Q J Med 2000; 93: 191-195
© 2000 Association of Physicians
Commentary |
Cheating sudden death: how to do it, and what life's like after it
From the Department of Cardiology, Royal Infirmary of Edinburgh, Edinburgh, UK
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Introduction |
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 Top Introduction Reducing mortalityBasic life supportRapid defibrillation, emergency...Morbidity--the hidden costSummaryReferences |
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Before the development of portable external defibrillators and the adoption of this technology by the emergency medical services, survival from out-of-hospital cardiac arrest was a very rare occurrence. Although CPR could be administered by ambulance crews, the delays involved in moving the victim to hospital prior to defibrillation were too great to allow many to survive. The first major advance in prehospital care occurred when Frank Pantridge addressed possible ways of reducing the high mortality rate associated with myocardial infarction. He recognized that most individuals who died did so within an hour of the onset of symptoms. Despite opposition from colleagues and the authorities, he and his resident, John Geddes, implemented the world's first mobile coronary care unit (MCCU) in Belfast in 1966. During the first 15 months of operation, the MCCU attended 10 patients who had ventricular fibrillation outside hospital, and all were successfully defibrillated.1 Soon after, MCCUs were introduced in many cities world-wide, their main role being to transport victims of myocardial infarction quickly, and to provide defibrillation if needed. However, time was often wasted waiting for staff to arrive at the MCCUs prior to dispatch, and many cities had only a single MCCU serving a large geographic area. Response times were often slow, and those who had cardiac arrests before the MCCU arrived usually did not survive. The MCCU system was a breakthrough in prehospital care, but was limited by the concept that defibrillation had to be administered by a physician. The first move towards paramedic-administered defibrillation occurred just 3 years after Pantridge's MCCU saved its first patient. Eugene Nagel, an emergency room physician from Miami, recognized the limitations of the MCCU system. Because of legal impediments which forbade paramedics from administering treatments other than first aid and CPR without orders from a physician, Nagel used a system of ECG telemetry and radio communication to allow the emergency room physicians to issue orders to paramedics, allowing intervention at the scene. The first successful paramedic-administered defibrillation was performed in 1969, after which the 60-year-old victim was discharged from hospital without disability.2 Once the effectiveness of paramedic interventions was proven, the legal impediments to paramedic-administered defibrillation were removed, and paramedics were allowed to defibrillate victims of cardiac arrest without authorization by a physician. Paramedic-led defibrillation is now commonplace.
As a result of this evolution of practice, it is now common for victims of cardiac arrest to be successfully resuscitated outside hospital. Out-of-hospital resuscitation programmes such as Heartstart Scotland have enabled ambulance technicians to rapidly defibrillate victims of cardiac arrest in the community, saving many lives each year.3 In Edinburgh, each year, approximately 40 people are successfully resuscitated in this manner and survive to be discharged home from hospital. Most of them are still alive after 1 year.3,4 The impact of this treatment on mortality from heart disease is comparable to that of thrombolytic therapy for myocardial infarction. For example, streptokinase and aspirin, which save around 40 lives per 1000 patients treated in the first year, would save approximately 40 lives per year in the same city.5 From this, the value of out-of-hospital resuscitation is clear, but several key questions now need to be addressed. Is it possible to improve on the survival rates achieved with current initiatives? If so, what strategies should be adopted? Also, what about the quality of survival after cardiac arrest? Do cardiac arrest survivors encounter specific problems that should be recognized and which require specific help?
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Reducing mortality |
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TopIntroductionReducing mortalityBasic life supportRapid defibrillation, emergency...Morbidity--the hidden costSummaryReferences |
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Educating the public
The first two components of the ‘Chain of Survival’ are the recognition of the signs of a heart attack or cardiac arrest, and activation of the emergency medical services.6 In itself, this comprises several elements: recognition of the event, decision to call the emergency services, time spent locating a telephone, dialogue between dispatcher and caller, and dispatch of the emergency vehicle. Public education programmes have been used successfully in the US to make the public aware of what should be done if a cardiac arrest is witnessed.7 The most important message to the public is to summon the emergency services; cardiopulmonary resuscitation is only a holding measure prior to defibrillation. In Iowa, a simple but effective programme called ‘Phone First’ has been implemented to convey this message.8 In Scotland, there is significant scope for improvement. In North Glasgow, the proportion of out-of-hospital cardiac arrest victims who survived to discharge increased from 0/296 in 1984 to 2/267 in 1990, the first year of the Heartstart Scotland programme.9 The authors of this study cited weaknesses in the links of the ‘Chain of Survival’ as possible reasons for this disappointing result. The call for assistance came after the patient collapsed in 56% of cases; most calls before fatal collapse were made to general practitioners rather than the ambulance service. The initial call for help was only made to the ambulance service in 35% of cases, and often after the collapse despite the presence of warning symptoms. The authors of that study concluded: ‘The impact of equipping ambulances with defibrillators will remain small unless strategies are introduced that focus on improving the public's response to coronary emergencies by calling for help promptly, and initiating cardiopulmonary resuscitation before the arrival of the emergency services’. Public education is clearly required, especially in regions such as this, before the benefits of sophisticated dispatch and emergency services systems are realized.
