AED – The Early Career Voice

How is the AHA leading the way in Cardiopulmonary resuscitation (CPR)?

August 18, 2020August 18, 2020 Lina Ya'qoub, MD

In writing this last post as a junior blogger, I decided to highlight the tremendous efforts by the American Heart Association (AHA) to improve cardiovascular care in the field of cardiac arrest and cardiopulmonary resuscitation (CPR). As we know, the AHA is a worldwide leader in first aid, CPR, and Automated External Defibrillator (AED) training – educating millions of people globally in CPR every year. Here, I will share some fun facts about CPR, and you can refer to the AHA website for further details about this important topic.

Important CPR statistics

Majority of cardiac arrests occur outside of the hospital, with estimated 475,000 Americans dying from cardiac arrests every year [1]
Bystander CPR is a key component in the out-of-hospital “chain of survival” [Figure 1] and studies have shown it improves survival in cardiac arrest [1-3].

Figure 1: The adult out-of-hospital “chain of survival”. Each link of the chain from left to right is numbered 1 through 5: 1- Recognize cardiac arrest and activate the emergency response system, 2- early CPR with high-quality chest compressions, 3- Use AED for rapid defibrillation, 4- basic and advanced emergency services and 5- post-cardiac arrest care and advanced life support [2].

Bystander CPR has been increasing over the recent years in both men and women. Despite that, survival improved in men only, but not women [2]. This is important as it highlights that more work is needed to identify additional predictors of survival in women with cardiac arrest.
Efforts mandating CPR training in high schools in multiple states [5] and availability of AED in public places, including airports [Figure 2], have helped in increasing the awareness and familiarity of bystander CPR in cardiac arrest [4].

Figure 2: A photo of Automated External Defibrillator (AED) in one of the airports.

Personal Experience

From a personal experience, I have visited multiple high schools in my home country as well as in the United States, and have participated as an organizer in the sessions teaching high school students how to perform effective CPR. It is inspiring to see junior students interested in learning and saving lives. The takeaway from my experience is that engagement plays a major role in spreading the word and encouraging the general public to take the extra step and learn how to perform basic and advanced life support techniques.

In conclusion, it is important to remember that the general public are oftentimes our first “link” in the chain of survival; making them an important part of our efforts to improve survival and cardiovascular care in patients with cardiac arrest. A strong chain of survival improves survival and recovery after cardiac arrest. Although there have been improvements in CPR and advanced life support, there remains room for further improvement, and perhaps we can do our part by encouraging our patients, friends and relatives to take the first step and learn how to perform effective CPR and possibly how to use AEDs!!

I have added a few online references for those interested in sharing this with their patients and encouraging them to sign up for both the online and class programs [3,6]!!

References:

Meaney PA, Bobrow BJ, Mancini ME, et al. Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association [published correction appears in Circulation. 2013 Aug 20;128(8):e120] [published correction appears in Circulation. 2013 Nov 12;128(20):e408]. Circulation. 2013;128(4):417-435. doi:10.1161/CIR.0b013e31829d8654
Malta Hansen C, Kragholm K, Dupre ME, et al. Association of Bystander and First-Responder Efforts and Outcomes According to Sex: Results From the North Carolina HeartRescue Statewide Quality Improvement Initiative. J Am Heart Assoc. 2018;7(18):e009873. doi:10.1161/JAHA.118.009873
CPR facts and stats:

https://cpr.heart.org/en/resources/cpr-facts-and-stats

Chain of Survival:

https://cpr.heart.org/en/resources/cpr-facts-and-stats/out-of-hospital-chain-of-survival

Mandatory CPR training in high school:

https://www.sca-aware.org/schools/school-news/mandatory-cpr-training-in-us-high-schools

CPR AED and first aid classes:

https://cpr.heart.org/en/course-catalog-search

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

We Need to Be Better About Recognizing Sudden Cardiac Arrest

January 16, 2020January 17, 2020 Alyssa Vermeulen, DO, FAAP

“10-year-old dies of an apparent heart attack on Delta flight,” “High School Football Player Dies Suddenly,” “Teen Dies on the Court,”— these stories shock the community, cause people to ask questions, and are too soon forgotten. We need to be better about recognizing cardiac arrest in the young, and that starts with better cardiac arrest education. Many people do not realize the difference between cardiac arrest and myocardial infarction or “heart attack.” While a heart attack is often preceded by chest pain and other symptoms, cardiac arrest is usually not.

