Sudden death from cardiac arrest--improving the odds

Flight safety in patients with arrhythmia

As it is comfortable, fast, and safe, an increasing number of patients with heart disease prefer to travel by flight. However, there is not much information about the problems that patients with arrhythmia may experience during air travel. In addition, the precautions to be taken with these patients during a flight are uncertain. In this review, the management of patients with cardiac conduction problems during flight was examined in detail.

Effect of Optimized Versus Guidelines-Based Automated External Defibrillator Placement on Out-of-Hospital Cardiac Arrest Coverage: An In Silico Trial

Background

Mathematical optimization of automated external defibrillator (AED) placement may improve AED accessibility and out‐of‐hospital cardiac arrest (OHCA) outcomes compared with American Heart Association (AHA) and European Resuscitation Council (ERC) placement guidelines. We conducted an in silico trial (simulated prospective cohort study) comparing mathematically optimized placements with placements derived from current AHA and ERC guidelines, which recommend placement in locations where OHCAs are usually witnessed.

Methods and Results

We identified all public OHCAs of presumed cardiac cause from 2008 to 2016 in Copenhagen, Denmark. For the control, we computationally simulated placing 24/7‐accessible AEDs at every unique, public, witnessed OHCA location at monthly intervals over the study period. The intervention consisted of an equal number of simulated AEDs placements, deployed monthly, at mathematically optimized locations, using a model that analyzed historical OHCAs before that month. For each approach, we calculated the number of OHCAs in the study period that occurred within a 100‐m route distance based on Copenhagen’s road network of an available AED after it was placed (“OHCA coverage”). Estimated impact on bystander defibrillation and 30‐day survival was calculated by multivariate logistic regression. The control scenario involved 393 AEDs at historical, public, witnessed OHCA locations, covering 15.8% of the 653 public OHCAs from 2008 to 2016. The optimized locations provided significantly higher coverage (24.2%; P<0.001). Estimated bystander defibrillation and 30‐day survival rates increased from 15.6% to 18.2% (P<0.05) and from 32.6% to 34.0% (P<0.05), respectively. As a baseline, the 1573 real AEDs in Copenhagen covered 14.4% of the OHCAs.

Conclusions

Mathematical optimization can significantly improve OHCA coverage and estimated clinical outcomes compared with a guidelines‐based approach to AED placement.

Is Distance to the Nearest Registered Public Automated Defibrillator Associated with the Probability of Bystander Shock for Victims of Out-of-Hospital Cardiac Arrest?

Introduction Rapid access to defibrillation is a key element in the management of out-of-hospital cardiac arrests (OHCAs). Public automated external defibrillators (PAEDs) are becoming increasingly available, but little information exists regarding the relation between the proximity to the arrest and their usage in urban areas.

METHODS

This study is a retrospective, observational, cross-sectional analysis of non-traumatic OHCA during a 24-month period in the greater Montreal area (Quebec, Canada). Using logistic regression, bystander shock odds are described with regards to distance from the OHCA scene to the nearest PAED, adjusted for prehospital care arrival delay and time of day, and stratifying for type of location.

RESULTS

Out of a total of 2,443 OHCA victims identified, 77 (3%) received bystander PAED shock, 622 (26%) occurred out-of-home, and 743 (30%) occurred during business hours. When controlling for time (business hours versus other hours) and minimum response delay for prehospital care arrival, a marginal negative association was found between bystander shock and distance to the nearest PAED in logged meters (aOR=0.80; CI, 0.64-0.99) for out-of-home cardiac arrests. No significant association was found between distance and bystander shock for at-home arrests. Out-of-home victims had significantly higher odds of receiving bystander shock up to 175 meters of distance to a PAED inclusively (aOR=2.52; CI, 1.07-5.89).

CONCLUSION

For out-of-home cardiac arrests, proximity to a PAED was associated with bystander shock in the greater Montreal area. Strategies aiming to increase accessibility and use of these life-saving devices could further expand this advantage by assisting bystanders in rapidly locating nearby PAEDs. Neves Briard J , de Montigny L , Ross D , de Champlain F , Segal E . Is distance to the nearest registered public automated defibrillator associated with the probability of bystander shock for victims of out-of-hospital cardiac arrest? Prehosp Disaster Med. 2018;33(2):153-159.