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Basic life support |
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TopIntroductionReducing mortalityBasic life supportRapid defibrillation, emergency...Morbidity--the hidden costSummaryReferences |
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A person having a cardiac arrest is most likely to survive if their collapse is witnessed by a bystander who can perform cardiopulmonary resuscitation (CPR), and if defibrillation is delivered promptly.10–13 However, the benefits of CPR may have been understated in these studies because CPR is treated as an ‘all or nothing’ intervention. This could result in the ‘CPR-treated’ groups including patients resuscitated by bystanders with diverse levels of ability, ranging from those who have had formal CPR training to those who have very little skill at all. The fact that training makes a difference was highlighted in a study which examined in-hospital mortality rates after out-of-hospital cardiac arrest.4 That study showed that patients initially resuscitated from cardiac arrest were twice as likely to survive to discharge if CPR was administered by a trained person (e.g. an off-duty doctor or nurse) than if administered by an untrained person. This is likely to be due to a combination of effective CPR, and knowledge that the emergency services should be summoned immediately the cardiac arrest is recognised. Since the median time from cardiac arrest to first shock in that study was 10 min, basic life support was important in ‘buying time’ for the cardiac arrest victim.
In that study, 14% of victims of witnessed ventricular fibrillation survived to leave hospital. This compares favourably with survival rates elsewhere in Scotland, and the survival rate is similar to that published from other major European cities such as Maastricht and Vienna.4,14,15 In places where survival rates are higher, such as Seattle, two links in the ‘Chain of Survival’ are stronger. Over 60% of the adult population is trained in basic life support methods through a successful large-scale training programme, and emergency service response times are much more rapid.16
In many European cities, even when a cardiac arrest is witnessed, cardiopulmonary resuscitation is attempted in less than half of cases.3,17,18 In the UK, no centrally organized system of school or adult resuscitation training exists at present. Current schemes for training the public in basic life support techniques are mainly led by charitable organisations, and no central initiative exists to augment the relatively small amount of training that these organizations are able to provide. Recommendations to include resuscitation training in the school National Curriculum have not been endorsed, although a pilot study is in progress to evaluate this option.
What lessons can be learned from other programmes? In a survey of public CPR training in Minneapolis, 23% of adults were trained in CPR, but only 19% of those initially trained attended for retraining.19 Motivation is clearly a key issue. In Seattle, where over 60% of adults are trained in cardiopulmonary resuscitation, only 7% of trained persons actually live with a person known to have heart disease.20 This experience was mirrored in Göteborg, where despite the introduction of a programme which trained over 100 000 citizens, CPR was only attempted in 20% of cases, and the number of bystander attempts only increased slightly. The reason cited was the fact that most individuals trained were young, and were not likely to encounter the people at greatest risk.18 Given these findings, and the fact that approximately 70% of cardiac arrests occur in the home (usually in individuals with known heart disease), targeting training at the relatives of those with known heart disease may be more effective.16 This approach has been successfully adopted in some communities abroad, and has been applied in a limited fashion in Scotland.21–23 The cost of implementing this strategy was estimated by the Scottish Home and Health Department (SHHD) in 1993.24 They estimated that 60 000 individuals suffer a non-fatal myocardial infarction per year in Scotland. If CPR training were offered to one family member for each of these individuals, with a projected uptake of 25%, this would produce an annual cost of £200 000. The cost of a blanket CPR training programme, aiming for a target of 20% of the adult population, would be much higher. This would involve an initial training of 200 000 members of the public per year for 3 years, at an annual cost of £1.5m, with additional costs for administering the project. However, although large-scale training of the public in basic life support is expensive, it cannot be regarded as an initiative with short-term benefits. Rather, it is an investment of training of young people who are most likely to be receptive to learning and who are most likely to retain these skills when they are needed. As in Seattle, the benefits are seen decades after the training programme is initiated.
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Rapid defibrillation, emergency services infrastructure |
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TopIntroductionReducing mortalityBasic life supportRapid defibrillation, emergency...Morbidity--the hidden costSummaryReferences |
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Response times of emergency medical services may be limited by the geographic layout of the area, traffic density, and road networks. Thus, even in cities with relatively advanced emergency services, response times may be long, and the opportunity may be missed to intervene when the heart is most amenable to defibrillation.14,25 Training individuals to defibrillate before the arrival of the ambulance/paramedic crew is a complementary approach to this problem. In 1993, the American Heart Association set up the Automatic External Defibrillation Task Force, with the remit of appraising equipment and strategies to allow designated individuals to defibrillate while waiting for the emergency services.26 At the 1986 World Exposition in Vancouver, Canada, security personnel were trained to defibrillate cardiac arrest victims. Two cases of ventricular fibrillation occurred, and both victims were successfully defibrillated.27 Since 1991, Quantas Airlines have trained cabin crews in aircraft and major airport terminals to use defibrillators. Since then, there have been six successful resuscitations from ventricular fibrillation out of 23 episodes. Their survival rate compares favourably with that of many community out-of-hospital resuscitation programmes.28 This approach has also been applied to other public transportation systems, isolated settings such as oil platforms, and high-risk work settings such as electricity generating stations.29 However, although public access defibrillation lends itself to application in the settings described here, it does not address the needs of the majority of victims who suffer cardiac arrest in their own homes. For these individuals, basic life support and a rapid response emergency service are paramount.
