Automated external defibrillators: What`s established? What`s new?

162
H.-J. Trappe
Applied Cardiopulmonary Pathophysiology 16: 162-173, 2012
Automated external defibrillators:
What’s established? What’s new?
Hans-Joachim Trappe
Department of Cardiology and Angiology, University of Bochum, Germany
Abstract
Prognosis of patients (pts) with out-of-hospital cardiac arrest (CA) due to ventricular fibrillation
(VF) or ventricular tachycardia (VT) is bad and the survival rate is 5-8%. Bystander first aid, defibrillation and advanced life support is essential for neurologic outcome in pts after cardiac arrest due to VF/VT. In those pts defibrillation should be performed as soon as possible, at least
within 5 minutes after CA. Public access defibrillation in the hands of trained laypersons (first
responder) with automated external defibrillators (AED) seems to be a good approach in the
treatment of VF or VT. The use of AEDs by basic life support ambulance providers or first responder in early defibrillation programs has been associated with a significant increase in survival rates. This is caused by a shorter “call-to-arrival-time” in first responders compared to professionals. Nevertheless, ideal places for installation of AED are still unclear and further studies
are necessary.
Key words: emergency medicine, automated external defibrillators, out-of-hospital cardiac arrest
Introduction
Emergency medicine and critical care are
fields that often require rapid diagnosis and
intervention for specific situations (1). These
critical interventions can be life-saving or severely debilitating depending on their appropriateness and timeliness. In cardiac emergencies, accurate differentiation of ventricular and supraventricular tachyarrhythmias is
essential for appropriate management (2).
Most frequently, the diagnosis of the underlying arrhythmia is readily apparent, but occasionally it is necessary to use clues from the
physical examination, the response to maneuvers or drugs, in addition to the 12-lead
surface electrocardiogram (3,4). Treatment of
cardiac arrhythmias in intensive care and
emergency medicine is sometimes difficult.
Correct therapy based on an understanding
of the mechanism that caused the arrhythmia
may not only be life-saving in the immediate
situation but may also improve the quality of
life. The purpose of the present manuscript is
to summarize the experiences of automated
external defibrillators (AED) in the management of patients with cardiac arrest due to
ventricular fibrillation or fast ventricular
tachycardia.
Ventricular fibrillation and
cardiac arrest
Approximately 1.000 people in the United
States suffer from cardiac arrest each day,
Automated external defibrillators: What’s established? What’s new?
most often as a complication of an acute myocardial infarction with accompanying ventricular fibrillation or unstable ventricular
tachycardia. The American Heart Association
(AHA) reported several times about the chain
of survival concept, with four links – early access, cardiopulmonary resuscitation, defibrillation, and advanced care – as the way to approach cardiac arrest (5). It has been pointed
out that the highest potential survival rate
from cardiac arrest can be achieved only
when the following sequence of events occurs as rapidly as possible: (a) recognition of
early warning signs, (b) activation of the
emergency medical services system, (c) basic
cardiopulmonary resuscitation, (d) defibrillation, (e) management of the airway and ventilation, and (f) intravenous administration of
medications (5).
Neurologic outcome in patients
with cardiac arrest
Bystander first aid, defibrillation and advanced life support is essential for neurologic
outcome in patients after cardiac arrest. Bur
et al. (6) evaluated the effects of basic life
support, time to first defibrillation and emergency medical service arrival on neurologic
outcome in 276 patients after cardiac arrest.
In contrast to intubation (odds ratio 1.08;
95% CI, 0.51-2.31; p=0.84), basic life support
(odds ratio 0.44; 95% CI, 0.24-0.77;
p=0.004) and time to first defibrillation (odds
ratio 1.08; 95% CI, 1.03-1.13; p=0.001) were
significantly correlated with good neurologic
outcome. In addition to the better neurologic outcome, among the patients who did not
receive basic life support, the average cost
per patient with good neurologic outcome
significantly increased with the delay of the
first defibrillation (p<0.001). The importance
of cerebral perfusion and pressure and cerebral tissue oxygen tension during cardiopulmnonary resuscitation has been described also
by others (7).