Mechanism underlying impaired cardiac pacemaking rhythm during ischemia: A simulation study

Ischemia in the heart impairs function of the cardiac pacemaker, the sinoatrial node (SAN). However, the ionic mechanisms underlying the ischemia-induced dysfunction of the SAN remain elusive. In order to investigate the ionic mechanisms by which ischemia causes SAN dysfunction, action potential models of rabbit SAN and atrial cells were modified to incorporate extant experimental data of ischemia-induced changes to membrane ion channels and intracellular ion homeostasis. The cell models were incorporated into an anatomically detailed 2D model of the intact SAN-atrium. Using the multi-scale models, the functional impact of ischemia-induced electrical alterations on cardiac pacemaking action potentials (APs) and their conduction was investigated. The effects of vagal tone activity on the regulation of cardiac pacemaker activity in control and ischemic conditions were also investigated. The simulation results showed that at the cellular level ischemia slowed the SAN pacemaking rate, which was mainly attributable to the altered Na+-Ca2+ exchange current and the ATP-sensitive potassium current. In the 2D SAN-atrium tissue model, ischemia slowed down both the pacemaking rate and the conduction velocity of APs into the surrounding atrial tissue. Simulated vagal nerve activity, including the actions of acetylcholine in the model, amplified the effects of ischemia, leading to possible SAN arrest and/or conduction exit block, which are major features of the sick sinus syndrome. In conclusion, this study provides novel insights into understanding the mechanisms by which ischemia alters SAN function, identifying specific conductances as contributors to bradycardia and conduction block.

Overcoming Spatial and Temporal Barriers to Public Access Defibrillators Via Optimization

BACKGROUND

Immediate access to an automated external defibrillator (AED) increases the chance of survival for out-of-hospital cardiac arrest (OHCA). Current deployment usually considers spatial AED access, assuming AEDs are available 24 h a day.

OBJECTIVES

The goal of this study was to develop an optimization model for AED deployment, accounting for spatial and temporal accessibility, to evaluate if OHCA coverage would improve compared with deployment based on spatial accessibility alone.

METHODS

This study was a retrospective population-based cohort trial using data from the Toronto Regional RescuNET Epistry cardiac arrest database. We identified all nontraumatic public location OHCAs in Toronto, Ontario, Canada (January 2006 through August 2014) and obtained a list of registered AEDs (March 2015) from Toronto Paramedic Services. Coverage loss due to limited temporal access was quantified by comparing the number of OHCAs that occurred within 100 meters of a registered AED (assumed coverage 24 h per day, 7 days per week) with the number that occurred both within 100 meters of a registered AED and when the AED was available (actual coverage). A spatiotemporal optimization model was then developed that determined AED locations to maximize OHCA actual coverage and overcome the reported coverage loss. The coverage gain between the spatiotemporal model and a spatial-only model was computed by using 10-fold cross-validation.

RESULTS

A total of 2,440 nontraumatic public OHCAs and 737 registered AED locations were identified. A total of 451 OHCAs were covered by registered AEDs under assumed coverage 24 h per day, 7 days per week, and 354 OHCAs under actual coverage, representing a coverage loss of 21.5% (p < 0.001). Using the spatiotemporal model to optimize AED deployment, a 25.3% relative increase in actual coverage was achieved compared with the spatial-only approach (p < 0.001).

CONCLUSIONS

One in 5 OHCAs occurred near an inaccessible AED at the time of the OHCA. Potential AED use was significantly improved with a spatiotemporal optimization model guiding deployment.

Ranking Businesses and Municipal Locations by Spatiotemporal Cardiac Arrest Risk to Guide Public Defibrillator Placement

BACKGROUND

Efforts to guide automated external defibrillator placement for out-of-hospital cardiac arrest (OHCA) treatment have focused on identifying broadly defined location categories without considering hours of operation. Broad location categories may be composed of many businesses with varying accessibility. Identifying specific locations for automated external defibrillator deployment incorporating operating hours and time of OHCA occurrence may improve automated external defibrillator accessibility. We aim to identify specific businesses and municipal locations that maximize OHCA coverage on the basis of spatiotemporal assessment of OHCA risk in the immediate vicinity of franchise locations.