New approaches to existing emergency service provision may also help to reduce delays in defibrillation, accounting for local factors such as city layout and existing emergency service provisions. In some cities in the US, the emergency services have been adapted to make the best use of the existing infrastructure. In Seattle and in King County, Washington, the Fire Departments have been successfully adapted to provide first response to cardiac arrest.16,25 In Rochester, Minnesota, the police service provides first-line defibrillation, with reported survival to discharge for witnessed ventricular fibrillation of over 40%.30 The use of police motorcycles equipped with fully automatic defibrillators could be used to increase the number of rapid response units, and to improve response times, in areas with high traffic congestion. In the UK, in which this is a particular problem, these approaches might usefully improve the performance of the emergency services. This would require investment in additional training of police personnel, modification of the existing dispatch system, and provision of equipment.
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Morbidity—the hidden cost |
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TopIntroductionReducing mortalityBasic life supportRapid defibrillation, emergency...Morbidity--the hidden costSummaryReferences |
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Most studies which assess outcome after out-of-hospital resuscitation have focused on mortality rates, but not on morbidity in those who survive. This lack of emphasis on quality of survival is reflected in the scarcity of information about neuropsychological assessment and management of cardiac arrest survivors. One published set of guidelines for the ‘general evaluation of out-of-hospital sudden cardiac death survivors’ made no reference to the possible effects of cerebral hypoxia on brain function after cardiac arrest.31 Although cerebral hypoxia during cardiac arrest can cause severe neurological disability, florid deficits appear to be rare among those cardiac arrest victims who survive.32 Patients may appear fit to be discharged into their normal home environment, but cognitive disability is common. A (medical) patient who had survived a cardiac arrest wrote to our clinic,
‘The problems as a result of cerebral ischaemia are much greater than the heart problems. What I have found is that a few of my doctor friends couldn’t understand or could not cope with the consequences of this type of heart attack ... the idea of a tailored rehabilitation programme is excellent.’33
Over 30% of survivors suffer memory impairment severe enough to interfere with functional recovery and daily activities.34 For example, it is common for these individuals to have marked difficulty in retaining verbal information from a conversation or television programme, or to forget names, faces or appointments. Other cognitive processes may also be compromised such as those relating to motor ability, information coding speed and abstract thought.33–36 As a result, these individuals may struggle in conventional cardiac rehabilitation programmes, designed for patients recovering from myocardial infarction. Cognitive impairment affects the ability of individuals to rehabilitate from other illnesses such as head injury and stroke, and are important in determining whether an individual can drive or return to work. In our centre, one half of cardiac arrest survivors are of working age, and one half are eligible to drive (when the cardiac arrest is caused by an acute myocardial infarction). Future strategies for rehabilitating these individuals may use elements from current cardiac and neurological rehabilitation programmes, but further investigation is first required to better define the cognitive deficits which they suffer.
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Summary |
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TopIntroductionReducing mortalityBasic life supportRapid defibrillation, emergency...Morbidity--the hidden costSummaryReferences |
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In an era when limited resources are increasingly directed at evidence-based treatments such as thrombolysis, further investment in out-of-hospital resuscitation can certainly be justified, because it is an effective treatment. Studies of community intervention throughout Europe show that although survival rates have improved in some cities, there is the potential to do significantly better. However, improving survival rates requires investment in the emergency services and in public education. Public training in CPR is feasible, but requires co-ordination and investment in trainers and equipment. Large-scale community CPR training should be regarded as an investment for the future, with little potential for short-term gain. Legislation may be helpful to implement this; in other countries, basic life support is a teaching requirement in schools, but it is not included at present in the National Curriculum. In the short term, CPR training targeted at spouses and relatives of patients with known ischaemic heart disease is more likely to affect survival rates. Use of the media may increase public awareness of the importance of resuscitation, and increase voluntary uptake of CPR training. Finally, more attention has to be directed at the consequences of cardiac arrest on cognitive function in this increasing population of cardiac arrest survivors. For successful rehabilitation, targeted treatment strategies will be required which account for their disabilities and which address their specific needs.
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Notes |
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Address correspondence to Dr N. Grubb, Department of Cardiology, Royal Infirmary of Edinburgh, 1 Lauriston Place, Edinburgh EH3 9YW
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References |
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TopIntroductionReducing mortalityBasic life supportRapid defibrillation, emergency...Morbidity--the hidden costSummaryReferences |
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