163
Early defibrillation
Public access defibrillation, which places automatic external defibrillators (AED) in the
hands of trained laypersons (first responder)
has the potential to be the single greatest advance in the treatment of ventricular fibrillation since the development of cardiopulmonary resuscitation. Time to defibrillation is
the most important determinant of survival
from cardiac arrest (8). The earlier the defibrillation is performed the better the success
rates for resuscitation, irrespective of who is
doing the first defibrillation (9). In the last few
years there has been a significant increase in
the use of AEDs in early defibrillation programs in a variety of settings, including hospitals, emergency medical service, police departments, casinos, airport terminals, and
commercial aircraft, among others. In most
of these settings, use of AEDs by basic life
support ambulance providers or first responder in early defibrillation programs has been
associated with a significant increase in survival rates (10-12).
Importance of the time
interval between cardiac arrest
and defibrillation
Expert guidelines advocate defibrillation
within 2 minutes after an in-hospital cardiac
arrest caused by ventricular fibrillation or fast
ventricular tachycardia. However, empirical
data on the prevalence of delayed defibrillation in the United States and its effect on survival are limited. Chan et al. (13) identified
6789 patients who had cardiac arrest due to
ventricular fibrillation or pulseless ventricular
tachycardia at 369 hospitals participating in
the National Registry of Cardiopulmonary
Resuscitation. Using multivariable logistic regression, they identified characteristics associated with delayed defibrillation and examined the association between delayed defibrillation (more than 2 minutes) and survival to
discharge after adjusting for differences in patient and hospital characteristics. Delayed de-
164
fibrillation occurred in 2045 patients
(30.1%). Characteristics associated with delayed defibrillation included black race, noncardiac admitting diagnosis, and occurrence
of cardiac arrest at a hospital with fewer than
250 beds, in an unmonitored hospital unit,
and during after-hours periods (5 p.m. to 8
a.m. or weekends). Delayed defibrillation was
associated with a significantly lower probability of surviving to hospital discharge (22.2%,
vs. 39.3% when defibrillation was not delayed; adjusted odds ratio, 0.48; 95% confidence interval, 0.42 to 0.54; p<0.001). In addition, a graded association was seen between increasing time to defibrillation and
lower rates of survival to hospital discharge
for each minute of delay (p < 0.001). Chan et
al. (13) concluded that delayed defibrillation
was common and associated with lower rates
of survival after in-hospital cardiac arrest.
Beginning of the “AED-era”:
First clinical results
AEDs were used in 105 patients with ventricular fibrillation suffered in casinos (10). Fiftysix of the patients (53%) survived to discharge from the hospital. Among the 90 patients whose collaps was witnessed (86%),
the clinically relevant time intervals were a
mean of 3.5±2.9 minutes from collapse to
the delivery of the first defibrillation shock,
and 9.8±4.3 minutes from collapse to the arrival of the paramedics. The survival rate was
74% for those who received their first defibrillation no later than three minutes after a
witnessed collapse and 49% for those who
received their first defibrillation after more
than three minutes. Caffrey et al. reported
the public use of AEDs in three Chicago airports (12). During a two-year period, 21 persons had nontraumatic cardiac arrest, 18 of
whom had ventricular fibrillation. In the case
of four patients with ventricular fibrillation,
defibrillators were neither nearby nor used
within five minutes, and none of these patients survived. Three others remained in ventricular fibrillation and eventually died later,
H.-J. Trappe
despite the rapid use of a defibrillator within
five minutes. Eleven patients with ventricular
fibrillation were successfully resuscitated, including eight who regained consciousness
before hospital admission. No shock was delivered in four cases of suspected cardiac arrest, and the device correctly indicated that
the problem was not due to ventricular fibrillation (Tab. 1) (14-22).