METHODS

This study was a retrospective population-based cohort study using data from the Toronto Regional RescuNET Epistry cardiac arrest database. We identified all nontraumatic public OHCAs occurring in Toronto, ON, Canada, from January 2007 through December 2015. We identified 41 unique businesses and municipal location types with ≥20 locations in Toronto from the YellowPages, Canadian Franchise Association, and the City of Toronto Open Data Portal. We obtained their geographic coordinates and hours of operation from Web sites, by phone, or in person. We determined the number of OHCAs that occurred within 100 m of each location when it was open (spatiotemporal coverage) for Toronto overall and downtown. The businesses and municipal locations were then ranked by spatiotemporal OHCA coverage. To evaluate temporal stability of the rankings, we calculated intraclass correlation of the annual coverage values.

RESULTS

There were 2654 nontraumatic public OHCAs. Tim Hortons ranked first in Toronto, covering 286 OHCAs. Starbucks ranked first in downtown, covering 110 OHCAs. Coffee shops and bank machines from the 5 largest Canadian banks occupied 8 of the top 10 spots in both Toronto and downtown. The rankings exhibited high temporal stability with intraclass correlation values of 0.88 (95% confidence interval, 0.83-0.93) in Toronto and 0.79 (95% confidence interval, 0.71-0.86) in downtown.

CONCLUSIONS

We identified and ranked businesses and municipal locations by spatiotemporal OHCA risk in their immediate vicinity. This approach may help policy makers and funders to identify and prioritize potential partnerships for automated external defibrillator deployment in public-access defibrillator programs.

The association between diabetes status and survival following an out-of-hospital cardiac arrest: A retrospective cohort study

BACKGROUND

Sudden cardiac arrest (SCA), confirmed absence of cardiac mechanical activity, is the leading cause of heart-related death in the US. Almost 85% of SCA occur out-of-hospital (OHCA), with very poor rates of return of spontaneous circulation (ROSC) and survival to hospital discharge. We sought to determine if diabetes status was associated with survival or ROSC following an OHCA.

METHODS

We completed a retrospective cohort study using data from the Toronto Regional RescuNet Epistry dataset, based upon data definitions defined by the Resuscitation Outcomes Consortium (ROC) Epistry-Cardiac Arrest and the Strategies for Post Arrest Resuscitation Care (SPARC) network datasets. Adults ≥18years of age who experienced an OHCA, had data on diabetes status, and were treated by Emergency Medical Services (EMS) between 2012-2014 were included in the analysis (n=10,097). We used bivariate analyses to examine relationships between diabetes status, Utstein elements and outcomes, and logistic regression to determine predictors of survival.

RESULTS

Diabetes prevalence was 27.8% (95% CI: 27.0-28.7). A larger proportion of those with diabetes had a non-shockable initial rhythm (28.8% vs. 25.1%; p<0.01) and did not survive to hospital discharge (92.1% vs. 89.2%, p<0.001). Diabetes status is associated with a decrease in survival, independent from a number of Utstein elements (adjusted OR=0.76; 95% CI: 0.64-0.91, p=0.003).

CONCLUSIONS

This is the first Canadian study to examine the association between diabetes status and OHCA outcomes. Our findings suggest that diabetes status prior to arrest is associated with decreased survival. The growing prevalence of diabetes globally suggests a future burden related to OHCAs.

Microparticles and sudden cardiac death due to coronary occlusion. The TIDE (Thrombus and Inflammation in sudden DEath) study

AIMS

The pattern of coronary occlusion might contribute to the onset of ventricular arrhythmia and sudden cardiac death (SCD). We hypothesized that the concentrations of microparticles might differ between SCD and ST-elevation myocardial infarction (STEMI) patients without rhythmic disturbances.

METHODS AND RESULTS

The study sample includes consecutive patients hospitalized in two French tertiary centres between 2006 and 2011 for SCD with angiographically-proven acute coronary occlusion (n=23), for STEMI (n=61) and for a planned percutaneous coronary angioplasty (PCI) (n=35, controls). During PCI blood was collected in the arch of aorta (systemic blood) before and after the procedure and in the culprit coronary lesion with an aspiration catheter. Microparticles were analysed by flow cytometry in a blinded manner to quantify endothelial (CD144+), platelet (CD41+), leucocyte (CD11a+) and erythrocyte (CD235a+) derived microparticles. After multivariate analysis, intracoronary concentrations of endothelial-derived microparticles were significantly higher in SCD than in STEMI patients (129 (74-185) vs. 50 (21-118) nb/µl; p < 0.01). Intracoronary and systemic blood concentrations of platelet-derived microparticles were not different between SCD and controls, suggesting limited impact of cardiac massage and electric defibrillation in microparticle concentrations.