Sudden Cardiac Arrest (SCA) is a life-threatening emergency that occurs when the heart suddenly stops beating;¹ this can be due to a structural abnormality of the heart, a rhythm disturbance, or often an unknown cause.² A heart attack usually has a different cause, occurring when the supply of blood to the heart becomes blocked, typically by a plaque or blood clot in an artery.³

Sudden Cardiac Death (SCD) is the leading cause of death in athletes during a sport.⁴Delay in recognition leads to a rapid decline in survival, with a decline of survival by 10% for every 1-minute defibrillation is delayed.⁵Studies show that survival can be improved if AED is applied and used within 3-5 minutes of arrest. Schools with on-site AED demonstrate survival from SCA as high as 71%.⁴However, in order for proper AED use to occur the arrest must be recognized quickly.

What makes it hard to recognize sudden cardiac arrest?

Lack of Education on the subject— SCA is not on peoples’ radar for the young patient. Our brains are programmed to think about heart attacks involving older people clenching their chest, sweating, proclaiming pain, and not about SCA, which is much more silent. Anyone who suddenly collapses and is non-responsive to verbal stimuli should be treated as a sudden cardiac arrest until proven otherwise.⁵
SCA may present with seizure-like activity; in as many as 20% of SCA events, there will be myoclonic jerking activity such as shaking, quivering, or twitching.⁵This activity may lead to observers mistaking the arrest for a seizure and not applying the right emergency protocol.
A victim of SCA may still be “breathing”; Agonal respirations/gasping appear like chest and abdominal movement. These breaths can be mistaken for breathing, but are ineffective to sustain life.⁴
Lack of AED’s or access to AED’s and Emergency Action Plans (EAP); some schools may not have AED’s, or they are locked after hours in an office or locations far from the athletic venue. Surveys have demonstrated that low socioeconomic status, schools with primarily black race, and rural schools are the most common barriers to AED use.⁶

Recently, the Parent Heart Watch has started a campaign to make the use of AED’s easier and to educate the public on their use with the campaign Call, Push, Shock. In addition, Dr. Jonathan Drezner and the NFL to educate the public on recognizing sudden cardiac arrest (Recognize, React, Rescue). These resources are helpful in sending a unified message to the public, providers and to everyone involved to help save lives.

What can we do to improve?

Early recognition and emergency activation – Suspect SCA in any collapsed or unresponsive athlete/person and call 911 immediately.
Access to early defibrillation – the goal is less than 3-5 minutes until the first shock.
Provide high-quality CPR and early access to advanced life support/EMS – Currently, the average time of EMS arrival is 6.1 minutes and can be longer in some communities.⁴ The more people trained and educated to start CPR while awaiting EMS, the better the outcomes.
Make sure all venues have EAP’s that encompass the above and more. An EAP should be established at any athletic venue and should be specific to the athletic venue. An effective EAP should encompass emergency communication (working with local EMS and having a detailed location/address of the venues available, including directions to access points from major roads), personnel, and equipment. They should be reviewed and practiced annually to ensure they work with mock SCA scenarios.
Continue to push for legislation to enforce the use of AED’s in schools. As of 2017, only 17 states required AED installation in schools, and only 5 of these offered funding for AED equipment.⁷

Want to learn more? Check out the Call, Push, Shock page to explore the mission and find local organizations— chances are there is a passionate person in your state or city who has been directly affected by SCA and could use your support and help!