Capucci et al. (23) established Piacenza
Progetto Vita (PPV), the first system of out-ofhospital early defibrillation by first-responder
volunteers. The system serves a population of
173 114 residents in the Piacenza region of
Italy. Equipment for the system comprises 39
semiautomatic external biphasic defibrillators
(AEDs): 12 placed in high-risk locations, 12 in
lay-staffed ambulances, and 15 in police cars;
1285 lay volunteers trained in use of the
AED, without traditional education in cardiac
pulmonary resuscitation, responded to all
cases of suspected SCA, in coordination with
the Emergency Medical System (EMS). During the first 22 months, 354 SCA occurred
(72±12 years, 73% witnessed). The PPV volunteers treated 143 SCA cases (40.4%), with
an EMS call-to-arrival time of 4.8±1.2 minutes
(versus 6.2±2.3 minutes for EMS, p=0.05).
Overall survival rate to hospital discharge was
tripled from 3.3% (7 of 211) for EMS intervention to 10.5% (15 of 143) for PPV intervention (P=0.006). The survival rate for witnessed SCA was tripled by PPV: 15.5% versus 4.3% in the EMS-treated group
(p=0.002). A “shockable” rhythm was present in 23.8% (34 of 143) of the PPV patients
versus 15.6% (33 of 211) of the EMS patients
(p=0.055). The survival rate from shockable
dysrhythmias was higher for PPV versus EMS:
44.1% (15 of 34) versus 21.2% (7 of 33),
p=0.046. The neurologically intact survival
rate was higher in PPV-treated versus EMStreated patients: 8.4% (12 of 143) versus
2.4% (5 of 211), p=0.009.
165
Automated external defibrillators: What’s established? What’s new?
Table 1a: AED programs in communities
Author
Study design
Patients
SR
p
Eisenberg (14)
Paramedics+BLS
vs
BLS+AED
179 with CA
18%
38%
< 0,05
Paramedics
vs
FR+AED
610337 IN
10%
14%
*
Police+AED
vs
Paramedics-AED
1181612 IN
17%
9%
0,047
FR+AED
vs
PM
173114 IN
11%
3%
0,006
FM+BLS
vs
FM+AED
1287 IN
19%
30%
*
Police+AED
vs
PM
7 urban communi- 26%
ties
3%
BLS
vs
BLS+AED
993 communities
in 24 regions of
North America
14%
23%
0,03
FM+police
vs
PM
469 CA
25%
21%
ns
Kellermann (15)
Myerburg (16)
Capucci (17)
Weaver (18)
Mosesso (19)
PAD Trial (20)
Van Alem (21)
0,01
Abbreviations: AED=automated external defibrillator, BLS=„Basic life support“, CA=out-of-hospital cardiac
arrest, FR=first responder, IN=inhabitants, FM=fireman, PM=paramedics, ns=non significant, SR=survival
rate, *=no data
Table 1b: AED programs in public places
Author
No of persons
AED-location
AED-user
Patients
SR
Venezuela (10)
casinos
FR
105 pts VF
53%
Caffrey (12)
100 mill pass, AI
O’Hare, Midway,
Meig Field
(per year)
FR/Paramedics
18 pts CA
56%
Page (11)
70801874 pass
727956 flights
American Airlines
(per year)
FR
14 pts VF
40%
O’Rourke (22)
31 mill pass
203191 flights
Quantas
(per year)
FR
46 pts CA
26%
Abbreviations: AED=automated external defibrillator, FR=first responder, AI=airport, CA=out-of-hospital cardiac arrest, VF=ventricular fibrillation, mill=millions, pass=passangers, SR=survival rate
166
Resuscitation with or without
AED use?
The rate of survival after out-of-hospital cardiac arrest is low. It is not known whether this
rate will increase if laypersons are trained to
attempt defibrillation with the use of automated external defibrillators (AEDs). The Public Access Defibrillation Trial (PAD trial) was a
prospective, community-based, multicenter
clinical trial in which randomly assigned community units (e.g., shopping malls and apartment complexes) were studied with regard to
a structured and monitored emergency-response system involving lay volunteers
trained in cardiopulmonary resuscitation
(CPR) alone or in CPR and the use of AEDs
(20). The primary outcome was survival to
hospital discharge. More than 19,000 volunteer responders from 993 community units in
24 North American regions participated. The
two study groups had similar unit and volunteer characteristics. Patients with treated outof-hospital cardiac arrest in the two groups
were similar in age (mean, 69.8 years), proportion of men (67%), rate of cardiac arrest
in a public location (70%), and rate of witnessed cardiac arrest (72%). No inappropriate shocks were delivered. There were more
survivors to hospital discharge in the units assigned to have volunteers trained in CPR plus
the use of AEDs (30 survivors among 128 arrests) than there were in the units assigned to
have volunteers trained only in CPR (15
among 107; p=0.03; relative risk, 2.0; 95%
confidence interval, 1.07 to 3.77); there were
only 2 survivors in residential complexes.