CONCLUSION

The higher concentrations of endothelial-derived microparticles in SCD due to acute coronary occlusion compared with STEMI without rhythmic disturbances suggests different patterns of acute coronary occlusion.

Defibrillation delivered during the upstroke phase of manual chest compression improves shock success

OBJECTIVE

The current standard of manual chest compression during cardiopulmonary resuscitation requires pauses for rhythm analysis and shock delivery. However, interruptions of chest compression greatly decrease the likelihood of successful defibrillations, and significantly better outcomes are reported if this interruption is avoided. We therefore undertook a prospective randomized controlled animal study in an electrically induced ventricular fibrillation pig model to assess the effects of timing of defibrillation on the manual chest compression cycle on the defibrillation threshold.

DESIGN

Prospective, randomized, controlled animal study.

SETTING

University-affiliated research laboratory.

SUBJECTS

Yorkshire-X domestic pigs (Sus scrofa).

INTERVENTIONS

In eight domestic male pigs weighing between 24 and 31 kg, ventricular fibrillation was electrically induced and untreated for 10 secs. Manual chest compression was then performed and continued for 25 secs with the protection of an isolation blanket. The depth and frequency of chest compressions were guided by a cardiopulmonary resuscitation prompter. Animals were randomized to receive a biphasic electrical shock in five different compression phases with a predetermined energy setting. A control phase was chosen at a constant 2 secs after discontinued chest compression. A grouped up-down defibrillation threshold testing protocol was used to compare the success rate at different coupling phases. After a recovery interval of 4 mins, the sequence was repeated for a total of 60 test shocks for each animal.

MEASUREMENTS AND MAIN RESULTS

No difference in coronary perfusion pressure before delivering of the shock was observed among the six study phases. The defibrillation success rate, however, was significantly higher when shocks were delivered in the upstroke phase of manual chest compression.

CONCLUSION

Defibrillation efficacy is maximal when electrical shock is delivered during the upstroke phase of manual chest compression.

Patients with a history of diabetes have a lower survival rate after in-hospital cardiac arrest

AIM

To describe the association between a history of diabetes and outcome among patients suffering an in-hospital cardiac arrest.

METHOD

All patients suffering an in-hospital cardiac arrest in whom cardiopulmonary resuscitation (CPR) was attempted at Sahlgrenska University Hospital in Göteborg between 1994 and 2006 and at nine further hospitals in Sweden between 2005 and 2006.

RESULTS

In all, 1810 patients were included in the survey, 395 (22%) of whom had a previous history of diabetes. Patients with a history of diabetes differed from those without such a history by having a higher prevalence of previous myocardial infarction, stroke, heart failure and renal disease. They were more frequently treated with anti-arrhythmic drugs during resuscitation. Whereas immediate survival did not differ between groups (51.7% and 53.1%, respectively), patients with diabetes were discharged alive from hospital (29.3%) less frequently compared with those without diabetes (37.6%). When correcting for dissimilarities at baseline, the adjusted odds ratio for being discharged alive (diabetes/no diabetes) was 0.57 (95% CL 0.40-0.79).

CONCLUSION

Among patients suffering an in-hospital cardiac arrest in Sweden in whom CPR was attempted, 22% had a history of diabetes. These patients had a lower survival rate, which cannot simply be explained by different co-morbidity.

T-wave vector alternans detection based on Holter ECG recordings

This paper proposes a new method for detecting T-wave alternans (TWA) based on 3-channel Holter ECG recordings. The current standard method, based on spectral analysis of each signal lead, enables low amplitude alternans detection at the microvolt level. However, the method requires a controlled test environment where the mean heart rate is artificially increased. T Proposed method aims at realizing the reliable alternans detection from 24 hour Holter recordings during normal daily activities. To achieve this, the method utilizes singular value decomposition (SVD) for highly sensitive differentiation of T-wave morphology in noisy recording conditions. We propose the name T-wave Vector Alternance (TWVA) for TWA detected by SVD in decomposed ECG signals. The method was applied to three normal subjects and two subjects with TWA, and it correctly detected the TWA.

