Lay person use of automatic external defibrillation

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimising pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

A qualitative study to identify barriers to deployment and student training in the use of automated external defibrillators in schools

BACKGROUND

Student training in use of automated external defibrillators and deployment of such defibrillators in schools is recommended to increase survival after out-of-hospital cardiac arrest. Low implementation rates have been observed, and even at schools with a defibrillator, challenges such as delayed access have been reported. The purpose of this study was to identify barriers to the implementation of defibrillator training of students and deployment of defibrillators in schools.

METHODS

A qualitative study based on semi-structured individual interviews and focus groups with a total of 25 participants, nine school leaders, and 16 teachers at eight different secondary schools in Denmark (2012-2013). Thematic analysis was used to identify regular patterns of meaning using the technology acceptance model and focusing on the concepts of perceived usefulness and perceived ease of use.

RESULTS

School leaders and teachers are concerned that automated external defibrillators are potentially dangerous, overly technical, and difficult to use, which was related to their limited familiarity with them. They were ambiguous about whether or not students are the right target group or which grade is suitable for defibrillator training. They were also ambiguous about deployment of defibrillators at schools. Those only accounting for the risk of students, considering their schools to be small, and that time for professional help was limited, found the relevance to be low. Due to safety concerns, some recommended that defibrillators at schools should be inaccessible to students. They lacked knowledge about how they work and are operated, and about the defibrillators already placed at their campuses (e.g., how to access them). Prior training and even a little knowledge about defibrillators were crucial to their perception of student training but not for their considerations on the relevance of their placement at schools.

CONCLUSIONS

It is crucial for implementation of automated external defibrillators in schools to inform staff about how they work and are operated and that students are an appropriate target group for defibrillator training. Furthermore, it is important to provide schools with a basis for decision making about when to install defibrillators, and to ensure that school staff and students are informed about their placement.

Technological Caregiving: A Qualitative Perspective

Despite its importance, few studies have focused specifically on the informal technological caregiver. Therefore, this study explored the technological caregiving experience from the perspective of individuals assuming this role. Caregivers were asked to describe their experiences of caring for individuals dependent on inotropic infusion therapy for the management of their end-stage heart failure. Twenty themes reflecting the essence of the technological caregiving experience emerged from the qualitative narratives. Although technological caregiving was financially burdensome, socially confining, and psychologically distressing, caregivers still perceived it as a positive and rewarding experience.

Minor Variations in Electrode Pad Placement Impact Defibrillation Success

Defibrillation is essential for resuscitating patients with ventricular fibrillation (VF), but shocks often fail to defibrillate. We hypothesized that small variations in pad placement affect shock success, and that defibrillation waveform and shock dose could compensate for suboptimal pad placement. In 10 swine experiments, electrode pads were attached at 3 adjacent anterolateral positions, less than 3 centimeters apart. At each position, 24 episodes of VF were induced and shocked, 8 episodes for each of 3 defibrillation therapies. This resulted in 9 tested combinations of pad position and defibrillation therapy, with 80 episodes of VF for each combination. An episode consisted of 15 seconds of untreated VF, followed by a first shock and, if necessary, a repeat shock. Episodes were separated by four minutes of recovery. Both electrode pad position and therapy order were randomized by experiment. Primary outcome was defined as successful VF termination after the first shock; secondary outcome was the cumulative success of the first and second shocks. First shock efficacy varied widely across the 9 tested combinations of pad position and defibrillation therapy, ranging from 11.3% to 86.3%. When grouped by therapy, first shock efficacy varied significantly between the 3 pad positions: 38.3%, 48.3%, 36.7% (p = 0.02, ANOVA), and, when grouped by pad position, it varied significantly between therapies: 15.0%, 32.5%, 75.8% (p < 0.001, ANOVA). Cumulative 2-shock success varied significantly with therapy (p < 0.001, ANOVA) but not with pad position (p = 0.30, ANOVA). The lowest first shock success was at one position in 6 of 10 animals, at another position in 4 of 10 animals, and never at the third position. Small variations in pad placement can significantly affect defibrillation shock efficacy. However, anatomical variation between individuals and the challenging conditions of real-world resuscitations make optimal pad placement impractical. Suboptimal pad placement can be overcome with defibrillation waveform and shock dose.

Effect of a reminder video using a mobile phone on the retention of CPR and AED skills in lay responders

BACKGROUND

Skills related to cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use by lay responders decay rapidly after training, and efforts are required to maintain competence among trainees. We examined whether repeated viewing of a reminder video on a mobile phone would be an effective means of maintaining CPR and AED skills in lay responders.

METHODS

In a single-blind case-control study, 75 male students received training in CPR and AED use. They were allocated either to the control or to the video-reminded group, who received a memory card containing a video clip about CPR and AED use for their mobile phone, which they were repeatedly encouraged to watch by SMS text message. CPR and AED skills were assessed in scenario format by examiners immediately and 3 months after initial training.

RESULTS

Three months after initial training, the video-reminded group showed more accurate airway opening (P<0.001), breathing check (P<0.001), first rescue breathing (P=0.004), hand positioning (P=0.004), AED electrode positioning (P<0.001), pre-shock safety check (P<0.001), defibrillation within 90s (P=0.010), and resuming CPR after defibrillation (P<0.001) than controls. They also showed significantly higher self-assessed CPR confidence scores and increased willingness to perform bystander CPR in cardiac arrest than the controls at 3 months (P<0.001, P=0.024, respectively).

