One year's experience of early defibrillation in Stockholm

Cardiopulmonary resuscitation in real life: the most frequent fears of lay rescuers

INTRODUCTION

Surviving cardiac arrest depends on early cardiopulmonary resuscitation (CPR). Only one third of cardiac arrest victims receive prompt CPR in spite of well-attended Basic Life Support (BLS) courses. Our study aimed to investigate that how many lay rescuers, capable of performing CPR, would do so, and to analyse their impeding fears.

MATERIALS AND METHODS

After each BLS course for lay rescuers (American Heart Association (AHA) CPR for family and friends), an anonymous questionnaire was distributed asking participants whether they would perform CPR on an adult or on a child in a real case of cardiac arrest. In the case of a negative response, we questioned them why.

RESULTS

A total of 1000 questionnaires were analysed. The sample group was predominantly made up of males (77.7%), Italians (82.2%), individuals aged between 26 and 35 years (41.2%) and individuals possessing a high-school diploma (61.8%). The percentages that would perform CPR on an unknown adult or child were different (86.2% vs. 73.9% p = 0.005). The prevalent fears were regarding infection, being incapable, legal implications and causing damage and fear in general. The first three differ significantly in adult and paediatric cases. Subdividing the population according to sex, age and education did not demonstrate significant differences regarding willingness to perform adult or paediatric CPR.

CONCLUSIONS

This descriptive study demonstrates that the percentage that would really perform CPR is too low, particularly in the case of a child. Part of the course should be dedicated to discussing these arguments to ensure that all those capable of performing good CPR would immediately do so.

Prospective assessment of integrating the existing emergency medical system with automated external defibrillators fully operated by volunteers and laypersons for out-of-hospital cardiac arrest: the Brescia Early Defibrillation Study (BEDS)

AIMS

There are few data on the outcomes of cardiac arrest (CA) victims when the defibrillation capability of broad rural and urban territories is fully operated by volunteers and laypersons.

METHODS AND RESULTS

In this study, we investigated whether a programme based on diffuse deployment of automated external defibrillators (AEDs) operated by 2186 trained volunteers and laypersons across the County of Brescia, Italy (area: 4826 km(2); population: 1 112 628), would safely and effectively impact the current survival among victims of out-of-hospital CA. Forty-nine AEDs were added to the former emergency medical system that uses manual EDs in the emergency department of 10 county hospitals and in five medically equipped ambulances. The primary endpoint was survival free of neurological impairment at 1-year follow-up. Data were analysed in 692 victims before and in 702 victims after the deployment of the AEDs. Survival increased from 0.9% (95% CI 0.4-1.8%) in the historical cohort to 3.0% (95% CI 1.7-4.3%) (P=0.0015), despite similar intervals from dispatch to arrival at the site of collapse [median (quartile range): 7 (4) min vs. 6 (6) min]. Increase of survival was noted both in the urban [from 1.4% (95% CI 0.4-3.4 %) to 4.0% (95% CI 2.0-6.9 %), P=0.024] and in the rural territory [from 0.5% (95% CI 0.1-1.6%) to 2.5% (95% CI 1.3-4.2%), P=0.013]. The additional costs per quality-adjusted life year saved amounted to euro39 388 (95% CI euro16 731-49 329) during the start-up phase of the study and to euro23 661 (95% CI euro10 327-35 528) at steady state.

CONCLUSION

Diffuse implementation of AEDs fully operated by trained volunteers and laypersons within a broad and unselected environment proved safe and was associated with a significantly higher long-term survival of CA victims.

Obstacles to bystander cardiopulmonary resuscitation in Japan

OBJECTIVE

bystander cardiopulmonary resuscitation (CPR) is performed infrequently in Japan. We conducted this study to identify Japanese attitudes toward the performance of bystander CPR.

METHODS

participants were asked about their willingness to perform CPR with varying scenarios and CPR techniques (mouth-to-mouth ventilation plus chest compression (MMV plus CC) versus chest compression alone (CC)).

RESULTS

a total of 1302/1355 individuals completed the questionnaire, including high school students, teachers, emergency medical technicians, medical nurses, and medical students. About 2% of high school students, 3% of teachers, 26% of emergency medical technicians, 3% of medical nurses and 16% of medical students claimed they would 'definitely' perform MMV plus CC on a stranger. However, 21-72% claimed they would prefer the alternative of performing CC alone. Respondents claimed their unwillingness to perform MMV is not due to the fear of contracting a communicable disease, but the lack of confidence in their ability to perform CPR properly.

CONCLUSION

in all categories of respondents, willingness to perform MMV plus CC for a stranger was disappointingly low. Better training in MMV together with teaching awareness that CC alone can be given should be instituted to maximize the number of potential providers of CPR in the community, even in communities where the incidence of HIV is very low.