Community Lay Rescuer Automated External Defibrillation Programs

Cardiovascular disease is a leading cause of death for adults ≥40 years of age. The American Heart Association (AHA) estimates that sudden cardiac arrest is responsible for about 250 000 out-of-hospital deaths annually in the United States. Since the early 1990s, the AHA has called for innovative approaches to reduce time to cardiopulmonary resuscitation (CPR) and defibrillation and improve survival from sudden cardiac arrest. In the mid-1990s, the AHA launched a public health initiative to promote early CPR and early use of automated external defibrillators (AEDs) by trained lay responders in community (lay rescuer) AED programs. Between 1995 and 2000, all 50 states passed laws and regulations concerning lay rescuer AED programs. In addition, the Cardiac Arrest Survival Act (CASA, Public Law 106-505) was passed and signed into federal law in 2000. The variations in state and federal legislation and regulations have complicated efforts to promote lay rescuer AED programs and in some cases have created impediments to such programs. Since 2000, most states have reexamined lay rescuer AED statutes, and many have passed legislation to remove impediments and encourage the development of lay rescuer AED programs. The purpose of this statement is to help policymakers develop new legislation or revise existing legislation to remove barriers to effective community lay rescuer AED programs. Important areas that should be considered in state legislation and regulations are highlighted, and sample legislation sections are included. Potential sources of controversy and the rationale for proposed legislative components are noted. This statement will not address legislation to support home AED programs. Such recommendations may be made after the conclusion of a large study of home AED use.

Factors influencing survival after in-hospital cardiopulmonary resuscitation

INTRODUCTION

During recent years, in-hospital cardiopulmonary resuscitation (CPR) management has received much attention. However, the rate of survival after in-hospital resuscitation in Iran hospitals is not known. Therefore, a study was designed to evaluate the outcome of in-hospital cardiopulmonary resuscitation (CPR) in the city of Kashan, Iran, during a 6-month period during 2002.

MATERIAL AND METHODS

A prospective descriptive study was conducted on all cases of in-hospital cardiopulmonary resuscitation. Necessary data including the age and sex of patients, shift, time from cardiac arrest until initiating of CPR, time from cardiac arrest until defibrillation, duration and result of CPR, were recorded in a checklist. Descriptive statistics presented.

RESULTS

A total of 206 cases of CPR were attempted during the research period. The study population consisted of 59.2% males and 40.8% females. The survival rate was similar for both sexes. Short-term survival was observed in 19.9% of cases and only 5.3% survived to discharge. The key predictors of survival to hospital discharge were CPR duration, time of cardiac arrest, time from cardiac arrest to initiation of CPR, and defibrillation within the first few minutes of cardiac arrest.

CONCLUSIONS

Our study showed that it needs more attention to be paid to cardiopulmonary resuscitation management in Iran's hospitals. The results of this study could be an important first step toward a national study on the survival after cardiopulmonary resuscitation to provide accurate data on our performance with regards to the chain of survival.

Diabetes, glucose level, and risk of sudden cardiac death

AIMS

The prevalence of diabetes mellitus in industrialized countries is rapidly increasing, and diabetes is suspected to carry a particular high risk for sudden cardiac death (SCD).

METHODS AND RESULTS

We conducted a population-based case-control study at Group Health Cooperative. Cases (n=2040) experienced out-of-hospital cardiac arrest due to heart disease between 1980 and 1994. Controls (n=3800) were a stratified random sample of enrollees. Diabetes status was classified into four exclusive groups: (i) no diabetes, (ii) borderline, (iii) diabetes without microvascular disease (retinopathy or proteinuria), and (iv) diabetes with microvascular disease. When compared with no diabetes, we observed progressively higher risk of SCD associated with borderline diabetes [Odds ratio (OR)=1.24 (0.98-1.57)], diabetes without microvascular disease [OR=1.73 (1.28-2.34)], and diabetes with microvascular disease [OR=2.66 (1.84-3.85)], after adjustment for potential confounders (P-value for trend <0.001). Higher glucose levels were also associated with the risk of SCD both in the absence and in the presence of microvascular disease. However, subjects with microvascular complications but with glucose level <7.7 mmol/L were not at significant increased risk of SCD.

CONCLUSION

These results emphasize the role of diabetes as a strong risk factor for SCD and outline the importance of glucose level at every stage of diabetes severity.

