Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Donot give up with the public access defibrillators
- Muthuramalingam Thirumaran (8 September 2002)
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Defibrillators in Public Places save lives
- Michael C Colquhoun, None (9 September 2002)
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Is the aim overall or individual survival?
- Philip Eisenburger (9 September 2002)
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Potential efficacy of public access defibrillation may be under-estimated
- Malcolm F Woollard (10 September 2002)
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Good Outcome Following Out of Hospital Cardiac Arrest in a Child with Long QT Syndrome
- Richard M Beringer, James Fraser and Andrew Gibson (11 December 2002)
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Public Access Defibrillation Program Should be Implemented
- A.A. Jennifer Adgey, Simon J. Walsh, Nicholas A. Cromie (3 January 2003)
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Muthuramalingam Thirumaran, Staff Grade Respiratory Medicine Dewsbury and District Hospital,Dewsbury,WestYorkshire WF13 4HS
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This is a impressive data produced by the author as a retrospective cohort study. The data clearly suggests that most of the places are not suitable for public access Defibrillators.This study and many other previous studies done on this topic clearly suggests that there is a survival benefit with early defibrillation of a shockable rhythm.Yes it is not going to be cost effective,but we are talking about human lives here.May be we should look at other options like encouraging non medical persons to learn resucitation and recieve basic training in using AED .Also encouraging Institutions and organisations not related to health servivce to buy AED and train their staff in resucitation may reduce the cost for health service.Most of the houses do have fire extinguishers now.I do not think any one can argue that they use them regularly and they are cost effective.So public access defibrillators shouldnt be written off completely.We live in an era of having a dotor on site if the crowd in a specific place is higher than certain number.Why not a Defibrillator? |
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Michael C Colquhoun, Senior Lecturer University of Wales College of Medicine, Cardiff CF14 4XN, None
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Most of the 70 000+ deaths every year in the UK from sudden cardiac arrest are due to ventricular fibrillation. Strategies to reduce the delay in performing defibrillation (the main factor determining survival) include placing defibrillators in busy public places for use by those present, or equipping ‘first responders’ who can reach a victim before an ambulance. Pell and colleagues (BMJ 7th September) (1) apply a statistical model to estimate potential survival following more widespread public provision of defibrillators. Their technique relies heavily on historical data from patients attended by the Scottish Ambulance Service within 3 minutes, which they consider analogous to a defibrillator placed in a public place. They consider the predicted increase in survival (5% to 6.3%) inadequate to justify such deployment, and that it is more appropriate to equip ‘first responders’. The Resuscitation Council (UK) has recently launched a national database of resuscitation attempts in both scenarios, and data already collected does not support their predictions. Attempted resuscitation reported in 126 subjects in public places (British Heart Foundation or Department of Health defibrillators) record defibrillator attachment on average 4.5 minutes after collapse, (63%) given shocks and 20 (15.9%) known survivors to hospital discharge. In 177 cases attended by first responders, the defibrillator was attached at 11.34 minutes (mean), (33%) received shocks, but only 5 (2.8%) survived. The difference between the proportions surviving in the two groups is highly statistically significant (P < .001). The reasons for the discrepancy between data from actual cardiac arrests and their predictions is unclear but may include: 1. Defibrillators in public places more effectively reduce time to
defibrillation.
The data agrees with other studies (2,3) showing the value of having defibrillators available in public places with the minimum delay; they offer a valuable means of saving some victims of cardiopulmonary arrest. Although first responders may provide a means of treating others, this data confirms other reports (4) that only modest benefit will result until their response times are greatly improved. M. Colquhoun References 1. Pell JP, Sirel JM, Marsden AK et al. Potential impact of public access defibrillators on survival after out of hospital cardiac arrest: retrospective cohort study. BMJ 2002;325:515-7 2. Valenzuela TD, Roe DJ, Nichol G et al. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. N.Engl J Med.2000; 343:1206-9 3. Willoughby PJ, Caffrey S. Improved survival with an airport based PAD system. Circulation 2000:102: II-828. Abstract 4. Myerburg RJ, Fenster J, Velez M et al. Impact of community-wide police car deployment of automated external defibrillators on survival from out of hospital cardiac arrest. Circulation 2002;106:1058-64 |
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Philip Eisenburger, paternity (sabbatical) leave Vienna
