demonstrate this particular feature. On the opening screen, the player may choose between the "Start" and "Exit" buttons. Should the player choose to begin the game, the following screen will display a victim lying on the ground alongside instructions detailing the required actions (see Figure 1). If the MVP is being used on a desktop device, a mouse click will be required to advance to the next step. If the player is using a mobile device, a screen tap will be required. The next step involves checking whether the victim is responsive and breathing. Upon confirming the absence of consciousness and respiratory movements, the player is directed to the following screen, where they must call for help — in this case, referring to a call to the Mobile Emergency Care Service (Serviço de Atendimento Móvel de Urgência — SAMU). In the right corner of the screen, a mobile phone will appear, allowing the player to dial the emergency service number (192). At this stage, the player is expected to know the correct phone number; otherwise, progression to the next screen will not be possible. Within the game, in addition to placing the call, the player will be placed in scenarios that may vary between: requesting assistance from a bystander and instructing them to make the call, or asking them to retrieve an Automated External Defibrillator (AED) (see Figure 2). Following the call for help, chest compressions must be initiated. Given that the SG will also be made available to children who have not had the opportunity to receive prior training, it was decided to include a tutorial at this stage. Accordingly, the player will be guided on the correct technique for performing CPR: the thoracic region to be compressed, hand positioning, rhythm, and depth. In addition to the visual elements, a musical track featuring multiple rhythmic components is introduced, with the bass drum sound, the lowest-pitched beat, serving as the temporal marker. Over a period of 60 seconds, the beat can be heard 120 times, matching the compression rate recommended by the AHA, which suggests a range of 100 to 120 compressions per minute. An electrocardiographic trace displays an image simulating the QRS complex (see Figure 3). This image is synchronized with the bass drum beat, and whenever it approaches the heart graphic, the player must tap the screen to simulate a compression. In the prototype under consideration, a musical track with a beat of 120 per minute was selected, and the player is required to perform compressions over two minutes. For each compression performed, the player will receive feedback (see Figure 4) regarding their performance. If the player compresses the chest at the precise moment the QRS complex reaches the heart graphic, the word "Perfect" will appear on the screen. If the compression is performed when the QRS complex is in close proximity to the heart graphic, the word "Good" will be displayed. Should the player fail to maintain the appropriate rhythm, their performance will be rated as "Poor" or "Failed". In this first developed version, the player has both visual and auditory (musical) assistance to understand and internalize the appropriate rhythm. For subsequent versions of the game, the inclusion of difficulty levels is anticipated — for instance, in an initial phase, both forms of assistance will be available, whereas in the following phase, only the musical cue will be provided, thereby encouraging the comprehension and internalization of the appropriate rhythm. If, within two minutes, the player performs high-quality CPR, the reward will be the arrival of SAMU to assist the victim. If the adequate rhythm is not achieved and the compressions are not effective, the player will receive a suggestion to try again (see Figure 5). The engine GameMaker Studio 2 provides libraries that support game development, including features for graphics rendering, physics simulation, collision detection, input handling, and audio playback. It also supports exporting games to different platforms. The development process involved an interdisciplinary collaboration between the health and technology fields at Amazonas State University (UEA), bringing together faculty members, undergraduate students, and graduate students. The prototype was conceived as an independent (indie) digital game, characterized by development autonomy and the involvement of an academic team. The prototype features a straightforward logic oriented toward the health domain. The entire game flow follows a pedagogical narrative based on the stages of CPR. The commands employed are simple, based on either mouse clicks or touchscreen input on mobile devices. The actions are designed to reinforce the memorization of correct first aid procedures through repetition, rhythm, and feedback. The tremor animations, the gradual appearance of objects, and the transitions between screens were created to enhance engagement and reduce monotony through visual and interactive elements. Tutorial text is displayed in a centralized position on the screen to facilitate readability. Fade effects and smooth motion through linear interpolation (lerp) were implemented to render the experience more fluid and visually refined. Regarding the control flow — that is, the order in which instructions, expressions, and function calls are executed or evaluated — Alpha control was employed. This approach was selected to achieve gradual appearance and disappearance effects (fade-in and fade-out), applied to sprites in order to produce a more polished user experience. During the prototyping phase, continuous testing and iteration cycles were conducted, including Quality Assurance testing to assess software performance, identify bugs, and implement corrections, as well as internal usability testing to assess the game’s intuitiveness. Accordingly, a modular programming approach was adopted, consisting of dividing the program into independent and well-defined modules, each responsible for a specific aspect of the system's functionality, thereby facilitating maintenance and future expansions of the prototype. This structure allows for the straightforward incorporation of new features such as accuracy-based scoring, leaderboards, additional tutorials, and visual or auditory adjustments, rendering the prototype flexible and scalable for diverse educational contexts. The development of the prototype followed the proposed methodological framework, and all phases conducted in this study were grounded in internationally recognized and widely used evidence-based guidelines. The serious game was built upon the AHA chain of survival and presented, in a clear and objective manner, the procedures required for the management of CRA victims. The SG is believed to hold considerable innovative potential by enabling the integration of scientific content, accessible language, and playful elements, thereby fostering active learning, engagement, and interaction among children during its future applications. Furthermore, it represents a resource for health education in both the school setting and the pre-hospital care context, given that its structure encompasses scenarios allowing for near-realistic simulation, capable of promoting skill development among children, stimulating rapid reasoning, and supporting decision-making. It is emphasized that this study is part of an ongoing project, in which future stages must still be completed for the application of the technology and subsequent evaluations within the knowledge production and transfer process. It is anticipated that the findings of this study may support new initiatives aimed at the development of innovative educational technologies in the health field, particularly those directed at the early training of laypeople in initial CRA response, thereby optimizing the chain of survival and improving patient outcomes in the pre-hospital setting. Equally noteworthy, as it was developed within the Amazonian context, which is characterized by unique geographical features and the presence of communities in remote areas, this technology has the potential to help overcome geographical barriers and expand access to health education strategies in these settings.