CONCLUSION

Repeated viewing of a reminder video clip on a mobile phone increases retention of CPR and AED skills in lay responders.

Skill acquisition by health care workers in the Resuscitation Council (UK) 2005 Guidelines for Adult Basic Life Support

This prospective study compared pre- and post-class performance in basic life support (BLS) on a recording manikin in a convenience sample of 34 health care workers undertaking a two-hour class provided by a hospital resuscitation department teaching the 2005 Resuscitation Council (UK) guidelines. On completion of training there were significant improvements in the proportion of subjects correctly performing a safe approach (14/34 vs. 25/33, 95%CI +11 to +55%, p=0.004), checking for response (17/34 vs. 24/32, 95%CI +1 to +46%, p=0.029), shouting for help (18/34 vs. 28/32, 95%CI +13 to +54%, p=0.002), opening the airway (6/34 vs. 26/32, 95%CI +42 to +79%, p<0.001), checking for breathing (9/34 vs. 27/32, 95%CI +35 to +74%, p<0.001), calling a cardiac arrest team (1/34 vs. 24/32, 95%CI +53 to +85%, p<0.001), and providing the correct compression to breath ratio (11/34 vs. 20/34, +3 to +48%, p=0.033). The median number of correct chest compressions increased from 3 to 41 (p<0.001) with improvements in adequate depth (median depth 36 vs. 40mm, p=0.006), although the compression rate was too fast before training and increased afterwards (median 123 vs. 147, p<0.001). Ventilation performance could not be measured accurately as the manikin was calibrated incorrectly by the manufacturers.

Validation of a Predictive Model for Automated External Defibrillator Placement in Rural America

OBJECTIVE

The development of Automated External Defibrillators (AEDs) to treat out-of-hospital cardiac arrest (OOHCA) has greatly expanded the availability of life saving defibrillatory shocks in various settings. However, placement of AEDs in rural areas remains perplexing since OOHCAs are rare and unpredictable. We set out to develop a cost-effective rural AED placement model and to test the validity of the resulting model using OOHCAs attended by EMS.

METHODS

DESIGN

A population-based cross-sectional study. Analytic Plan: An exhaustive literature search was conducted to identify community attributes correlated with successful placement of AEDs in rural regions. Identified attributes were characterized using U.S. Census and CDC heart disease mortality data to estimate the potential risk for AED use and applied this estimate to rural census tracts in all 50 states. Based upon risk, AEDS were assigned to each tract using a first responder model and cost effectiveness was assessed. Using Utah State EMS data, the predicted placement of AEDs in each tract was validated using the actual number of OOHCAs attended by EMS.

RESULTS

A total of 14,586 rural census tracts in 50 U.S. states were evaluated. On average, 2,600 AEDs were situated within each state. AED placement in rural areas proved as cost effective as health screening programs. In Utah, predicted AED placement correlated with the frequency of OOHCAs attended by EMS personnel (rho= 0.55, p < 0.001).

CONCLUSIONS

The resulting model illustrates one potential way to determine the most beneficial location for rural AED placement.

Development and evaluation of a just-in-time support system

OBJECTIVE

To lay the foundation for a framework of just-in-time support (JITS) for novices dealing with urgent, unfamiliar tasks, and to evaluate a JITS system.

BACKGROUND

More than 350,000 people die annually of cardiac arrest in the United States. In response, automated defibrillators are advocated that, unfortunately, do not provide important respiratory support. This paper presents elements of a framework for a JITS system that instructs a lay responder to follow a treatment protocol for integrating respiratory support with the use of an automatic external defibrillator.

METHOD

We simulated a medical emergency using a high-fidelity patient simulator and asked participants to care for the patient.

RESULTS

When using a paper-based NASA treatment protocol, participants made more errors and took longer to stabilize the injured person than when using the JITS system.

CONCLUSION

These findings demonstrate the benefit of a JITS system to instruct novices in unfamiliar tasks.

APPLICATION

The JITS system has the potential to improve the treatment outcome of victims of cardiac arrest. The JITS framework can be applied to many situations in which novices deal with urgent tasks without expertise available.

Cardiac arrest on the links: are we up to par? Availability of automated external defibrillators on golf courses in southeastern Pennsylvania

OBJECTIVES

A growing number of golfers are senior citizens, and it may be predicted that the number of golf-related medical emergencies, including the incidence of cardiac arrest, will increase. This study was designed to survey the level of preparedness of golf courses in southeastern Pennsylvania to respond to cardiac arrest among their members.

METHODS

A telephone survey of all of the 180 golf courses in the area was conducted to determine their type (public/private), volume in rounds per year, presence of automated external defibrillator (AED) devices, number of employees, and percentage of employees with cardiopulmonary resuscitation (CPR) training. Participants also were asked to estimate the time needed to reach the farthest point on their course in order to estimate a maximum time to the application of an AED device.

RESULTS

A total of 131 of 180 golf courses completed the survey (53 private, 78 public) for an overall response rate of 73%. Private courses reported a greater average number of employees with CPR training [private = 9.1, public = 3.6; p = 0.001] and in AED presence [public = 9%, private = 58.5%; p = 0.0001]. Public courses support a higher volume of play than do private courses [public = 32,000, private = 24,000; p = 0.001], yet have far fewer employees [public=25, private=44; p = 0.004]. The longest time necessary to reach the most remote point on the course was between four and five minutes in all courses. Analysis was performed using the Student's t-test and Pearson's Chi-square as appropriate.