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Is defibrillation with an AED feasible for trained or even untrained lay rescuers? If so, the application may bear a benefit for the individual patient and lay people should be allowed to purchase one, no matter how rare the applications are. The probability of an application (such as the 1 in 5 years quoted in the resuscitation guidelines) can only be related to the cost effectiveness of a program and the OVERALL benefit. The alternative would then be focusing on furhter shorting the response times of rescue teams or first responders (which should be the primary goal of any emergency medical services director anyway). If someone wants to buy a fire extinguisher for his house, is there a minimum probability of a fire required before he may be allowed to do so? Or should we just let people who think the price is worth the safety do what they want to do with their money (as in relatives of high risk patients)? A different issue is whether using an AED instead of performing CPR actually lowers the chances of survival, as one could imagine in non-VF patients where time is wasted with the ECG analysis. In this case, one clearly needs to reconsider PAD. But retrospective studies can never answer whether the implementation of a PAD program increases the awareness of the problem of sudden death and augments the willingness to perform CPR under the instructions of such a device. In that case, even non-VF patients may benefit from an AED without being shocked. Without any proof of potential harm, rejection of the idea of PAD is therefore unjustified. |
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Malcolm F Woollard, Executive Officer Pre-hospital Emergency Research Unit, University of Wales College of Medicine, Cardiff, CF11 8PL
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Pell et al have undertaken a complex and worthwhile study providing useful data on the appropriate location of public access defibrillators (PAD). [1] It appears, however, that not all of the authors’ conclusions are based on firm evidence. The authors state 'Arrests that occur in obvious sites for locating defibrillators already have the shortest response times…' yet their paper identifies that only 340/2646 (13%) of patients in a suitable site received an ambulance within 3 minutes. 'Response time' is not defined: a detail important in allowing valid comparisons to be made with other early defibrillation strategies. The Department of Health define this interval as starting when a 'chief complaint' is identified by an ambulance dispatcher and ending when an ambulance stops at the scene. The time taken for a bystander to determine that action is needed and make a 999 call, and also the time taken by the crew to reach the patient's side and deliver a counter-shock, are excluded. The complete interval from collapse to first counter-shock is a key variable in determining outcome from cardiac arrest. [2] PAD may reduce the delays inherent in dialling 999 and consequently the time to first shock, even when the ambulance response is under 3 minutes. This potential benefit has not been included in the model used by Pell et al. Nor do they allow for the incremental benefits of a reduction in response time at intervals of more than four minutes. Mortality increases by four percent for each minute’s delay to first shock. [3] The authors suggest '… provision of automated external defibrillators to other first responders could double overall survival to discharge…' referring to their previously published article. [4] This paper does not provide such evidence, concluding only that 'Responding to 90% of calls within five minutes would increase the proportion of survivors to 10-11%'. It requires a very large assumption to suggest that first responders could produce such a huge reduction in response times. Pell et al recommend PAD should not be preferred to bystander CPR. However, early CPR combined with early defibrillation results in double the number of survivors than early CPR alone. [5] The predictions made by Pell et al for the impact of PAD are based on a model that does not include all of its potential benefits. They have not conclusively demonstrated that PAD is less effective than bystander CPR or first responder defibrillation schemes. References 1. Pell JP, Sirel JM, Marsden AK, Ford I, Walker NL, Cobbe SM. Potential impact of public access defibrillators on survival after out of hospital cardiopulmonary arrest: retrospective cohort study. BMJ, 2002;325:515-517. 2. Nichol G, Stiell IG, Laupacis A, Pham B, De Maio VJ, Wells GA. A cumulative meta-analysis of the effectiveness of defibrillator capable emergency medical services for victims of out-of-hospital cardiac arrest’ Ann Emerg Med, 1999;34:517-525. 3. Weaver WD, Cobb LA, Hallstrom AP, Copass MK, Ray R, Emery M, Fahrenbruch C. Considerations for improving survival from out-of-hospital cardiac arrest. Ann Emerg Med, 1986;15:1181-6. 4. Pell JP, Sirel JM, Marsden AK, Ford I, Cobbe SM. Effect of reducing ambulance response times on deaths from out of hospital cardiac arrest: cohort study. BMJ, 2001;322:1385-1388. 5. Eitel DR, Walton SL, Guerci AD, Hess DR, Sabulsky NK. Out-of- hospital cardiac arrest: a six year experience in a suburban-rural system’ Ann Emerg Med, 1988;17:808-812. |
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Richard M Beringer, Clinical fellow, Paediatric Intensive Care Unit, Bristol Royal Hospital for Children Bristol Royal Hospital for Children, Marlborough Street, Bristol, BS2 8BJ, James Fraser and Andrew Gibson
