Saving Time Saves Lives
2001; Lippincott Williams & Wilkins; Volume: 104; Issue: 21 Linguagem: Norueguês
10.1161/circ.104.21.2506
ISSN1524-4539
Autores Tópico(s)Congenital Heart Disease Studies
ResumoHomeCirculationVol. 104, No. 21Saving Time Saves Lives Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBSaving Time Saves Lives Douglas P. Zipes, MD Douglas P. ZipesDouglas P. Zipes From the Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis. Originally published20 Nov 2001https://doi.org/10.1161/circ.104.21.2506Circulation. 2001;104:2506–2508Consider the following 3 patient stories:Reluctantly, A.B. heaved his bulk out of the air-conditioned car and into the hot, bright afternoon sun. The walk across the steaming macadam parking lot left him breathless, and his hand shook as he buried the cigarette butt into the sand on top of the shining brass receptacle guarding the entrance to the casino. His head pounded with the exertion, and he realized he forgot to take his blood pressure pill. Once he adjusted to the dimly lit interior and breathed the cool air, he caught his breath and cashed in $500 worth of chips. He quickly gravitated to the blackjack table, but in 30 minutes was cleaned out. His chest now ached with a soreness that had been waking him up at night for the last 2 weeks. As A.B. massaged his left breast, he began to feel lightheaded, and then the room went black.When C.D. heard the overhead page announcing that his flight was finally ready for boarding, he gulped down his wine and hurried out of the VIP lounge, lugging the distended briefcase over his shoulder. After showing his passport for what seemed the tenth time, he boarded the DC 10 and headed for the business section. The plane was already 2 hours late, and he was angry that he would miss his connection at Heathrow. But that seemed unimportant now as the fluttering in his chest started again. The doctor had told him it was ventricular tachycardia because of his enlarged heart and suggested a new medication, but he didn't want to take it. The fluttering increased as the plane took off and continued through dinner. As C.D. settled back with his cognac, he looked down on the Atlantic, making out a few diamonds of light sparkling on the steamers crossing the pitch-black ocean. And that was the last he remembered.E.F. heard his wife call him to dinner as he shoveled the last bale of hay into the barn and turned to bolt the door. He squinted at the evening sun setting behind his neighbor's house, barely visible in the distance. Perhaps he would take his wife to a movie tonight, he thought, but the long drive back from town on the dark country roads concerned him. Besides, he could do with a good night's sleep. He was nervous about that study he was to have on his heart in a couple of days, an ablation, the doctor called it, and he wanted to be well rested when they burned the extra pathway that caused his lightheaded spells. As E.F. walked to the house, his wife looked up from feeding their son in his highchair. He waved back but then seemed to lose his balance, and fell to the ground.See p 2513In each of these anecdotes, the victim experienced a witnessed sudden cardiac arrest (SCA) due to diverse causes, eg, coronary artery disease, dilated cardiomyopathy, and Wolff-Parkinson-White syndrome. However, the immediate projected outcome for each victim is markedly different, not just because of the different underlying cardiac problem, but because of where the cardiac arrest occurred. A.B., who had a SCA episode in a Las Vegas casino,1 and C.D., who experienced the event on a transatlantic flight,2 both have an excellent chance, probably >50%, of being resuscitated and living to hospital discharge. Unfortunately, E.F, who had the event at home (where, ironically, ≥75% of SCAs occur),3,4 has a dismal outlook, despite being young and having a structurally normal heart. His chance of leaving the hospital alive is probably only in the range of 3% to 5%. In some cities, which focus major initiatives on such victims, with intense civilian rescue training and strategic deployment of automated external defibrillators (AEDs), survival may be as high as 15%.5 However, generally these cities do not achieve the survival rates reported in the airplane and casino studies. The survival disparity has to do with the time elapsed before beginning effective resuscitation procedures and delivering the life-restoring shock that terminates the ventricular tachyarrhythmia.In the present issue of Circulation, Rea et al5 present important information indicating that early cardiopulmonary resuscitation (CPR), provided by bystanders