Do not move player requiring resuscitation on field until return of spontaneous circulation

We read the recent letter by Lyon et al with interest [1]. European public interest has recently focused on cardiac arrest occurring in the overtly healthy. Firstly, Fabrice Muamba, a UK premier league football player collapsed during a live televised match. Cardiac arrest was quickly diagnosed, cardiopulmonary resuscitation (CPR) started and an external automated defibrillator (AED) attached. Despite over 70 minutes of CPR before return of spontaneous circulation, Mr Muamba walked out of hospital a few weeks later having reportedly made an excellent recovery. By contrast, Piermario Morosini tragically died playing Serie B football in Italy. Unfortunately, there was then a long delay before CPR was started and no AED was available [2].

Much of the debate following these events has revolved around cardiac screening, which can identify those at risk [3], but false negatives (and positives) can occur and genetic or acquired disease may only express after the screening episode. Both of the football players above, had themselves had been screened in the past.

A key step to reducing mortality therefore remains CPR. Presently in Europe around 10% of individuals survive an out of hospital cardiac arrest [4]. The most important determinant of survival is the presence of trained lay rescuer who is “ready, willing and able to act [5].”
Herein lies a problem; CPR is an overtly medical procedure for the lay person.

There are psychological barriers to an individual to stepping forward to intervene in a situation by starting CPR, including fear of doing something wrong, lack of knowledge and worry about contracting an infection from the casualty, particularly from mouth-to-mouth ventilation [4]. The result in the UK is bystander CPR only being performed in 30% of cases [6].

A cultural change is needed. CPR needs to be de-medicalised, made simpler and de-stigmatised. There is now plenty of evidence that mouth to mouth ventilation has no impact on adult patient outcome in witnessed cardiac arrest and unnecessary [7]. Many people will have seen the recent British Heart Foundation (BHF) national CPR television advert campaign in which the actor and retired football player, Vinnie Jones, shows how to perform hands only CPR to rhythm of the Bee Gees song “Staying Alive.” Hopefully this will help to improve the willingness of bystanders to perform CPR.

Whilst training works [8], delivery needs to be on a population scale. We support the BHF and UK Resuscitation Council campaigns for CPR to be taught in schools [9]. This approach has international guideline recommendation [10], and evidence of benefit. For example, in a German study, pupils aged 10 were taught CPR once yearly over a 4 year period by their own teachers, the latter having attended a one hour training course [11]. The training markedly increased confidence and willingness to help in the event of a cardiac arrest. In the United States, 32 states now advocate CPR teaching in schools [9]. In Seattle, where 17,792 secondary school students were taught CPR in 2010, bystander CPR rates of 61% and survival of 49% from out of hospital arrest (in a shockable rhythm) have been reported [12]. Lay CPR training was thought to be central to these impressive figures.

Finally, the recent UK and Italy football experience shows the importance of an emergency response plan to cardiac arrest in high risk areas [13] Although having trained lay responders is the most important part of this, it should also involve having access to an AED. Early defibrillation is crucial with a 10% fall in success rate with each minute that passes after the onset of ventricular fibrillation [4]. Devices are now extremely easy to use – switch on, copy the diagram showing pad positioning and follow the machine’s verbal instructions.

We, the authors of this article have all been involved with patients who have made full recovery following prolonged resuscitation after effective, prompt CPR (and usually defibrillation) but sadly far more cases with delayed CPR and subsequent death or poor neurological outcome. Recent, public events have highlighted the importance of CPR, and we believe that the time is now right to encourage the UK government to consider how we best train as many people as possible in this basic, lifesaving skill.

References
1) Lyon RM, Wiggins C. Do not move player requiring resuscitation on field until return of spontaneous circulation. BMJ 2012; 344: e2448.
2) http://news.sky.com/home/world-news/article/16208705
3) Thompson P. Preparticipation screening of competitive athletes. Seeking simple solutions to a complex problem. Circulation 2009; 119: 1072-74.
4) Nolan J, Soar J, Zideman D et al. European resuscitation council guidelines for resuscitation 2010 section 1. Executive summary. Resuscitation 2010; 81: 1219-76.
5) Hazinski M, Nolan J, Billi J et al. Part 1 executive summary. 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation 2010; 122 (suppl 2): S250-75.
6) Ambulance Service Association and Joint Royal College Ambulance Liaison Committee: National Cardiac Arrest Audit Report. 2006
7) Bohm K, Rosenqvist M, Herltiz J et al. Survival is similar after standard treatment and chest compression only in out-of-hospital bystander cardiopulmonary resuscitation. Circulation 2007;116:2908-12.
8) Swor R, Khan I, Domeier R et al. CPR training and CPR performance: do CPR-trained bystanders perform CPR? Acad Emerg Med 2006; 13: 596-601.
9) http://www.bhf.org.uk/get-involved/campaigning/emergency-life-saving-ski...
10) Cave D, Aufderheide T, Beeson J et al. Importance and implementation of training in Cardiopulmonary Resuscitation and Automated External Defibrillation in Schools. Circulation 2011; 123: 691-706.
11) Bohn A, Van Aken H, Mollhoff T et al. Teaching resuscitation in schools: annual tuition by trained teachers is effective starting at age 10. A four-year prospective cohort study. Resuscitation 2012. Epub ahead of print.
12)http://www.kingcounty.gov/healthservices/health/ems/~/media/health/publi...
13) Drezner J. Preparing for sudden cardiac arrest – the essential role of automated external defibrillators in athletic medicine: a critical review. Br J Sports Med 2009; 43: 702-7.

Whether or not a regional air ambulance service provides support to cardiac events depends on how rural that area is and the corresponding likelihood of delay in transferring a patient to a cardiac centre. As ambulance response times in London are consistently below 8 minutes (1) and specialist hospitals are readily accessible, London patients are only considered for aero-medical support if they have suffered from major trauma.

Jones and Moorehouse suggest HEMS as a potential solution to the dilemma of whether to continue to try and obtain a cardiac output “stay and play” or to transfer to a specialist center whilst continuing CPR “scoop and run”. Despite HEMS being undoubtedly useful in expertly intubating the footballer and expediting transfer to a specialist unit their capabilities would not greatly supersede those of the attending paramedics, as unlike in a trauma scenario rapid sequence induction of anaesthesia is not required, indeed paramedics are trained to intubate arrested patients as part of their core competencies.

Whereas the use of ALS in pre-hospital, non-traumatic, cardiac arrest is a contentious issue, with intubation shown not to increase survival (2), skilled personnel, advanced techniques and helicopter transfer are shown to significantly benefit the outcomes for trauma patients (3). Although a helicopter extraction from White Hart Lane may have benefited this extremely unusual case (and looked astounding on match of the day), the standard use of HEMS in urban cardiac arrests would overwhelm the service and reduce the benefit to those that need it most – the severely injured.

References:

1 – The information centre for health and social sciences. Ambulance services England. 2011. http://www.ic.nhs.uk/webfiles/publications/Audits%20and%20Performance/Am...

2 – Stieg IG, Wells GA, Field B et al. Advanced cardiac life support in out-of-cardiac arrest. New England Journal of Medicine. 2004. 351: 647-56 http://www.nejm.org/doi/full/10.1056/NEJMoa040325

3 - Helicopters and the civilian trauma system: national utilization patterns demonstrate improved outcomes after traumatic injury. Brown JB, Stassen NA, Bankey PE, J Trauma. 2010 Nov;69(5):1030-4; discussion 1034-6.
http://www.ncbi.nlm.nih.gov/pubmed/21068607