Cardiac arrest in Saudi Arabia: a 7-year experience in Riyadh

All out-of-hospital and Emergency Department (ED) cardiac arrests treated at a tertiary care hospital in Riyadh, Saudi Arabia, from 1989 through 1995 were studied. Of patients arresting out-of-hospital, 3.0% received bystander cardiopulmonary resuscitation (CPR), 9.1% had some prehospital CPR, 12.1% were transported via ambulance, and 13.6% had ventricular fibrillation (VF) on ED arrival. In the witnessed arrests (80%), the estimated interval from arrest to initiation of CPR was 21.1 +/- 14.7 min. None of these variables was shown to influence outcome. Survival to hospital discharge from out-of-hospital arrest was 5.1% for adults and 7.4% for children; all had poor neurologic outcome. For patients arresting in the ED, an initial rhythm of ventricular tachycardia (VT) or VF was strongly correlated with survival. Survival from ED arrest was 30.4% in adults, 42.9% in children; all but one had normal neurologic outcome. These results are similar to those reported from large cities and EDs elsewhere. The unique set of variables influencing out-of-hospital care and transportation in Riyadh are discussed, and potential areas for improvement are noted.

Effects of early defibrillation by ambulance personnel on short- and long-term outcome of cardiac arrest survival: the Munich experiment

OBJECTIVES

This study evaluates the feasibility of implementing early defibrillation of out-of-hospital cardiac arrest patients for basic life-support providers (EMT-D) in a two-tier emergency system in the city of Munich, Germany.

DESIGN

Retrospective consecutive analysis of all EMT-D attempts during a 5-year initiation phase (1990 to 1994) and prospective follow-up of all cardiac arrest survivors discharged from hospital.

SETTING

A strictly defined inner-city and suburban area of 978 km2 and a residential population of 1,530,000 inhabitants with 22 ICUs in urban hospitals. One dispatching center to alert a two-tier emergency system with 56 EMT-D-staffed ambulances and physician-staffed mobile ICUs stationed at the nearest of nine hospitals.

METHODS

AH EMT-D cases were identified and data on patients were documented in a standardized manner from patients' records, including the resuscitation protocol in the hospitals to which the patients were referred. For those patients discharged from the hospital, a standardized telephone interview was undertaken with the physician in charge of the patient and with the patient/relative leading to an assessment of the patient's status according to the Glasgow-Pittsburgh cerebral performance categories.

INTERVENTION

None.

RESULTS

During the 5-year initiation phase of the EMT-D program in the two-tier emergency system in Munich, there were 243 resuscitation attempts by EMTs, using the semiautomated defibrillator; 125 patients died immediately on the scene. In 118 patients, spontaneous circulation was reestablished and these patients were admitted to an ICU in 1 of the 22 urban hospitals. Median call-response interval for the EMT-D was 5 min (interquartile range, 3 to 6) and was 10 min (interquartile range, 7 to 13) for the second tier (p < or = 0.0001). In 34 cases (28.8%), EMT-D staff had reestablished spontaneous circulation (ROSC) before the second tier arrived on the scene. Patients with ROSC on the arrival of the second tier were more frequently discharged alive from hospital than were patients without ROSC at that time (p < or = 0.0001). The hospital discharge rate of initially successful resuscitated patients presenting with out-of-hospital ventricular fibrillation was 38.1% (45/118). Overall success rate of all EMT-D attempts was 18.5% (45/243). After a mean follow-up time of 39 (range, 22 to 64) months, 29 (66%) patients were still living. Twenty-five (56.8%) were neurologically not disabled or mildly disabled (CPC 1/2); disability was moderate in 3 (6.8%) patients and was severe in 1 (2.3%) patient. One case was lost to follow-up.

CONCLUSION

The present study demonstrates that the upgrading of basic life support providers with semiautomated defibrillators has a significant benefit for cardiac arrest victims outside the hospital in an urban environment.

Designing a prehospital system for a developing country: estimated cost and benefits