with dispatcher assistance, improves the survival of out-of-hospital SCA victims. Using survival-to-hospital discharge as the outcome measure, dispatcher-assisted bystander CPR was associated with an ≈50% improvement in the survival odds compared with the survival of those victims who received no CPR before the arrival of emergency medical services (EMS). The mean time from collapse of witnessed arrests to starting CPR for the dispatcher-assisted bystander CPR group was ≈1 minute longer than for the bystander CPR group without dispatcher assistance. However, the survival difference between dispatcher-assisted CPR and bystander CPR without dispatcher assistance that was present when basic life support response time was ≤4 minutes disappeared when the basic life support response time exceeded 5 minutes. Overall survival was 15.1%. The authors conclude that dispatcher-assisted bystander CPR increased the proportion of arrest victims who received bystander CPR by 25%, and they postulate that such a response could save thousands of lives annually.Interestingly, in the group that received no bystander CPR (44.1%), most of the cardiac arrests (80.8%) occurred in the home. This was similar to the dispatcher-assisted bystander CPR group (25.7%), in which 93.6% of the SCAs occurred in the home. In contrast, in the group receiving bystander CPR without dispatcher assistance (32%), only 38.3% of the arrests occurred in the home; 34.6% of the SCAs occurred in public places, and 22.7% occurred in medical clinics and nursing facilities. These data suggest that a SCA victim is more likely to receive CPR in places outside the home, despite the fact that the majority of SCAs occur in the home. It is also important to note that the recent guidelines of the American Heart Association recommend that dispatcher instruction of untrained bystanders be limited to chest compression only and exclude ventilations.6 This simplification is designed to increase the proportion of SCA victims who also receive bystander CPR and to decrease the interval required to institute CPR. Bystander CPR with only chest compression seems to be as effective as bystander CPR with ventilation and chest compression in an adult SCA of relatively short duration (average response interval, 4 minutes).7 Whether this effect extends to longer durations of bystander CPR typical of most out-of-hospital SCAs is uncertain.From these observations of Rea et al5 in a cohort of >7000 SCA victims accumulated between 1983 and 2000, one can conclude that the more rapid delivery of CPR, even when dispatcher assisted, improves survival from out-of-hospital SCA. From their data, however, it would seem that a particular focus of the effort should be for victims in the home.3,4 How to do it effectively and economically is problematic for at least 2 reasons: (1) the SCA may be more apt to go unwitnessed in the home and, (2) even if it is witnessed, the arrival of a rescue team that can deliver a shock from an AED make take a long time. After all, although CPR is important, it merely delays death, whereas a defibrillating shock restores life.8In an editorial I wrote on the cost-effectiveness of implantable cardioverter defibrillators,9 I presented an example of a patient with SCA resuscitated so quickly with an AED that he wanted to continue watching the football game in which his son was playing and not be taken to the hospital. I suggested that we needed to make AEDs as available as fire extinguishers, as I had published in an article almost 10 years ago,10 and that such an approach offered an incredible return on the investment. (As an aside, in that article10 I also suggested that we begin teaching the basics about CPR as a mandatory course in public safety or health class in each of the last 4 years of high school to increase the pool of individuals capable of delivering such emergency care.) The US Senate Health, Education, Labor, and Pensions Committee recently passed by voice vote the Teaching Children Saves Lives Act, which would provide schools with $30 million over 3 years to teach children CPR. Although I readily acknowledge that we may not have data to support such an expansive deployment of AEDs, which could be quite an expensive proposition if the number of "saves" are relatively small per AED, I would suggest that we have little choice if we are going to try to limit the toll from SCA. One life saved that would otherwise have been lost represents, in my estimation, an "incredible return on the investment," even if it is costly. Data from such studies as the Public Access Defibrillation trial, which is supported by the American