CONCLUSION

Neither public nor private golf courses are well equipped to respond to cardiac arrest, but outcomes on public courses likely are to be far worse.

Reality of out of hospital cardiac arrest

The high mortality rates associated with out of hospital cardiac arrest, particularly those occurring in the home, stress the need for early treatment in the form of publicly accessible external defibrillators.

Minimal instructions improve the performance of laypersons in the use of semiautomatic and automatic external defibrillators

INTRODUCTION

There is evidence that use of automated external defibrillators (AEDs) by laypersons improves rates of survival from cardiac arrest, but there is no consensus on the optimal content and duration of training for this purpose. In this study we examined the use of semiautomatic or automatic AEDs by laypersons who had received no training (intuitive use) and the effects of minimal general theoretical instructions on their performance.

METHODS

In a mock cardiac arrest scenario, 236 first year medical students who had not previously attended any preclinical courses were evaluated in their first study week, before and after receiving prespecified instructions (15 min) once. The primary end-point was the time to first shock for each time point; secondary end-points were correct electrode pad positioning, safety of the procedure and the subjective feelings of the students.

RESULTS

The mean time to shock for both AED types was 81.2 +/- 19.2 s (range 45-178 s). Correct pad placement was observed in 85.6% and adequate safety in 94.1%. The time to shock after instruction decreased significantly to 56.8 +/- 9.9 s (range 35-95 s; P < or = 0.01), with correct electrode placement in 92.8% and adequate safety in 97%. The students were significantly quicker at both evaluations using the semiautomatic device than with the automatic AED (first evaluation: 77.5 +/- 20.5 s versus 85.2 +/- 17 s, P < or = 0.01; second evaluation: 55 +/- 10.3 s versus 59.6 +/- 9.6 s, P < or = 0.01).

CONCLUSION

Untrained laypersons can use semiautomatic and automatic AEDs sufficiently quickly and without instruction. After one use and minimal instructions, improvements in practical performance were significant. All tested laypersons were able to deliver the first shock in under 1 min.

Method for determining automatic external defibrillator need at mass gatherings

OBJECTIVES

A method for determining the number of automatic external defibrillators (AEDs) required for a 3-min response at mass gatherings has been described previously. Our study sought to modify the method, replicate it, then validate the results.

METHODS

Emergency medical technicians (EMTs) were timed walking defined courses in a football stadium. Velocities were obtained for a horizontal distance and ascending/descending upper and lower decks. This was replicated in a basketball arena. To validate, actual response times were compared to predicted times for predetermined distances in each venue. Predicted response times were calculated using the second standard deviation velocities as the most pessimistic. Numbers of AEDs needed were calculated using predicted response times for each venue's longest distance.

RESULTS

Average velocities in m/s (football) were horizontal 1.7, lower deck 1.6 ascending and 1.4 descending, upper deck 1.0 ascending and 1.1 descending. Average velocities (basketball) were horizontal 1.7, lower deck 1.2 ascending and descending, upper deck 0.9 ascending and descending. In the validation phase, every EMT completed the four predetermined courses within the predicted intervals. Predicted response times were 363 s for the longest football stadium distance, and 187 s for the basketball arena. For a 3-min (180 s) response, the number of AEDs required can be calculated.

CONCLUSION

This method was easily replicated and appears to be useful for determining the number of AEDs at mass gatherings. The number of AEDs needed for any desired response interval can be calculated using the predicted response time for the longest distance within an arena.

Use of a wearable defibrillator in terminating tachyarrhythmias in patients at high risk for sudden death: results of the WEARIT/BIROAD

The automatic ICD improves survival in patients with a history of sudden cardiac arrest. However, some patients do not meet the guidelines for ICD implantation or are unable to receive an implantable device. This study tested the hypothesis that these patients could benefit from a wearable cardioverter defibrillator. Patients with symptomatic heart failure and an ejection fraction of <0.30 (WEARIT Study) or patients having complications associated with high risk for sudden death after a myocardial infarction or bypass surgery not receiving an ICD for up to 4 months (BIROAD Study) were enrolled into two studies. After a total of 289 patients had been enrolled in the trial (177 in WEARIT and 112 in BIROAD), prespecified safety and effectiveness guidelines had been met. Six (75%) of eight defibrillation attempts were successful. Six inappropriate shock episodes occurred during 901 months of patient use (0.67% unnecessary shocks per month of use). Twelve deaths occurred during the study 6 sudden deaths: 5 not wearing and 1 incorrectly wearing the device). Most patients tolerated the device although 68 patients quit due to comfort issues or adverse reactions. The results of the present study suggest that a wearable defibrillator is beneficial in detecting and effectively treating ventricular tachyarrhythmias in patients at high risk for sudden death who are not clear candidates for an ICD and may be useful as a bridge to transplantation or ICD in some patients.