Sources:

“You Can Save A Life from Sudden Cardiac Arrest.” Call, callpushshock.org/.
Harmon, Kimberly G. “Incidence and Etiology of Sudden Cardiac Death in Athletes.” IOC Manual of Sports Cardiology, 2016, pp. 63–73., doi:10.1002/9781119046899.ch7.
“Heart Attack.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 30 May 2018, www.mayoclinic.org/diseases-conditions/heart-attack/symptoms-causes/syc-20373106.
Toresdahl, Brett, et al. “Emergency Cardiac Care in the Athletic Setting: from Schools to the Olympics.” British Journal of Sports Medicine, vol. 46, no. Suppl 1, 2012, pp. i85–i89., doi:10.1136/bjsports-2012-091447.
Drezner, Jonathan A., et al. “Inter Association Task Force Recommendations on Emergency Preparedness and Management of Sudden Cardiac Arrest in High School and College Athletic Programs: A Consensus Statement.” Prehospital Emergency Care, vol. 11, no. 3, 2007, pp. 253–271., doi: 10.1080/10903120701204839.Soun ds
Saberian, Sepehr, et al. “Disparities Regarding Inadequate Automated External Defibrillator Training and Potential Barriers to Successful Cardiac Resuscitation in Public School Systems.” The American Journal of Cardiology, vol. 122, no. 9, 2018, pp. 1565–1569., doi:10.1016/j.amjcard.2018.07.015.
Lou, Nicole. “Few States Require AEDs in Schools.” Medical News and Free CME Online, MedpageToday, 27 Mar. 2017, www.medpagetoday.com/cardiology/arrhythmias/64159.

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.

Paradigm Shifts In Resuscitation

March 2, 2018 David Werho, MD

We go through a series of paradigm shifts during our childhood and development: the moments that change our outlook on the world around us and how we influence it.

“There’s a whole world outside of my home!”
“People can be really cruel!”
“Sharing is caring.”
“Chicken pox are contagious!”

Similar shifts occur in our development as physicians. I remember very distinctly the moment that the pathophysiology of heart failure finally just “clicked” in my mind.

A similar shift occurred as I reviewed a recent AHA news brief on survival in out-of-hospital cardiac arrest. Unconsciously, I had developed a thought-process around out-of-hospital cardiac arrest that was very skewed.

As a child, I thought of CPR as some sort of strange voodoo magic that only lifeguards and doctors could perform. It always worked and brought people back to life immediately with nothing but a residual cough (as they spit out water and seaweed, usually).
Then, as I trained to become a BLS instructor during medical school, I realized that anyone could do CPR, but it didn’t always work. There was no magic about it – it was pure science.
Through my years in medical school, residency, cardiology fellowship, and critical care fellowship, I saw patients who never recovered, or who had profoundly poor outcomes despite survival and I began to think of out-of-hospital cardiac arrest as sort of hopeless. Of course, there was the occasional patient who walked out of the ICU, but I felt like most of the time, if CPR was done outside the hospital, it was not going to end well.

However, after reading about the profound increase in survival and improved functional outcomes after bystanders used AEDs for patients with out-of-hospital cardiac arrest, I suddenly have much more hope. I look back on my own experiences and realize that those patients who did well were the ones who had immediate bystander CPR /- the AED, depending on the etiology of arrest. I think my learned pessimism made it more difficult for me to recognize this connection. But, studies like this show that the evolution in resuscitation science, public health and safety culture, and education can make huge differences in our world. It makes me more hopeful for the future and more thoughtful about ways that I can influence the health and safety of those around me. I think I’m more hopeful now that even small efforts towards improved public health, not just around resuscitation, but anything that makes a positive impact, are worthwhile.

David K. Werho, MD is an Assistant Clinical Professor at the University of California San Diego and a Pediatric Cardiac Intensivist at Rady Children’s Hospital – San Diego. His research focuses on pediatric cardiac ICU outcomes as well as interventions and curriculum development in medical education. He tweets @DWerho and contributes to the Pediatric Cardiac Intensive Care Society Newsletter as editor and contributor.