Heart Association, the National Heart, Lung, and Blood Institute, and industry, may provide help in choosing how best to deploy the AEDs.However, there are now abundant data to support the notion that the earlier CPR and an effective shock can be administered, the greater the likelihood that the victim will survive the SCA.11 We need to come up with new scenarios to make this happen in the home, because immediate CPR and an AED shock still represent our best approach to the victim experiencing SCA. We lack the tools to identify most people at risk before the SCA with a degree of accuracy sufficient to warrant major therapeutic interventions, such as implantation of an implantable cardiac defibrillator. Although progress has been made with studies such as the Multicenter Automatic Defibrillator Implantation Trial (MADIT)12 and the Multicenter Unsustained Tachycardia Trial (MUSTT)13 to identify the individual at risk for SCA and efforts continue in the primary prevention of SCA, we must use our available resources to maximize our rescue of victims of SCA, including those not previously identified as having high risk.I suggested an approach recently that I called the "Save a Victim Everywhere" (SAVE) program.14 It is based on 2 public initiatives that have been effective in the United States for many years, the Volunteer Firemen and the Neighborhood Watch programs. Volunteers who comprise the Volunteer Firemen respond to a wide array of emergencies every day as a first line of defense against fires, emergency medical incidents, and disasters. It is estimated that they save localities across the United States almost $37 million yearly. The well-known Neighborhood Watch programs, which are adopted by many communities to protect their residents from crime, enroll >30 million people nationwide. Neighborhoods cite a major reduction in crime after initiating such a program.We could capitalize on such initiatives with SAVE. For example, we could have teams of neighbors trained to administer CPR and to deliver a shock with an AED that is strategically placed in selected homes throughout the neighborhood. A heart watch team with an AED could be centralized in the middle of several blocks or streets, depending on the community's configuration and density, or distributed on various floors of high-rise apartments, or otherwise dispensed in concentrated areas of population. Then, when the 911 dispatch center receives a cardiac distress call, the call would immediately be shunted to both the paramedics and the nearest heart watch team. In the scenario for E.F. above, his home is so far out of town that even if the police set out for his farm immediately, it might take at least 7 or 8 minutes to arrive, while a neighbor might be there in <4 minutes. And, in those precious minutes, the neighbor could have used the AED to save E.F.'s life. We have found, for example, that simply equipping police cars with AEDs did not improve out-of-hospital cardiac arrest survival in suburban and rural Indiana, in part due to limited response by police and to the long distances they had to travel to reach the victim.15 Others have improved survival by having AEDs deployed in police cars.16I think we need to take action now to help the SCA victim in the home by creating new ways to enable the speedy delivery of CPR and a shock from an AED. The best approach to that problem would be to have more people capable of delivering CPR (hence, training in high school) and to create ways of delivering CPR and AED treatment rapidly (hence, the neighborhood heart watch concept and SAVE). The SAVE concept should be tested in the future.The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.FootnotesCorrespondence to Douglas P. Zipes, MD, Krannert Institute of Cardiology, Indiana University School of Medicine, 1800 North Capital, Room E475, Indianapolis, IN 46202. E-mail [email protected] References 1 Valenzuela TD, Roe DJ, Nichol G, et al. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. N Engl J Med. 2000; 343: 1206–1209.CrossrefMedlineGoogle Scholar2 Page RL, Joglar JA, Kowal RC, et al. Use of automated external defibrillators by a US airline. N Engl J Med. 2000; 343: 1210–1216.CrossrefMedlineGoogle Scholar3 Zipes DP, Wellens JHH. Sudden cardiac death. Circulation. 1998; 98: 22334–2351.Google Scholar4 Prior SG, Aliot E, Blomstron-Lundqvist C, et al. Task Force on Sudden Cardiac Death of the European Society of Cardiology. Eur Heart J. 2001; 22: 1374–1450.CrossrefMedlineGoogle Scholar5 Rea TD, Eisenberg MS, Culley LL, et al. Dispatcher-assisted cardiopulmonary resuscitation and survival in cardiac arrest. Circulation. 