Skill acquisition and retention in automated external defibrillator (AED) use and CPR by lay responders: a prospective study

This prospective study evaluated the acquisition and retention of skills in cardio-pulmonary resuscitation (CPR) and the use of the automated external defibrillator (AED) by lay volunteers involved in the Department of Health, England National Defibrillator Programme. One hundred and twelve trainees were tested immediately before and after and initial 4-h class; 76 were similarly reassessed at refresher training 6 months later. A standardised test scenario that required assessment of the casualty, CPR and the use of on AED was evaluated using recording manikin data and video recordings. Before training only 44% of subjects delivered a shock. Afterwards, all did so and the average delay to first shock was reduced by 57 s. All trainees placed the defibrillator electrodes in an "acceptable" position after training, but very few did so in the recommended "ideal" position. After refresher training 80% of subjects used the correct sequence for CPR and shock delivery, yet a third failed to perform adequate safety checks before all shocks. The trainees self-assessed AED competence score was 86 (scale 0-100) after the initial class and their confidence that they would act in a real emergency was rated at a similar level. Initial training improved performance of all CPR skills, although all except compression rate had deteriorated after 6 months. The proportion of subjects able to correctly perform most CPR skill was higher following refresher training that after the initial class. Although this course was judged to be effective in teaching delivery of counter-shocks, the need was identified for more emphasis on positioning of electrodes, pre-shock safety checks, airway opening, ventilation volume, checking for signs of a circulation, hand positioning, and depth and rate of chest compressions.

AED use in businesses, public facilities and homes by minimally trained first responders

BACKGROUND

Automated external defibrillators (AEDs) have become increasingly available outside of the Emergency Medical Systems (EMS) community to treat sudden cardiac arrest (SCA). We sought to study the use of AEDs in the home, businesses and other public settings by minimally trained first responders. The frequency of AED use, type of training offered to first responders, and outcomes of AED use were investigated. In addition, minimally trained responders were asked if they had encountered any safety problems associated with the AED.

METHODS

We conducted a telephone survey of businesses and public facilities (2683) and homes (145) owning at least one AED for at least 12 months. Use was defined as an AED taken to a medical emergency thought to be a SCA, regardless of whether the AED was applied to the patient or identified a shockable rhythm.

RESULTS

Of owners that participated in the survey, 13% (209/1581) of businesses and 5% (4/73) of homes had responded with the AED to a suspected cardiac arrest. Ninety-five percent of the businesses/public facilities offered training that specifically covered AED use. The rate of use for the AEDs was highest in residential buildings, public places, malls and recreational facilities with an overall usage rate of 11.6% per year. In-depth interviews were conducted with lay responders who had used the AED in a suspected cardiac arrest. In the four cases where the AED was used solely by a lay responder, all four patients survived to hospital admission and two were known to be discharged from the hospital. There were no reports of injury or harm.

CONCLUSIONS

This survey demonstrates that AEDs purchased by businesses and homes were frequently taken to suspected cardiac arrests. Lay responders were able to successfully use the AEDs in emergency situations. Further, there were no reports of harm or injury to the operators, bystanders or patients from lay responder use of the AEDs.

World Association for Disaster and Emergency Medicine: Psychosocial Task Force—Alert and Impact

The Stage of Alert refers to the time period leading up to a disaster or terrorism event, usually defined by warnings disseminated by the federal government about increased risk of a disaster or terrorism situation. The general consensus was the need for more accurate information from appropriate governmental agencies to the public about specific impending threats, to ensure better coping. The purpose of providing this information to the public is to avoid panic or inertia, and to encourage normal adaptive reactions. It is important for people in positions of leadership to realize that past experiences have shown that panic has not occurred if people were given accurate information about the anticipated threat and specific guidelines about what to do.

Treatment of cardiac arrest with automatic external defibrillators: impact on outcome

Sudden cardiac death is the leading cause of death in the US and most developed nations. Ventricular fibrillation (VF) is the most common initial rhythm in survivors of cardiac arrest. The most important factor in determining survival from VF is the time from collapse to administration of the first defibrillation shock. Automatic external defibrillators (AEDs) have been developed and widely deployed in an attempt to reduce the time to defibrillation. Data on early defibrillation using AEDs has led to a number of public access defibrillator placements in the US and ongoing studies of public access AED use. The safety of lay person AED use is clear. Clearly some concentrated captive populations (e.g. airports, airplanes) may benefit from public access AEDs. Therefore, widespread AED education as a means of increasing public acceptance of lay person AED use must be a priority. As technology evolves costs will decline, however, the current economic reality requires careful consideration of the cost effectiveness of specific AED placement.

Automated external defibrillation by very young, untrained children

For patients with sudden cardiac death (SCD), the time interval to defibrillation is the main determinant of survival. As such, the American Heart Association has attempted to promote public-access defibrillation (PAD). Previous studies have shown that automated external defibrillators (AEDs) can be used successfully by untrained adults.

OBJECTIVE

To determine whether very young, untrained children could use AEDs.

METHODS

Third-grade students from an elementary school participated in this study representing a convenience sample of volunteers. They were given no formal training, but were shown how to peel off the backing from the electrode pads, like a sticker. Students were then given a mock code situation using a training manikin. The time to delivery of first shock was recorded. Students were then trained during a 2-minute review of the process, one on one with an instructor, and the study was then repeated. Data were analyzed using a paired Student's t-test comparing pre- and post-training.

RESULTS

Thirty-one children participated in the study, with a median age of 9 years. For untrained children, the mean time for delivery of the first shock was 59.3 +/- 13.6 seconds, 95% CI = 54.3 to 64.3. Following training, the mean time for delivery of the first shock was 35.2 +/- 6.0 seconds, 95% CI = 33.0 to 37.4, p = 0.001.

