Public access to defibrillation. The Automatic Defibrillation Task Force

Prehospital Resuscitation of Out-of-Hospital Cardiac Arrest in Queen Mary Hospital

Management of out-of-hospital cardiac arrest is a major task of the accident and emergency department. The aim of this study is to evaluate the efficacy of prehospital resuscitation of out-of-hospital cardiac arrest in Hong Kong and identify areas for improvement. It was a prospective descriptive study of adults with non-traumatic out-of-hospital cardiac arrest who were admitted to the Accident and Emergency Department of Queen Mary Hospital by the ambulance service from March 15, 1999 to October 15, 1999. Patient characteristics and the response times of the ambulance service were recorded according to the Utstein style. One hundred and thirty patients were included. The overall immediate survival rate was 14.6% and the overall survival to discharge rate was 1.54%. The outcome of out-of-hospital cardiac arrest is poor. Every link in the chain of survival has to be improved.

The cardiocerebral resuscitation protocol for treatment of out-of-hospital primary cardiac arrest

Out-of-hospital cardiac arrest (OHCA) is a significant public health problem in most westernized industrialized nations. In spite of national and international guidelines for cardiopulmonary resuscitation and emergency cardiac care, the overall survival of patients with OHCA was essentially unchanged for 30 years--from 1978 to 2008 at 7.6%. Perhaps a better indicator of Emergency Medical System (EMS) effectiveness in treating patients with OHCA is to focus on the subgroup that has a reasonable chance of survival, e.g., patients found to be in ventricular fibrillation (VF). But even in this subgroup, the average survival rate was 17.7% in the United States, unchanged between 1980 and 2003, and 21% in Europe, unchanged between 1980 and 2004. Prior to 2003, the survival of patients with OHCA, in VF in Tucson, Arizona was less than 9% in spite of incorporating previous guideline recommendations. An alternative (non-guidelines) approach to the therapy of patients with OHCA and a shockable rhythm, called Cardiocerebral Resuscitation, based on our extensive physiologic laboratory studies, was introduced in Tucson in 2003, in rural Wisconsin in 2004, and in selected EMS areas in the metropolitan Phoenix area in 2005. Survival of patients with OHCA due to VF treated with Cardiocerebral Resuscitation in rural Wisconsin increased to 38% and in 60 EMS systems in Arizona to 39%. In 2004, we began a statewide program to advocate chest compression-only CPR for bystanders of witnessed primary OHCA. Over the next five years, we found that survival of patients with a shockable rhythm was 17.7% in those treated with standard bystander CPR (mouth-to-mouth ventilations plus chest compression) compared to 33.7% for those who received bystander chest-compression-only CPR. This article on Cardiocerebral Resuscitation, by invitation following a presentation at the 2011 Danish Society Emergency Medical Conference, summarizes the results of therapy of patients with primary OHCA treated with Cardiocerebral Resuscitation, with requested emphasis on the EMS protocol.

C ARDIAC A RREST AND R ESUSCITATION E PIDEMIOLOGY IN S INGAPORE (CARE I S TUDY )

OBJECTIVES

To describe the epidemiology of out-of-hospital cardiac arrest (OHCA) in Singapore, the emergency medical services (EMS) response, and to identify possible areas for improvement.

METHODS

This prospective observational study constitutes phase I of the Cardiac Arrest and Resuscitation Epidemiology (CARE) project. Included were all patients with nontraumatic OHCA conveyed by the national emergency ambulance service. Patient characteristics, cardiac arrest circumstances, EMS response, and outcomes were recorded according to the Utstein style.

RESULTS

From October 1, 2001, to April 30, 2002, 548 patients were enrolled into the study. Mean (standard deviation [SD]) age was 62.2 (17.9) years, with a male predominance (65.6%). A total of 59.8% of collapses occurred at home, 35.3% of arrests were not witnessed, and bystander cardiopulmonary resuscitation was present for 20.6%. Mean (SD) time from collapse to call received by EMS was 10.6 (13.1) minutes. Mean (SD) EMS response time was 10.2 (4.3) minutes. Mean (SD) time from call to defibrillation was 16.7 (7.2) minutes. Mean (SD) on-scene time was 9.9 (4.5) minutes. First presenting rhythm at the scene was asystole in 54.5%, pulseless electrical activity 22.9%, ventricular fibrillation 19.6%, and ventricular tachycardia 0.4%. Of all cardiac arrests, 351 had resuscitation attempted and were of cardiac origin. Among these patients, 17.9% had return of spontaneous circulation, 8.5% survived to hospital admission, and 2.0% survived to discharge.

CONCLUSION

CARE I establishes the baseline for the evaluation of incremental introduction of prehospital Advanced Cardiac Life Support interventions planned for future phases. Continuing efforts should be made to strengthen all chains of survival. This represents the most comprehensive OHCA study yet conducted in Singapore.