Risk factors for out-of-hospital cardiac arrest: the Reykjavik Study

AIMS

To examine risk factors for out-of-hospital cardiac arrest in the Reykjavik Study, a long-term, prospective, population-based cohort study that started in 1967.

METHODS AND RESULTS

From 1987 to 1996, 137 men and 44 women out of the 8006 men and 9435 women in the study sustained out-of-hospital cardiac arrest due to cardiac causes. Determinants included coronary artery disease (CAD), its classical risk factors, and age, body mass index (BMI), heart rate, cardiomegaly, and erythrocyte sedimentation rate. Electrocardiograms (ECGs) were examined for various abnormalities. Significance was determined by Cox regression analysis. In multivariable analysis, the risk in men was significantly associated with age, diastolic blood pressure, cholesterol, current smoking, and previous diagnosis of myocardial infarction (MI). In women, the risk was associated with diastolic blood pressure, elevated levels of cholesterol and triglycerides, and increased voltage on ECG. Increased BMI was inversely related to women's risk of out-of-hospital cardiac arrest.

CONCLUSION

In this prospective, population-based cohort study previous MI and the classical risk factors for CAD significantly increased the risk of out-of-hospital cardiac arrest, the endpoint of this study. Increased voltage on ECG additionally increased women's risk.

Sudden death in children and adolescents

This article focuses on sudden unexpected cardiac death (SCD) in children and adolescents. The authors discuss the epidemiology of SCD in children and adolescents, its incidence and etiologies, and strategies for prevention. Because most of the episodes of SCD or sudden cardiac arrest in children and adolescents occur in asymptomatic individuals unknown to have an underlying abnormality before their "event," the issues in this article primarily focus on this group of individuals.

Lay rescuer automated external defibrillator programs for children and adolescents

This article summarizes the controversies regarding the establishment of lay rescuer automated external defibrillator (AED) programs in schools. It describes the elements of one successful program and provides recommendations for critical elements of AED programs in schools, using the recommendations that were described by the American Heart Association statement and experience gained in the establishment of AED programs in high schools in Wisconsin.

Impact of community-wide police car deployment of automated external defibrillators on survival from out-of-hospital cardiac arrest

BACKGROUND

Disappointing survival rates from out-of-hospital cardiac arrests encourage strategies for faster defibrillation, such as use of automated external defibrillators (AEDs) by nonconventional responders.

METHODS AND RESULTS

AEDs were provided to all Miami-Dade County, Florida, police. AED-equipped police (P-AED) and conventional emergency medical rescue (EMS) responders are simultaneously deployed to possible cardiac arrests. Times from 9-1-1 contact to the scene were compared for P-AED and concurrently deployed EMS, and both were compared with historical EMS experience. Survival with P-AED was compared with outcomes when EMS was the sole responder. Among 420 paired dispatches of P-AED and EMS, the mean+/-SD P-AED time from 9-1-1 call to arrival at the scene was 6.16+/-4.27 minutes, compared with 7.56+/-3.60 minutes for EMS (P<0.001). Police arrived first to 56% of the calls. The time to first responder arrival among P-AED and EMS was 4.88+/-2.88 minutes (P<0.001), compared with a historical response time of 7.64+/-3.66 minutes when EMS was the sole responder. A 17.2% survival rate was observed for victims with ventricular fibrillation or pulseless ventricular tachycardia (VT/VF), compared with 9.0% for standard EMS before P-AED implementation (P=0.047). However, VT/VF benefit was diluted by the observation that 61% of the initial rhythms were nonshockable, reducing the absolute survival benefit among the total study population to 1.6% (P-AED, 7.6%; EMS, 6.0%).

CONCLUSIONS

P-AED establishes a layer of responders that generate improved response times and survival from VT/VF. There was no benefit for victims with nonshockable rhythms.

Unreliable post event report from an automated external defibrillator

Medical supervision of the use of automated external defibrillators (AEDs) is possible by the incorporation of a solid state memory system recording electrocardiography (ECG) tracings and information about the operation of the device. Since a post event report suggested inappropriate AED use erroneously, the information storage and printing processes of the Laerdal AED system were investigated. This analysis strongly suggests (yet unpredictable) incompatibilities between the software built in the solid state memory modules and the different components of the printing system. Although no problems were encountered during the resuscitation attempts, these findings may be clinically relevant because an unreliable post event report from a solid state memory module may lead to erroneous criticism of an AED user.