CONCLUSION

Although this study suggests that even very young, untrained children can successfully perform automated external defibrillation, training does significantly decrease the time to delivery of first shock.

Rapid on-site defibrillation versus community program

INTRODUCTION

For patients who suffer out-of-hospital cardiac arrest, the time from collapse to initial defibrillation is the single most important factor that affects survival to hospital discharge. The purpose of this study was to compare the survival rates of cardiac arrest victims within an institution that has a rapid defibrillation program with those of its own urban community, tiered EMS system.

METHODS

A logistic regression analysis of a retrospective data series (n = 23) and comparative analysis to a second retrospective data series (n = 724) were gathered for the study period September 1994 to September 1999. The first data series included all persons at Casino Windsor who suffered a cardiac arrest. Data collected included: age, gender, death/survival (neurologically intact discharge), presenting rhythm (ventricular fibrillation (VF), ventricular tachycardia (VT), or other), time of collapse, time to arrival of security personnel, time to initiation of cardiopulmonary resuscitation (CPR) prior to defibrillation (when applicable), time to arrival of staff nurse, time to initial defibrillation, and time to return of spontaneous circulation (if any). Significantly, all arrests within this series were witnessed by the surveillance camera systems, allowing time of collapse to be accurately determined rather than estimated. These data were compared to those of similar events, times, and intervals for all patients in the greater Windsor area who suffered cardiac arrest. This second series was based upon the Ontario Prehospital Advanced Life Support (OPALS) Study database, as coordinated by the Clinical Epidemiology Unit of the Ottawa Hospital, University of Ottawa.

RESULTS

The Casino Windsor had 23 cases of cardiac arrests. Of the cases, 13 (56.5%) were male and 10 (43.5%) were female. All cases (100%) were witnessed. The average of the ages was 61.1 years, of the time to initial defibrillation was 7.7 minutes, and of the time for EMS to reach the patient was 13.3 minutes. The presenting rhythm was VF/VT in 91% of the case. Fifteen patients were discharged alive from hospital for a 65% survival rate. The Greater Windsor Study area included 668 cases of out-of-hospital cardiac arrest: Of these, 410 (61.4%) were male and 258 (38.6%) were female, 365 (54.6%) were witnessed, and 303 (45.4%) were not witnessed. The initial rhythm was VF/VT was in 34.3%. Thirty-seven (5.5%) were discharged alive from the hospital.

CONCLUSION

This study provides further evidence that PAD Programs may enhance cardiac arrest survival rates and should be considered for any venue with large numbers of adults as well as areas with difficult medical access.

Intentions to use an automated external defibrillator during a cardiac emergency among a group of seniors trained in its operation

OBJECTIVE

By decreasing the time to defibrillation, automated external defibrillators (AEDs) provide an opportunity for lay people to improve survival in out-of-hospital sudden cardiac arrest. We examined how beliefs, expectations, and actual performance are related to intentions to use an AED during a future heart emergency among a group of seniors.

DESIGN AND OUTCOME MEASURES

One hundred fifty-nine seniors who had been previously trained in the operation of an AED were tested on their AED skills and asked about their perceptions regarding their AED skills; their expectations that an AED would save the life of a cardiac arrest victim; and their intentions to use an AED during a future cardiac event.

RESULTS

Logistic regression analyses showed that greater self-perceived ability to use an AED better actual performance on skills assessment but not expectations regarding the efficacy of AED treatment were independently associated with positive intentions to use an AED in a future heart emergency.

CONCLUSIONS

The likelihood that an elderly lay bystander will actually use an AED during a cardiac event may be closely tied to perceptions of his or her ability to operate an AED.

Training seniors in the operation of an automated external defibrillator: a randomized trial comparing two training methods

STUDY OBJECTIVE

This study evaluated the differences in efficacy of 2 methods for training seniors in the use of an automated external defibrillator (AED). We tested the hypothesis that each training method (face-to-face instruction compared with video-based instruction) would result in similar AED performance on a manikin.

METHODS

Two hundred ten seniors from various senior centers were randomized to receive face-to-face or video-based instruction on AED skills. Seniors were assessed individually and tested on the speed and quality of AED performance. We retested 177 of these initial trainees 3 months after initial training. Similar performance measures were assessed.

RESULTS

Although there were statistically significant differences between the 2 training methods in terms of average time to shock at both evaluations, the results in general demonstrate that there were no clinically meaningful distinctions (time differences of <20 seconds) between the AED performance of seniors trained with a video and seniors trained in a face-to-face setting at the initial training or at the retention assessment. At the initial evaluation, overall performance was satisfactory, with greater than 98% trained with either method delivering a shock. However, at the 3-month follow-up, almost one fourth of trainees were not able to deliver a shock, and almost half were not able to correctly place the pads on the manikin.

CONCLUSION

We believe that seniors can be trained equally well in AED performance with video-based self-instruction or face-to-face instruction. How to maintain acceptable AED performance skills over time remains a challenge.

The locations of nonresidential out-of-hospital cardiac arrests in the City of Pittsburgh over a three-year period: implications for automated external defibrillator placement

OBJECTIVES

To determine the locations of nonresidential out-of-hospital cardiac arrests (OHCAs) in the City of Pittsburgh and to determine whether there are "high-risk" locations that might benefit from placement of automated external defibrillators (AEDs).