Functional status at hospital discharge did
not differ between the two groups. Training
and equipping volunteers to attempt early
defibrillation within a structured response
system can increase the number of survivors
to hospital discharge after out-of-hospital cardiac arrest in public locations. Trained laypersons can use AEDs safely and effectively.
H.-J. Trappe
Experience with AED in Japan
It is unclear whether dissemination of automated external defibrillators (AEDs) in public
places can improve the rate of survival
among patients who have had an out-of-hospital cardiac arrest.
From January 1, 2005, through December 31, 2007, Kitamura et al. (24) conducted
a prospective, population-based, observational study involving consecutive patients
across Japan who had an out-of-hospital cardiac arrest and in whom resuscitation was attempted by emergency responders. They
evaluated the effect of nationwide dissemination of public-access AEDs on the rate of survival after an out-of-hospital cardiac arrest.
The primary outcome measure was the 1month rate of survival with minimal neurologic impairment. A multivariate logistic-regression analysis was performed to assess factors
associated with a good neurologic outcome.
A total of 312,319 adults who had an out-ofhospital cardiac arrest were included in the
study; 12,631 of these patients had ventricular fibrillation and had an arrest that was of
cardiac origin and that was witnessed by bystanders. In 462 of these patients (3.7%),
shocks were administered by laypersons with
the use of public-access AEDs, and the proportion increased, from 1.2% to 6.2%, as the
number of public-access AEDs increased
(p<0.001). Among all patients who had a bystander-witnessed arrest of cardiac origin and
who had ventricular fibrillation, 14.4% were
alive at 1 month with minimal neurologic impairment; among patients who received
shocks from public-access AEDs, 31.6% were
alive at 1 month with minimal neurologic impairment. Early defibrillation, regardless of
the type of provider (bystander or emergency-medical-services personnel), was associated with a good neurologic outcome after
a cardiac arrest with ventricular fibrillation
(adjusted odds ratio per 1-minute increase in
the time to administration of shock, 0.91;
95% confidence interval, 0.89 to 0.92;
p<0.001). The mean time to shock was reduced from 3.7 to 2.2 minutes, and the annu-
Automated external defibrillators: What’s established? What’s new?
al number of patients per 10 million population who survived with minimal neurologic
impairment increased from 2.4 to 8.9 as the
number of public-access AEDs increased
from fewer than 1 per square kilometer of inhabited area to 4 or more. Nationwide dissemination of public-access AEDs in Japan resulted in earlier administration of shocks by
laypersons and in an increase in the 1-month
rate of survival with minimal neurologic impairment after an out-of-hospital cardiac arrest.
167
tients, 14 received an appropriate shock, and
4 survived to hospital discharge. There were
no documented inappropriate shocks. Bardy
et al. (25) concluded from their study that
survivors of anterior-wall myocardial infarction who were not candidates for implantation of a cardioverter-defibrillator, access to a
home AED did not significantly improve overall survival, as compared with reliance on
conventional resuscitation methods.
AED-strategies in Germany
AED therapy at home:
Useful or not?
The most common location of out-of-hospital
sudden cardiac arrest is the home, a situation
in which emergency medical services are
challenged to provide timely care. Consequently, home use of an automated external
defibrillator might offer an opportunity to improve survival for patients at risk. Bardy et al.