2001; 104: 2513–2516.CrossrefMedlineGoogle Scholar6 Kern KB, Halperin HR, Field J. New guidelines for cardiopulmonary resuscitation and emergency cardiac care: changes in the management of cardiac arrest. JAMA. 2001; 285: 1267–1269.CrossrefMedlineGoogle Scholar7 Hallstrom A, Cobb L, Johnson E, et al. Cardiopulmonary resuscitation with chest compressions alone or with mouth-to-mouth ventilation. N Engl J Med. 2000; 342: 1546–1553.CrossrefMedlineGoogle Scholar8 Eisenberg MS, Mengert TJ. Cardiac resuscitation. N Engl J Med. 2001; 344: 1304–1313.CrossrefMedlineGoogle Scholar9 Zipes DP. Implantable cardioverter-defibrillator: a Volkswagen or a Rolls Royce: how much will we pay to save a life? Circulation. 2001; 103: 1372–1374.CrossrefMedlineGoogle Scholar10 Zipes DP. Sudden cardiac death: future approaches. Circulation. 1992; 85: I-160–I-166.Google Scholar11 Marenco JP, Wang PJ, Link MS, et al. Improving survival from sudden cardiac arrest: the role of the automated external defibrillation. JAMA. 2001; 285: 1193–2000.CrossrefMedlineGoogle Scholar12 Moss AJ, Hall WJ, Cannom DS, et al. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia: Multicenter Automatic Defibrillator Implantation Trial Investigators. N Engl J Med. 1996; 335: 1933–1940.CrossrefMedlineGoogle Scholar13 Buxton AE, Lee KL, DiCarlo L, et al. Electrophysiologic testing to identify patients with coronary artery disease who are at risk for sudden death: Multicenter Unsustained Tachycardia Trial Investigators. N Engl J Med. 2000; 342: 1937–1945.CrossrefMedlineGoogle Scholar14 Zipes DP. President's page: the neighborhood heart watch program: Save A Victim Everywhere (SAVE). J Am Coll Cardiol. 2001; 37: 2004–2005.CrossrefMedlineGoogle Scholar15 Groh WJ, Newman MM, Beal PE, et al. Limited response to cardiac arrest by police equipped with automated external defibrillators: lack of survival benefit in suburban and rural Indiana: the Police as Responder Automated Defibrillation Evaluation (PARADE). Acad Emerg Med. 2001; 8: 324–330.CrossrefMedlineGoogle Scholar16 Fenster JS, Lopez M, Lai S, et al. Survival with community-wide police-car deployment of automated external defibrillators in a large metropolitan area. Pacing Clin Electrophysiol. 2001; 24(part II): 584.Abstract.Google Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Taglieri N, Saia F, Lanzillotti V, Marrozzini , Faccioli R, Iarussi B, Ortolani P, Palmerini T, Cortesi P, Gordini G, Gallo P, Branzi A and Marzocchi A (2011) Impact of a territorial ST-segment elevation myocardial infarction network on prognosis of patients with out-of-hospital cardiac arrest, Acute Cardiac Care, 10.3109/17482941.2011.606473, 13:3, (143-147), Online publication date: 1-Sep-2011. Weidringer J and Sefrin P (2006) Vorteile der LaienreanimationAdvantages of lay person reanimation, Trauma und Berufskrankheit, 10.1007/s10039-005-1074-y, 8:S03, (S299-S302), Online publication date: 1-Dec-2006. Culley L, Rea T, Murray J, Welles B, Fahrenbruch C, Olsufka M, Eisenberg M and Copass M (2004) Public Access Defibrillation in Out-of-Hospital Cardiac Arrest, Circulation, 109:15, (1859-1863), Online publication date: 20-Apr-2004. Straus S, Bleumink G, Dieleman J, Lei van der J, Stricker B and Sturkenboom M (2004) The incidence of sudden cardiac death in the general population, Journal of Clinical Epidemiology, 10.1016/S0895-4356(03)00210-5, 57:1, (98-102), Online publication date: 1-Jan-2004. Idris A and Roppolo L (2003) Barriers to dispatcher-assisted telephone cardiopulmonary resuscitation, Annals of Emergency Medicine, 10.1016/S0196-0644(03)00630-9, 42:6, (738-740), Online publication date: 1-Dec-2003. Rea T, Eisenberg M, Becker L, Lima A, Fahrenbruch C, Copass M and Cobb L (2003) Emergency medical services and mortality from heart disease: A community study, Annals of Emergency Medicine, 10.1067/mem.2003.149, 41:4, (494-499), Online publication date: 1-Apr-2003. Caffrey S (2002) Feasibility of public access to defibrillation, Current Opinion in Critical Care, 10.1097/00075198-200206000-00001, 8:3, (195-198), Online publication date: 1-Jun-2002. López-Sendón J, Escorial Hernández V, Meizoso Latova T, Alday Muñoz E and López de Sá E (2002) Respuesta, Revista Española de Cardiología, 10.1016/S0300-8932(02)76604-9, 55:3, (320), Online publication date: 1-Jan-2002. November 20, 2001Vol 104, Issue 21 Advertisement Article InformationMetrics https://doi.org/10.1161/circ.104.21.2506PMID: 11714641 Originally publishedNovember 20, 2001 KeywordsEditorialscardiopulmonary resuscitationheart arrestdefibrillationsyncopePDF download Advertisement
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