Many of the costs associated with prehospital care in developed countries are covered in budgets for fire suppression, police services, and the like. Determining these costs is therefore difficult. The costs and benefits of developing a prehospital care system for Kuala Lumpur, Malaysia, which now has essentially no emergency medical services (EMS) system, were estimated. Prehospital therapies that have been suggested to decrease mortality were identified. A minimal prehospital system was designed to deliver these treatments in Kuala Lumpur. The potential benefit of these therapies was calculated by using statistics from the United States corrected for demographic differences between the United States and Malaysia. Costs were extrapolated from the current operating budget of the Malaysian Red Crescent Society. Primary dysrhythmias are responsible for almost all potentially survivable cardiac arrests. A system designed to deliver a defibrillator to 85% of arrests within 6 minutes would require an estimated 48 ambulances. Kuala Lumpur has approximately 120 prehospital arrhythmic deaths per year. A 6% resuscitation rate was chosen for the denominator, resulting in seven survivors. Half of these would be expected to have significant neurological damage. Ambulances cost $53,000 (US dollars) to operate per year in Kuala Lumpur; 48 ambulances would cost a total of $2.5 million. Demographic factors and traffic problems would significantly increase the cost per patient. Other therapies, including medications, airway management, and trauma care, were discounted because both their additional cost and their benefit are small. Transport of patients (including trauma) is now performed by police or private vehicle and would probably take longer by ambulance. A prehospital system for Kuala Lumpur would cost approximately $2.5 million per year. It might save seven lives, three of which would be marred by significant neurological injury. Developing countries would do well to consider alternatives to a North American EMS model.

Community cardiac awareness teaching in a rural area: the potential for a health promotion message

Little information has been published on the uptake of cardiopulmonary resuscitation (CPR) training in rural areas or on the potential to associate a health promotion message with skills training. This paper describes CPR instructor and community training programmes in Ireland. Public interest in these programmes has been strongest in rural areas, which have constituted the main focus of activity to date. High-quality training of lay instructors has been a specific target of the programmes, which have included a significant health promotion message. In the pilot rural area, almost 2% of adults aged between 15 and 64 years attended a course during the first year of operation. However, the self-reported risk factor profile of participants suggests significant under-estimation of risk factors such as obesity, hypertension or raised blood cholesterol. While general population teaching programmes can attract large numbers of participants, even in isolated rural areas, the perceived relevance of an associated health promotion message may be very low.

Out-of-hospital cardiac arrests: an 8-year New York City experience

A retrospective study was conducted to determine the outcome of out-of-hospital cardiac arrests by one prehospital system in New York City from January, 1986, through December, 1993. The results were recorded consistent with the Utstein Style. Of 481 attempted patient resuscitations 406 were of cardiac etiology, with 382 patients having arrested prior to EMS arrival; their overall survival rate was 2.1% (8/382). Cardiac arrests were witnessed in 246 patients. Of the witnessed arrest patients found in ventricular fibrillation (96/246), the overall survival rate was 7.3% (7/96). Of the 7 survivors who were discharged from the hospital, 71.4% (5/7) had a good cerebral performance/good overall performance. Of 24 patients who arrested in the presence of EMS, the survival rate was 12.5% (3/24). This study confirms a poor survival rate for patients suffering out-of-hospital cardiac arrests in New York City.

The need for ventilatory support during bystander CPR

STUDY OBJECTIVE

To compare CPR with chest compressions plus ventilatory support (CC+V) and chest compressions alone (CC).

DESIGN

Prospective, randomized study.

SETTING

Research laboratory.

INTERVENTIONS

After 2 minutes of ventricular fibrillation, 18 domestic swine (20 to 35 kg) were treated first with CC or CC+V for 10 minutes, then with standard advanced cardiac life support.

RESULTS

Hemodynamics, survival, and neurologic outcome were determined. All 8 swine subjected to CC+V and all 10 subjected to CC showed return of spontaneous circulation. One animal in each group died within 1 hour. Seven of 8 animals in the CC+V group survived for 24 and 48 hours, compared with 9 of 10 CC animals at 24 hours and 8 of 10 at 48 hours. All 48-hour survivors were neurologically normal.

CONCLUSION

In this experimental model of bystander CPR, we could not detect a difference in hemodynamics, 48-hour survival, or neurologic outcome when CPR was applied with and without ventilatory support.

Methodology-dependent variation in documentation of outcome predictors in out-of-hospital cardiac arrest

OBJECTIVE

To identify variation in outcome predictor documentation in out-of-hospital cardiac arrest associated with two different methods of data collection: concurrent questioning of personnel following a resuscitation attempt and archival report review.

METHODS

All patients > or = 18 years old who had out-of-hospital cardiac arrests, verified using the New York City 911 telephone system, between October 1, 1990, and April 1, 1991, were eligible for inclusion. The authors reviewed the first 200 cases of presumed primary cardiac arrest involving a resuscitation attempt among 3,243 consecutive ambulance call reports for cardiac arrest occurring during the study period. This archival data set was compared with data for the same 200 cases gathered through direct interview of field personnel by trained paramedics. The two data sets had been compiled independently by different individuals, using the same data collection instrument, which conformed to the Utstein template.

RESULTS

Comparison of the data obtained from ambulance records with the data obtained from interviews of prehospital personnel revealed several areas of variance. Of note was a significantly lower proportion of bystander-witnessed ventricular fibrillation (VF) in the data set gathered from written reports (7% vs 18%; 95% CI for the difference 4-18%; p = 0.001).