(25) randomly assigned 7001 patients with
previous anterior-wall myocardial infarction
who were not candidates for an implantable
cardioverter–defibrillator to receive one of
two responses to sudden cardiac arrest occurring at home: either the control response
(calling emergency medical services and performing cardiopulmonary resuscitation
[CPR]) or the use of an AED, followed by calling emergency medical services and performing CPR. The primary outcome was
death from any cause. The median age of the
patients was 62 years; 17% were women.
The median follow-up was 37.3 months.
Overall, 450 patients died: 228 of 3506 patients (6.5%) in the control group and 222 of
3495 patients (6.4%) in the AED group (hazard ratio, 0.97; 95% confidence interval, 0.81
to 1.17; p=0.77). Mortality did not differ significantly in major prespecified subgroups.
Only 160 deaths (35.6%) were considered to
be from sudden cardiac arrest from tachyarrhythmia. Of these deaths, 117 occurred at
home; 58 at-home events were witnessed.
AEDs were used in 32 patients. Of these pa-
In Germany, three pilot AED projects were
performed in cooperation of the Ruhr-University Bochum, the German Society of Cardiology and the German Heart Foundation. AED
projects were started at the LAGO-die
Therme in Herne, a well known European
waterpark, at Frankfurt airport and the parliament of North Rhine Westfalia.
LAGO – die Therme Herne
LAGO-die Therme in Herne, is a well known
European waterpark with approximately
700,000 visitors per year. The total area of
this waterpark is five ha, the area with roof is
12.000 m2, with a water area of 3000 m2.
There are 16 sweating bathes and three Turkish bathes. Within this waterpark eight automated external defibrillators were placed
(Typ AED 500, Fa. Physiocontrol, Düsseldorf).
The locations where the defibrillators were
stored were chosen to make possible a target
interval of 60 seconds from collapse to first
defibrillation (fig. 1). Twenty waterpark officers were instructed in cardiopulmonary resuscitation and in the use of the AED. Every
six months the training was repeated. The
project was started November 16th, 2001.
During the last ten years 10,05 million visitors
were seen in the waterpark. None of the visitors died due to ventricular tachyarrhythmias. AED were used in two visitors with
nonarrhythmogenic syncope; no AED shock
was delivered.
168
H.-J. Trappe
Figure 1: Installation
of automated external
defibrillators in the LAGO – die Therme,
Herne
International airport Frankfurt
The pilot project „ automated external defibrillators“ at the International airport Frankfurt/Main was started 13.12.2002 in cooperation with the Ruhr-University Bochum, Fraport AG, German Society of Cardiology and
Unfallkasse Hessen. There are 52 million passengers per year in Frankfurt airport and
68.000 staff members who take care of
them. In the airport hospital 26.000 patients
per year were treated, the emergency medical system has 18.000 rescue efforts. In the
beginning of the project, 16 AED (Typ AED
500, Firma Physiocontrol) were installed in
the terminals 1 and 2 in regions with high
passenger numbers (baggage belts) (fig. 2,3).
In the mean time additional AED were installed (type „ Heartsave“ der Fa. PrimedicTM),
and until december 2010 44 AED are available. In the beginning of the study, 514 staff
members of Fraport were trained in cardiopulmary resuscitation and AED use. Until
December 2010 a total of 2514 trained first
responders are present at Frankfurt airport.
During the time interval 2003-2010 more
than 400 million passengers went through
Frankfurt airport (50-52 million passengers
per year). During the eight-year follow-up a
total of 21 cardiac arrests with AED use was
observed. There were 14 cardiac arrest from
2003-2008 and seven cardiac arrests during
the time interval 2009-2010. 18/21 patients
(86%) were males, three patients (14%) females. Nine patients (43%) had an age of
>70 years, eight patients (37%) between 6170 years. Two patients (10%) between 41-50
years and the remaining two patients (10%)
less than 41 years. Cardiac arrests with resuscitation and AED use occurred in 17 patients
(81%) in terminal 1 and in four patients
(19%) in terminal 2 (fig. 4).
Between 2003 and 2008 cardiac arrests
occurred in 14 patients, eight of them (57%)
survived, six patients (43%) died despite cardiopulmonary resuscitation and defibrilla-
Automated external defibrillators: What’s established? What’s new?