METHODS

This was a retrospective case review of paramedic calls for OHCA over a three-year period, in a mid-sized northeastern city. Cardiac arrests that were traumatic or for which the patients were dead on arrival (DOA) or had advanced directives for no resuscitation were excluded. Cardiac arrests that occurred in a public location (i.e., not a private residence) were categorized.

RESULTS

A total of 971 OHCAs occurred in the City of Pittsburgh from January 1, 1997, to December 31, 1999. Of these, 575 (59%) occurred in private residences, and 396 (41%) occurred in nonresidential locations. Fifteen locations had at least one cardiac arrest per year for three years, accounting for 166 (43%) of the total nonresidential OHCAs. Twelve locations had two arrests during the three-year period, accounting for 24 (6%) of the total nonresidential OHCAs. One hundred ninety-four locations had a single episode of cardiac arrest, accounting for 51% of the OHCAs. Nursing homes and dialysis centers accounted for 178 (94%) OHCAs in the 27 locations that had two or more cardiac arrests. A local sports/events complex (Three Rivers Stadium) was the only other single location to have more than two cardiac arrests in the three-year study period, with a total of three. However, events at this complex are routinely staffed by paramedics equipped with defibrillators.

CONCLUSION

The majority of nonresidential OHCAs occur as singular, isolated events. Other than nursing homes and dialysis centers, there were no identifiable high-risk locations for nonresidential OHCA within the City of Pittsburgh.

Comparison of naive sixth-grade children with trained professionals in the use of an automated external defibrillator

BACKGROUND

Survival after out-of-hospital cardiac arrest (OHCA) is strongly influenced by time to defibrillation. Wider availability of automated external defibrillators (AEDs) may decrease response times but only with increased lay use. Consequently, this study endeavored to improve our understanding of AED use in naive users by measuring times to shock and appropriateness of pad location. We chose sixth-grade students to simulate an extreme circumstance of unfamiliarity with the problem of OHCA and defibrillation. The children's AED use was then compared with that of professionals.

METHODS AND RESULTS

With the use of a mock cardiac arrest scenario, AED use by 15 children was compared with that of 22 emergency medical technicians (EMTs) or paramedics. The primary end point was time from entry onto the cardiac arrest scene to delivery of the shock into simulated ventricular fibrillation. The secondary end point was appropriateness of pad placement. All subject performances were videotaped to assess safety of use and compliance with AED prompts to remain clear of the mannequin during shock delivery. Mean time to defibrillation was 90+/-14 seconds (range, 69 to 111 seconds) for the children and 67+/-10 seconds (range, 50 to 87 seconds) for the EMTs/paramedics (P<0.0001). Electrode pad placement was appropriate for all subjects. All remained clear of the "patient" during shock delivery.

CONCLUSIONS

During mock cardiac arrest, the speed of AED use by untrained children is only modestly slower than that of professionals. The difference between the groups is surprisingly small, considering the naïveté of the children as untutored first-time users. These findings suggest that widespread use of AEDs will require only modest training.

Automatic external defibrillators: lessons from the past, present and future

Coronary artery disease remains the leading cause of death in the United States and most developed countries. Many of the victims die from sudden cardiac arrests, resulting from dysrhythmias-most commonly ventricular fibrillation. Since most cardiac arrests occur outside the hospital, implementing emergency services in the field will have a great impact on survival. With the development of the modern automatic external defibrillator (AED), early recognition and correction of these dysrhythmias by lay rescuers can significantly improve outcome from sudden death. This paper reviews the past, present and future development and applications of AEDs.

Life supporting first aid training of the public--review and recommendations

Since the introduction around 1960 of external cardiopulmonary resuscitation (CPR) basic life support (BLS) without equipment, i.e. steps A (airway control)-B (mouth-to-mouth breathing)-C (chest (cardiac) compressions), training courses by instructors have been provided, first to medical personnel and later to some but not all lay persons. At present, fewer than 30% of out-of-hospital resuscitation attempts are initiated by lay bystanders. The numbers of lives saved have remained suboptimal, in part because of a weak or absent first link in the life support chain. This review concerns education research aimed at helping more lay persons to acquire high life supporting first aid (LSFA) skill levels and to use these skills. In the 1960s, Safar and Laerdal studied and promoted self-training in LSFA, which includes: call for the ambulance (without abandoning the patient) (now also call for an automatic external defibrillator); CPR-BLS steps A-B-C; external hemorrhage control; and positioning for shock and unconsciousness (coma). LSFA steps are psychomotor skills. Organizations like the American Red Cross and the American Heart Association have produced instructor-courses of many more first aid skills, or for cardiac arrest only-not of LSFA skills needed by all suddenly comatose victims. Self-training methods might help all people acquire LSFA skills. Implementation is still lacking. Variable proportions of lay trainees evaluated, ranging from school children to elderly persons, were found capable of performing LSFA skills on manikins. Audio-tape or video-tape coached self-practice on manikins was more effective than instructor-courses. Mere viewing of demonstrations (e.g. televised films) without practice has enabled more persons to perform some skills effectively compared to untrained control groups. The quality of LSFA performance in the field and its impact on outcome of patients remain to be evaluated. Psychological factors have been associated with skill acquisition and retention, and motivational factors with application. Manikin practice proved necessary for best skill acquisition of steps B and C. Simplicity and repetition proved important. Repetitive television spots and brief internet movies for motivating and demonstrating would reach all people. LSFA should be part of basic health education. LSFA self-learning laboratories should be set up and maintained in schools and drivers' license stations. The trauma-focused steps of LSFA are important for 'buddy help' in military combat casualty care, and natural mass disasters.