CONCLUSION

differences in methods of collection of out-of-hospital cardiac arrest data are associated with a more than twofold variation in the reported incidences of witnessed cardiac arrests manifesting as VF. Methodology-dependent variation in this important "denominator" may produce substantially different estimates of survival within the same cohort of patients.

Methodology for data collection to study prehospital cardiac arrest in New York City: the PHASE methodology. PreHospital Arrest Survival Evaluation Group

STUDY OBJECTIVE

To describe an effective methodology for the investigation of prehospital cardiac arrest in large cities.

DESIGN

Observational cohort study.

SETTING

New York City emergency medical services system.

PARTICIPANTS

All cardiac arrests dispatched by the 911 system between October 1, 1990, and March 31, 1991.

INTERVENTIONS

Trained paramedics performed immediate postarrest interviews with prehospital and hospital care providers using a standardized data collection instrument.

RESULTS

Of 3,239 consecutive, confirmed cardiac arrests in which resuscitation was attempted, 2,329 (72%) were of cardiac etiology. Information was sought for 15 of the 17 core events and times recommended by the Utstein Consensus Conference Data were obtained in more than 98% of cases for all except one of these core events and times. One core time yielded data in 96% of cases. All patients were followed until death or discharge home. None were lost to follow-up.

CONCLUSION

Concurrent, interactive acquisition of prehospital cardiac arrest data in a large urban setting captured over 98% of the core data recommended for completion of the Utstein template. This methodology may be a suitable means of investigating prehospital cardiac arrest in large cities.

Out-of-hospital resuscitation in East Sussex: 1981 to 1989

OBJECTIVE

To assess the impact of extended training in advanced life support on the outcome of resuscitation.

DESIGN

Analysis of the successful resuscitations from 1981 to 1989.

SETTING

Brighton and East Sussex.

RESULTS

248 patients were resuscitated from cardiac or respiratory arrest in the community and subsequently survived to leave hospital. Their mean age was 64 years and one year survival was 77%. In most cases the cause of collapse was cardiac but 38 (15%) suffered a respiratory arrest. In 140 of the successful resuscitations (56%) collapse occurred before the arrival of the ambulance. Basic life support, with ventilation and chest compression where necessary, was sufficient to revive 35 (14%) of the patients. Defibrillation was also required in 107 patients (43%), and in a further 106 patients (43%) who had prolonged cardiorespiratory arrest requiring endotracheal intubation and the use of several drugs. Review of ambulance forms and case notes showed that in 87 cases (35%) the abilities of the paramedical ambulance staff in advanced resuscitation techniques contributed decisively to the success of resuscitation. These skills are illustrated by eight case reports.

CONCLUSIONS

Extended training for ambulance staff increases the likelihood of successful resuscitation from out-of-hospital cardiopulmonary arrest. Though instruction in defibrillation must have the highest priority, full paramedical training can bring appreciable additional benefits.

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.

Outcome of CPR in a large metropolitan area--where are the survivors?

STUDY OBJECTIVES

Survival from out-of-hospital cardiac arrest in cities with populations of more than 1 million has not been studied adequately. This study was undertaken to determine the overall survival rate for Chicago and the effect of previously reported variables on survival, and to compare the observed survival rates with those previously reported.

DESIGN

Consecutive prehospital arrest patients were studied prospectively during 1987.

SETTING

The study area was the city of Chicago, which has more than 3 million inhabitants in 228 square miles. The emergency medical services system, with 55 around-the-clock ambulances and 550 paramedics, is single-tiered and responds to more than 200,000 emergencies per year.

TYPE OF PARTICIPANTS

We studied 3,221 victims of out-of-hospital cardiac arrest on whom paramedics attempted resuscitation.

MEASUREMENTS AND MAIN RESULTS

Ninety-one percent of patients were pronounced dead in emergency departments, 7% died in hospitals, and 2% survived to hospital discharge. Survival was significantly greater with bystander-witnessed arrest, bystander-initiated CPR, paramedic-witnessed arrest, initial rhythm of ventricular fibrillation, and shorter treatment intervals.

CONCLUSIONS

The overall survival rates were significantly lower than those reported in most previous studies, all based on smaller communities; they were consistent with the rates reported in the one comparable study of a large city. The single factor that most likely contributed to the poor overall survival was the relatively long interval between collapse and defibrillation. Logistical, demographic, and other special characteristics of large cities may have affected the rates. To improve treatment of cardiac arrest in large cities and maximize the use of community resources, we recommend further study of comparable metropolitan areas using standardized terms and methodology. Detailed analysis of each component of the emergency medical services systems will aid in making improvements to maximize survival of out-of-hospital cardiac arrest.