Automated external defibrillators and first responders: a satisfaction survey

PRIMARY OBJECTIVE

Automated external defibrillators (AEDs) are used with increasing frequency in the United States by first responders (FR) such as police officers (PO) or firefighters (FF). However, FR satisfaction with use of AEDs has not been investigated. We hypothesized that FR satisfaction is comparable with that of paramedics (PA) and that, among those who have defibrillated with AEDs, those who have restored a pulse before PA arrival have a higher level of satisfaction than those who have not restored a pulse.

MATERIALS AND METHODS

A 21-item questionnaire with closed answers was sent to FR and PA in four communities. Each answer was scored 0, 1 or 2. A score between 10 and 16 correlated with the highest satisfaction level.

RESULTS

276 out of 311 questionnaires were returned (89%). Two hundred and eleven respondents (35 PA, 70 FF and 106 PO) had used an AED and 99 FF and PO had restored a pulse before PA arrival. The satisfaction level of PO, FF and PA was high as demonstrated by the scores: 13.26, 13.07 and 13.39, respectively. Use of AED and pulse restoration resulted in higher scores than those of groups who had been trained only and who had not restored a pulse.

CONCLUSION

FR demonstrated a high level of satisfaction with using AEDs, and also had a favorable attitude toward implementation of AED use. Restoration of a pulse was clearly a factor responsible for a higher satisfaction. This positive attitude should encourage further implementation of early defibrillation programs in non-medical first responder settings.

Automated external defibrillation in the occupational setting

ACOEM supports ongoing efforts to enhance emergency response to medical emergencies in the occupational environment. The development of training and use of AEDs is a reasonable and appropriate aspect of such programs for managing sudden cardiac arrest, an important cause of morbidity and mortality among working age adults. The implementation of such an AED program, which should be a component of a more general worksite emergency response plan, requires clearly defined medical direction and medical control.

Out-of-hospital cardiac arrest in Hong Kong

OBJECTIVES

To evaluate the effectiveness of the local emergency medical services system in resuscitation of out-of-hospital cardiac arrest and identify areas for improvement.

METHODS

This was a prospective descriptive study of adults with nontraumatic out-of-hospital cardiac arrest treated in the three accident & emergency departments that serve the whole of Hong Kong Island from March 15, 1999, to October 15, 1999. Patient characteristics, circumstances of cardiac arrest, final outcomes, and response times of the ambulance service were recorded according to the Utstein style.

RESULTS

Three hundred twenty patients were included. There was male predominance, and the mean age was 71.5 years. The majority of cardiac arrests occurred at patients' homes. In 57.5% of cases the arrest was not witnessed. The bystander cardiopulmonary resuscitation (CPR) rate was 15.6%. The most common electrocardiographic (ECG) rhythm at scene was asystole. Ventricular fibrillation or pulseless ventricular tachycardia constituted 14.1%. The average call to dispatch interval was 1.04 minutes. The average call to CPR interval was 9.82 minutes. The average total prehospital interval was 27.55 minutes. The overall immediate survival rate was 14.1% and the rate of survival to hospital discharge was 1.25%.

CONCLUSION

The prognosis of out-of-hospital cardiac arrest in Hong Kong was dismal. Every link in the chain of survival has to be improved.

Public-access defibrillation: where do we place the AEDs?

BACKGROUND

Many prehospital cardiac arrests occur in public places. Even the best EMS systems have a finite response time. Therefore, it has been recommended that automated external defibrillators (AEDs) be placed in public areas for immediate access by trained members of the general public.

OBJECTIVE

To determine the locations of multiple cardiac arrests in order to plan for placement of public-access AEDs.

METHODS

Retrospective review of all primary cardiac arrests in calendar year 1997. Cardiac arrests in which resuscitation was not attempted (DOA), traumatic cases, pediatric cases, and those due to "other" causes were excluded. Location of the cardiac arrest was obtained from the ambulance run ticket. The EMS system is an urban, Midwestern, all-ALS, public-utility model system with fire department first responders that transports approximately 58,000 patients annually.

RESULTS

There was scene response to 922 cardiac arrests. 377 DOAs and 219 nonprimary cardiac arrests were excluded. There were 326 primary cardiac arrests. Sixteen locations had more than one cardiac arrest: 11 locations had two cardiac arrests, four locations had three cardiac arrests, and one location had four cardiac arrests. The airport, an airline overhaul facility, a casino, and two hotels each had two cardiac arrests; the other locations of multiple cardiac arrests were in nursing homes. The professional sports stadiums had no cardiac arrests.

CONCLUSIONS

Since very few locations had more than one cardiac arrest, it may be difficult to identify high-yield public places in which to place an AED. Nursing homes may want to consider AED availability.