A comparison of two automated external defibrillator algorithms

OBJECTIVE

To compare the interval to delivery of the first shock by first responders in mannequin-based cardiac arrest scenarios using two automated external defibrillator (AED) algorithms.

METHODS

Thirty-six (18 pairs) of Toronto firefighters (FFs) trained in two AED algorithms, algorithm I (A-I) and algorithm II (A-II), were studied. A-II mandates the immediate application of the AED once pulselessness is established. In contrast to A-I, A-II dictates that no CPR be initiated until it is required by the AED voice prompts. Each FF pair alternated roles while performing "shock-indicated," mannequin-based scenarios according to A-I and A-II. The interval from mannequin contact to delivery of the first shock was recorded. Five pairs were videotaped. The intervals to complete predetermined steps were compared between algorithms to determine in which step(s) time saving occurred.

RESULTS

The mean (+/-SD) interval to the first shock in A-I was 80.7 seconds (+/-10.5 sec) (95% CI = 77.2 to 84.2 sec) vs 61.1 seconds (+/-8.75 sec) (95% CI = 58.2 to 64.0 sec) in A-II (p < 0.001). A-II shortened the interval to the first shock by 19.6 sec (+/-11.5) (95% CI = 15.8 to 23.4 sec). The time saving was a direct result of delaying CPR in A-II.

CONCLUSION

A-II reduced the interval from mannequin contact to the first shock in standard training scenarios.

Cardiopulmonary resuscitation: a review for clinicians

Attempts at cardiopulmonary resuscitation (CPR) date from antiquity, but it is only in the last 50 years that a scientifically-based methodology has been developed. External chest compressions is the standard method for managing circulatory arrest, however, numerous alterations of this technique have been proposed in attempts to improve outcome from CPR. Defibrillation is the single most important therapy for the management of ventricular fibrillation or pulseless ventricular tachycardia. Adrenergic agents used to improve myocardial and cerebral perfusion are also the subject of considerable investigation with new agents entering clinical study. This paper reviews the history, current techniques and pharmacotherapy as well as controversial issues in the management of patients with cardiac arrest.

Pre-hospital cardiac arrest: room for improvement

OBJECTIVE

To audit the outcome from pre-hospital cardiac arrest managed by ambulance personnel, and to assess their proficiency by analysing the time to initiate basic and advanced cardiac life support, the compliance with national guidelines, and the overall success of resuscitation.

DESIGN

A retrospective analysis of ambulance service report forms of pre-hospital cardiac arrests, where active resuscitation was attempted by ambulance personnel between October 1992 and May 1993.

SETTING

The City of Salford.

SUBJECTS

100 consecutive patients who suffered cardiac arrest out-of-hospital and who were brought to the accident and emergency department of Hope Hospital alive, or with resuscitation still in progress.

RESULTS

Only 4 of 100 patients were successfully resuscitated out of hospital, of whom 2 survived to leave hospital. Detailed analysis of pre-hospital performance was performed on 89 patients only, as 11 report forms were missing (no successful pre-hospital resuscitations in this 11). Ventricular fibrillation was the first recorded rhythm in 51.7%, but 85.7% were in asystole or electromechanical dissociation on arrival at hospital. No patient who was still in cardiac arrest on arrival at hospital was successfully resuscitated. 11 patients received 'bystander CPR'. The median time to basic life support was 6 min; the median call-to-response interval was 8 min; the median call-to-advanced cardiac life support interval was 21 min; the median on-scene time was 31 min (paramedics), or 15 min (technicians). The dose of drugs given by the intravenous route did not comply with the contemporary recommendations in 43.2%, and those doses given by the endotracheal route were inadequate in 37.9% of the cases. Endotracheal intubation was attempted in all paramedic resuscitations (91.4% success); intravenous access was attempted in 60.3% (91.7% success).

CONCLUSIONS

The survival from pre-hospital cardiac arrest in this community is worse than the national average. There is no single explanation for this. Better community CPR training, greater efficiency at the scene through additional personnel, and stricter compliance with national ACLS guidelines, facilitated by extended refresher training, are all required if outcome is to be improved.

Student nurses can defibrillate within 90 seconds. An evaluation of a training programme for third year student nurses in the use of an automatic external defibrillator

Automatic external defibrillators (AEDs) provide a means of reducing the response time in cardiac arrests but policies based on their use must take into account the costs of retraining. These depend on the level of retention of skills over time. This paper describes the retention of skills by student nurses following a training programme on the use of AEDs in cardiac resuscitation. Sixty-three student nurses were studied at intervals of 1 week, 1, 3 and 6 months following training. There was a slight deterioration in skills at 1 week and 1 month but the scores returned to the baseline level at 3 months and remained there. We conclude that there is now a case for a major study of the use of nurse-operated AEDs in the hospital setting.

Preventing Sudden Death

In brief To address the leading cause of brief sudden death in high school and college athletes, the sports medicine team can consider using automated external defibrillators. When incorporated into an emergency response plan, these devices have dramatically improved cardiac arrest survival rates. Issues to review carefully include safety, efficacy, personnel training, medical control, pertinent regulations, and cost.