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EDITOR - The study by Pell et al[1] and the subsequent editorial by Engdahl[2] both highlight the importance of effective bystander cardiopulmonary resuscitation and early defibrillation in adult out of hospital cardiac arrest. We would like to report a recent paediatric case of an out of hospital cardiac arrest that supports the conclusions of these articles, and emphasises the importance of Advanced Life Support techniques in out of hospital paediatric resuscitation. A previously well 6 year old girl collapsed at home with a cardiorespiratory arrest. Her mother and aunt were present and immediately called 999 for an ambulance. While waiting they were instructed over the telephone how to perform basic life support. Within 5 minutes, a paramedic with training in paediatric resuscitation arrived at the scene. ECG monitoring initially demonstrated asystole and then ventricular fibrillation (VF) which returned to asystole following a single shock from a biphasic defibrillator. With assistance from a second ambulance crew he intubated the child and gained central and intraosseous access for administration of adrenaline (epinephrine) and a bolus of fluid. Cardiopulmonary resuscitation (CPR) was continued throughout. After approximately 10 minutes of advanced life support she regained a cardiac output. She was subsequently transferred to the Emergency Department and then to our Paediatric Intensive Care Unit. An ECG confirmed the diagnosis of Long QT Syndrome and she was commenced on beta blockers. Following standard cerebral protective intensive care, she was extubated at 72 hours. An implantable cardioverter defibrillator (ICD) was inserted prior to discharge from hospital and four weeks after the event she has made a full recovery. Traditionally out of hospital cardiac arrests in children carry a very poor prognosis[3]. This case highlights several important points. Firstly it should be recognised that with increased survival following paediatric cardiac surgery, primary arrhythmias are now a more frequent cause of cardiac arrest than previously thought[4]. Henceforth ambulance and other first responders to paediatric out of hospital cardiac arrest need to be alert to the presence of a treatable dysrhythmia. Secondly, although effective bystander CPR remains the cornerstone of effective resuscitation practice, the provision of advanced life support was critical to the successful outcome in this case. Unfortunately suitably trained paramedic staff with skills in paediatric advanced life support are in short supply and therefore formal training in such techniques should be made more widely available. R Beringer. Clinical Fellow in Paediatric Intensive Care Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS2 8BJ. A Gibson. Paramedic Ambulance Officer and Community Response Co- ordinator Ambulance Headquarters, Marybush Lane, Bristol, BS2 08T. J Fraser. Consultant in Paediatric Intensive Care Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS2 8BJ. 1. Pell JP, Sirel JM, Marsden AK, Ford I, Walker Nicola L, Cobbe SM. Potential impact of public access defibrillators on survival after out of hospital cardiopulmonary arrest: retrospective cohort study. BMJ 2002;325:515-7 2. Engdahl J. Outcome after cardiac arrest outside hospital. BMJ 2002;325:503-4 3. Schindler MB, Bohn D, Cox PN, McCrindle BW, Jarvis A, Edmonds J et al. Outcome of out-of-hospital cardiac or respiratory arrest in children. N Eng J Med 1996;335:1473-9 4. Young KD, Seidel JS. Pediatric cardiopulmonary resuscitation: a collective review. Ann EmergMed 1999;33: 195-205 Competing interests: None declared Editorial note |
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A.A. Jennifer Adgey, consultant cardiologist Royal Group of Hospitals, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland, Simon J. Walsh, Nicholas A. Cromie
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Dear Sir We read with interest the article by Pell and colleagues.[1] It is well recognised that the majority of cardiac arrests occur in the patients home, in an area not easily accessible to emergency care. One approach therefore has been the establishment of public access defibrillation programmes (PAD). The guidelines offered for these PAD programmes include 1. The frequency of cardiac arrest events is such that there is a reasonable probability of automated external defibrillator (AED) use (an estimated event rate of one sudden cardiac arrest per 1000 person years). 2. An emergency medical services (EMS) call-to-shock interval of <5 minutes cannot be reliably achieved with conventional EMS services. 3. An EMS call-to-shock interval of <5 minutes can be reliably achieved (in > 90% of cases) by training and equipping lay persons to function as first responders in the community EMS system, recognising cardiac arrest, phoning an appropriate emergency telephone number, initiating CPR and attaching/operating an AED.[2] Much of resuscitative practice has been changing over the last five years including the usage of small lightweight biphasic defibrillators. A recent study from Italy where 87% of the cardiac arrests occurred at home, compared resuscitation success for patients managed initially by public access defibrillator volunteers and those with the traditional EMS response. They found that when the PAD volunteers initiated resuscitation there was a tripling in the rate of survival to hospital discharge from 3.3% to 10.5% (p=0.006), for those with “shockable” rhythms the survival rate increased from 21.2% to 44.1% (p=0.046) and neurologically intact survival was improved from 2.4% to 8.4% (p=0.009). These PAD volunteers did not receive traditional education in cardiopulmonary resuscitation nor in pulse detection.[3] With the evolution of defibrillator technology and increasing number of competitors in the AED market, there is likely to be an overall reduction in the cost of these programmes leading to greater accessibility of the devices particularly in the home. Yours sincerely Professor AAJ Adgey Dr Simon J Walsh Dr Nicholas Cromie REFERENCES 1 Pell JP, Sirel JM, Marsden AK et al. Potential impact of public access defibrillators on survival after out of hospital cardiopulmonary arrest: retrospective cohort study. BMJ 2002; 325: 515-519 2 ECC Guidelines. Part 4: The Automated External Defibrillator. Key Link in the Chain of Survival. Circulation 2000; 102 (Supplement I); I60 3 Capucci A, Aschieri D, Piepoli MF et al. Tripling Survival From Sudden Cardiac Arrest Via Early Defibrillation Without Traditional Education in Cardiopulmonary Resuscitation. Circulation 2002; 106: 1065- 1070. Competing interests: None declared |
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