169
Figure 2: Map of the Rhein-Main Airport Frankfurt/Main showing the locations of automated external
defibrillators in the terminals 1 and 2.
Figure 3: Examples of automated external defibrillators in the hall B (international flights) of the RheinMain Airport Frankfurt/Main.
170
H.-J. Trappe
Figure 4: Ventricular fibrillation recorded in the terminal 1
of the Rhein-Main Airport.
Ventricular fibrillation was
successful converted in this
passanger after a total recording of 21 seconds, resulting in a pause followed
by sinus rhythmus. This passanger survived to be discharged from the hospital.
The labels shown depict the
activity of the device as displayed on the electrocardiographic tracing.
tion. During the time interval 2009-2010 seven patients underwent resuscitation and AED
use: 57% of them survived and 43% of the
patients died.
million visitors were observed in the parliament. No visitor had cardiac arrest and no
AED use was necessary.
Conclusions
AED use in the Parliament of
North Rhine Westfalia
100.000 visitors per year were observed in
the parliament of North Rhine Westfalia in
Düsseldorf. Eight hundreds staff members are
working in this institution. To avoid sudden
cardiac death and to take care for the visitors,
six AED (type Heartstream, Firma Leardal,
München) were installed in the parliament
building (fig. 5). The AED project was started
in March 2003. Fourty-five staff members of
the parliament were trained in cardiopulmonary resuscitation and AED use with repeated training sessions every six months.
Until December 31, 2010, approximately 1
It has been shown in many studies that outcome is poor in patients with cardiac arrest
due to ventricular fibrillation or fast ventricular tachycardia. It has become clear that cardiopulmonary resuscitation with fast defibrillation is essential for survival and good neurological outcome. The concept of automated external defibrillators (AED) and first responder defibrillation was exciting and promised a new era of therapy in these “poor” patients.
After the enthusiastic results of the “casino study” by Valenzuela et al. (10) and the
initial results of the “Piazenza trial” by Capucci et al. (23) several “AED projects” were
Automated external defibrillators: What’s established? What’s new?
171
Figure 5: Installation of
an automated external
defibrillator in the parliament of North Rhine
Westfalia, Düsseldorf.
started in different locations and in different
countries. However, more than ten years later, we have to recognize that different questions are open and a “final solution” of the
problems is not visible. First of all, it is difficult
to select “ideal” places for AED installation. It
seems logical to install AED in places with
high number of human beings, but the results
of our three studies in Germany are very disappointing concerning this: More than 411
million people were followed and only few of
them had a need of AED use and survived.
Comparing the results of three Chicago airports with the results of Frankfurt airport a
low incidence of cardiac arrests due to ventricular fibrillation is visible despite millions of
passengers. In addition to these observations, there is a low incidence in waterparks
despite millions of visitors. And at thome?
Several years it has been pointed out that
sudden cardiac deaths occur at home and
“home AED” are the answer to this. After the
study of Bardy et al. (25) it has become clear
that the hypothesis to increase the survival
rate of patients with cardiac arrest at home
by AED use was impossible. The survival rate
was similar in patients with or without AED
use in “home cardiac arrests”.
What to do? It is certainly necessary to
perform further studies evaluating the incidence of sudden death and predicting risk
factors. The training of cardiopulmonary resuscitation techniques for everybody is nec-
essary particularly after the new resuscitation
guidelines 2010 without the need of mouthto-mouth ventilation (5). Cardiac compression only seems the solution for many patients with cardiac arrest due to ventricular
tachyarrhythmias. Nevertheless, emergency
medicine and critical care are fields that often require rapid diagnosis and intervention
for specific situations. It is well known that in
all patients with tachyarrhythmias, evaluation
of the underlying etiology and the degree of
left ventricular function (dysfunction) is essential. Correct treatment of arrhythmias in
the emergency patient based on an understanding of the mechanism that caused the
situation.
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Correspondence address
Prof. Hans-Joachim Trappe, M.D.
Department of Cardiology and
Angiology
University of Bochum
Hoelkeskampring 40
44625 Herne
Germany
[email protected]