Early defibrillation program: problems encountered in a rural/suburban EMS system

Many studies have shown improved survival of cardiac arrest patients by the use of early defibrillation (EMT-D) in the field. This prospective study was the first in Pennsylvania and was undertaken to determine if an EMT-D program would be successful in our suburban/rural setting. One hundred two EMTs were trained to use a semi-automatic defibrillator and data were collected over 16 months. There were 96 cardiac arrests, with only 33 patients (34%) presenting with initially treatable dysrhythmias--ventricular fibrillation (VF) or tachycardia (VT). Twenty-three patients (24%) were admitted to the hospital; survival to hospital discharge occurred in only 5 patients (5.2%). Survival to hospital admission was higher among VF/VT presenting rhythms (36%) than for those with other rhythms (17%, P = 0.07), but survival to discharge among VF/VT rhythms (9%) was not statistically different from other rhythms (3%, P = 0.45). Among VF/VT patients, survival to discharge was correlated with shorter call to first defibrillation intervals. Mean call to response interval was longer than in other reported studies (7.2 +/- 4.3 minutes). In addition, there was a high drop-out rate of EMT participants, no central/uniform early access system (that is, 911), and a lower rate of CPR than reported in other studies. It is concluded that introduction of an EMT-D program without careful analysis of systems response factors will not lead to the improved cardiac arrest survival percentages that have previously been reported.

An evaluation of automated defibrillation and manual defibrillation by emergency medical technicians in a rural setting

We show that automated external defibrillation training of emergency medical technicians (EMTs) is less time consuming than manual defibrillation training, and hypothesize that both improve survival from sudden cardiac death. Data on 91 cardiac arrests over 27 months among five basic life support services was collected before EMT-defibrillation (EMT-D) training. Subsequently, seven BLS services were trained in EMT-D using either manual difibrillation or automated external defibrillation technology, and 55 sudden cardiac death patients were entered after training. Manual defibrillation required 11 more hours per student in initial training. Survival to hospital discharge improved from two of 91 patients (2.2%) in the series before EMT-D training to nine of 55 patients (16.4%) after EMT-D training (P = .001). Improved survival was correlated with shorter prehospital defibrillation times, 8.84 minutes, when EMTs performed defibrillation versus 16.3 minutes before training when EMTs awaited advanced life support defibrillation (P < .001). To enhance equipment familiarity we allowed EMTs to apply three-lead electrode monitors to all medical/cardiac patients during transport (surveillance). There were six emergency medical service-witnessed "surveillance" arrests and three arrests survived to hospital discharge (50% survival). This group represented 33% of all survivors in the series. We recommend automated external defibrillation training for EMTs. Improved survival in sudden cardiac death cases in well-run emergency medical service systems should result from EMT-D training. Finally, we recommend that routine "surveillance" of high-risk patients during transport by defibrillation-capable EMTs be considered in EMT-D programs, rather than limiting EMT-D only to units capable of rapid "man-down" response.

Transtelephonic defibrillation

STUDY OBJECTIVES

This study was undertaken to assess the safety and reliability of a device for transtelephonic defibrillation.

DESIGN

The transtelephonic system consists of a patient unit and a base station. The patient unit contains a monitor-defibrillator, electrode pads, microphone, microprocessor, and DC defibrillator. The base station comprises a control panel, computer, and ECG display.

SETTING

Fifteen patients who were treated in our emergency department for cardiac arrest were placed on patient units that activated our base station in a remote location within the ED.

TYPE OF PARTICIPANTS

Thirteen patients were treated for ventricular fibrillation, and two patients were treated for ventricular tachycardia.

INTERVENTIONS

Thirty-one shocks were delivered transtelephonically.

MEASUREMENTS AND MAIN RESULTS

In all cases, voice and ECG transmission were established without difficulty.

CONCLUSIONS

We conclude that this system represents a safe and reliable method for the treatment of ventricular fibrillation, and we advocate additional use to study the prehospital applications of transtelephonic defibrillation.

Cardiac arrest and resuscitation: a tale of 29 cities

Published reports of out-of-hospital cardiac arrest give widely varying results. The variation in survival rates within each type of system is due, in part, to variation in definitions. To determine other reasons for differences in survival rates, we reviewed published studies conducted from 1967 to 1988 on 39 emergency medical services programs from 29 different locations. These programs could be grouped into five types of prehospital systems based on the personnel who deliver CPR, defibrillation, medications, and endotracheal intubation; the five systems were three types of single-response systems (basic emergency medical technician [EMT], EMT-defibrillation [EMT-D], and paramedic) and two double-response systems (EMT/paramedic and EMT-D/paramedic). Reported discharge rates ranged from 2% to 25% for all cardiac rhythms and from 3% to 33% for ventricular fibrillation. The lowest survival rates occurred in single-response systems and the highest rates in double-response systems, although there was considerable variation within each type of system. Hypothetical survival curves suggest that the ability to resuscitate is a function of time, type, and sequence of therapy. Survival appears to be highest in double-response systems because CPR is started early. We speculate that early CPR permits definitive procedures, including defibrillation, medications, and intubation, to be more effective.

Automatic external defibrillators

Early electrical therapy for patients with ventricular fibrillation and ventricular tachycardia can result in a significant increase of lives saved from sudden cardiac death. Rapid defibrillation has become a goal of prehospital and emergency department cardiac care, and the use of automatic external defibrillators can aid in reaching this objective. The history, mechanics, and implications of automatic external defibrillators are presented.