Author + information
- Sarah R. Gutbrod, MS and
- Igor R. Efimov, PhD∗ ()
- ↵∗Reprint requests and correspondence:
Dr. Igor R. Efimov, Department of Biomedical Engineering, Washington University, Whitaker Room #390E, 1 Brookings Drive, St. Louis, Missouri 63130.
For more than 2 centuries, resuscitation has had an intriguing and complicated relationship with the general public. London Middlesex and St. Bartholomew's hospitals purchased their first therapeutic electrical apparatus in 1767 and 1777, respectively (1). However, the first report of attempted therapy of “apparently dead” came from the community (2). Although performed naively, it still resulted in the formulation of the first published “guidelines” on resuscitation: “In the treatment of persons apparently dead by drowning, etc. our first attention should be directed to the inflation of the patient's lungs. When the distension of the lungs is accomplished, let the powerful stimulus of electricity be applied, by passing a shock through the heart…” (3). During the transition from the 18th to 19th centuries, there was a range of discharge devices, like the Leyden Jar, from which therapy was delivered by physicians and individuals outside the medical profession. However, falling victim to infamous quacks, irrational prescription of electrotherapy for a vast array of ailments, and overexaggerated descriptions of success led to a stagnant period of ill repute by the end of the nineteenth century (1). It would be almost a century before external defibrillation was again suggested as a therapeutic methodology in 1899 (4) and another half-century before it was finally demonstrated in the operating room on an open-chest patient in 1946 (5) and transthoracically in 1956 (6).
Fast forwarding to current times, external defibrillation has finally gained its deserved credit as an essential lifesaving tool. Following advancements in arrhythmia detection algorithms, American Heart Association emergency cardiac care guidelines stated in 2000 that the public access defibrillator (PAD) “has the potential to be the single greatest advance in the treatment of VF cardiac arrest since the development of CPR” (7). However, 15 years after that statement was published, it remains challenging to quantify the effects of automated external defibrillator (AED) placement in the hands of the general community. In March 2013, the U.S. Food and Drug Administration released a proposed change in approval of AEDs, requiring a pre-market approval to increase the safety and reliability requirements of the devices (8).
In this issue of the Journal, Page et al. (9) present an epidemiological study on the response to sudden cardiac arrests (SCAs) in the Seattle and King county regions. The study is limited to indoor exercise facilities but still contains valuable information on arrest survival with the use of PAD. The study refocuses our attention on current methods of deploying a critical lifesaving technology to the public to maximize effectiveness. The paper by Page et al. provides a platform to address any efficacy concerns of PAD use unrelated to device failure. The benefit of use by trained first responders is essentially irrefutable (10–13). Unfortunately, numerous studies have confirmed that the time delay from arrest to deployment is the most critical factor in survival (14,15). It is not possible for the ideal collapse-to-shock interval threshold to be met with these devices in the hands of only emergency medical services (EMS) personnel. Therefore, it becomes essential to optimize the interface between these devices and the lay community who will use them in an emergency. Studies such as the one by Page et al. do an enormous service toward this aim by quantifying the use and effectiveness of PAD, even if it is limited to a narrow population.
Sifting through more than a decade of arrests in the region, the researchers were able to tease out details of arrhythmia incidence by form of exertion and survival rates associated with type of indoor facility. The group must be commended for extracting a great deal of information from local registries, which can be applied to alterations in public health policies. There was no surprise in the correlation with the dynamics of exercise, with a larger percentage of SCAs occurring while performing high dynamic exercises. The most interesting results of the study are the higher survival to hospital discharge rates if the SCA occurred at traditional and alternative exercise facilities and the frequency of PAD deployment. The higher survival rates may be due to a number of factors that cannot be clarified from this data set. Does it depend on the population who frequents exercise facilities, training and familiarity with the devices, or availability? More significantly, PAD was applied in fewer than 25% of arrests, even though >90% of the ventricular fibrillation/ventricular tachycardia cases were witnessed across all facilities. Still, high survival rates were reported. The arrest cases in this area may be exceptional due to the impressively low EMS response time of less than 5 min. It would be valuable to have data on the collapse-to-shock interval regardless of whether the shock was applied by the public or EMS personnel. These data do not seem to be available in the current registry but perhaps should be something that communities aim to record to identify areas of weakness in current AED deployment strategies. Additionally, 136 SCA events of 849 occurred at facilities included in this study. This accounts for a relatively small percentage of total SCAs in the region—where are the rest taking place? The current recommendation to place AEDs in exercise facilities may not be substantial enough to reach 80% of SCA victims in this cohort. This is a gap in information that needs to be addressed in many communities.
This study highlights the need for collecting and distributing more data on PAD. On the distribution side, advancements in technology and the abundance of mobile Internet devices should encourage the development of free apps to locate the nearest AED and contact emergency personnel when a cardiac arrest occurs. Similar apps have been released, but there is not a complete nationwide registry of the location and condition of every AED in the city. A comprehensive study in 2010 of state by state laws pertaining to AEDs found that more than 40% of jurisdictions did not require location registration (15). This information should be provided to help convert more witnesses of SCA to lifesavers. There should also be an easy way to facilitate direct communication between the witness and emergency personnel en route to aid them in delivery of the defibrillation shocks. As of the 2009/2010 school year, 36 states had compulsory resuscitation training as part of their high school graduation requirements (16). A study in Vienna, Austria, found that students as young as 9 years of age could successfully perform lifesaving AED deployment with only 6 h of training (17). Therefore, there is a vast percentage of the general community who could perform this task if we can increase training and facilitate device location.
On the data collection side, it would be beneficial for more communities to keep a registry of PAD use and survival rates associated with it so that deployment weaknesses can be addressed without being resource intensive. Collapse-to-shock time is a critical criterion to try to record in any registry of SCA events to optimize AED placement. Organizing the location and monitoring of PAD could help push this treatment to reach its full potential of being the most significant advance since cardiopulmonary resuscitation and bring successful defibrillation back to the field in the hands of the community, as it was originally conceived.
↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
Dr. Efimov has served as a consultant for Philips; and is the cofounder and a member of the board of directors for Cardialen, Inc. Ms. Gutbrod has reported that she has no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- Colwell H.A.
- ↵Kite C. An Essay on the Recovery of the Apparently Dead. London, United Kingdom, 1788.
- ↵Urban S. Mr. Fell's electrical machine described. In: Gentlemen's Magazine. London, United Kingdom, 1792.
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- ↵(2000) Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 4: the automated external defibrillator: key link in the chain of survival. The American Heart Association in Collaboration with the International Liaison Committee on Resuscitation. Circulation 102:I60–I76.
- ↵Effective date of requirement for premarket approval for automated external defibrillator system. FDA 21 CFR Part 870. Doc No: 2013–06723. Federal Register Online via Government Printing Office, 2013.
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