Systematic review

Automated external defibrillators programs in the community – a

systematic review of observational studies

Class- 12 1 st year 2006/2007

Ana Vigário, Daniela Rodrigues, Diana Marques, Fátima Marisa Queirós, Inês Garrido, Leonor Matos, Liliana Tavares

Introduction of Medicine13 of Novembrer of 2006 Porto Medical Faculty

Class- 12 1st year 2006/2007

• Introduction: • Definition of sudden cardiac death (SCD)

• Epidemiology of SCD in the community

• Prevention of SCD in the community

• Automated external defibrillator programs

• Objective of the study

• Material and Methods• Query used in the systematic review

• Exclusion and Inclusion criteria

• Gantt Map of the group work

Contents

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Sudden Cardiac Death Definition:

• Natural cause death, secondary to cardiac causes, with sudden lost of conscience, until 1 hour after the onset of the acute symptoms (1).

– The previous existence of cardiac disease can be known

– The timing and death mode are unexpected.

• The expression “sudden death” has been used for several centuries.

Key points in the definition of sudden death: 1. non traumatic event 2. unexpected and instant event

Introduction

1. Priori S, et all. Task Force on sudden cardiac death. Europace; 2002, 4: 3-18

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• Is the most frequent cause of death in the adult population is the industrialized world (2)

• The incidence of extra-hospital sudden death varies with age, gender and the presence of cardiovascular disease (3)

• 225.000 americans/year died suddenly of SCD (4)• 21% of all deaths that occur in the men and 14,5% in women• 80% of SCD cases occur in home and 15% on the street or in a

public place• 40% are non-witness events • 40% of SCD victims present with ventricular fibrillation as cause of

the event.

Epidemiology of SCD (I)

2. Cobb L et al. Changing incidence of out-of-hospital ventricular fibrillation, 1980-2000. JAMA 2002; 288: 3008-13

3. DeVreede-Swagemakers et al. Out-of-hospital cardiac arrest in the 1990’: a population based study in the Maastricht area on incedence, characteristics and survival. JACC 1997; 30: 1500-5

4. American Heart Associaion. Heart disease and Stroke statístics – 2005 Update. Dallas, Texas: AHA 2004

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• Is the leading cause of death in Europe, affecting about

700 000 individuals a year (5)

• At the time of the first heart rhythm analysis, about 40%

of SCA victims have ventricular fibrillation (VF) (6)

• It is likely that many more victims have VF or rapid

ventricular tachycardia (VT) at the time of collapse but,

by the time the first ECG is recorded, their rhythm has

deteriorated to asystole (7)

Epidemiology of SCD (II)

5. Sans S et all. The burden of cardiovascular diseases mortality in Europe. Task force of ESC on cardiocascular mortality and morbidity statistics in Europe. Eur Heart J 1997; 18: 1231-48

6. Rea TD et all. Incidence of SEM-treated out-of-hospital cardiac arrest in the USA. Resuscitation 2004; 63: 17-24

7. Waalewijn RA et all. Prevention of deterioration of ventricular fibrillation by basic life support during out-of-hospital cardiac arrest. Resuscitation 2002; 54: 31-6

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Prevention of SCD in the community• SCD that occurs in apparent healthy individuals cannot be prevented. • The overall survival of out-of-hospital SCD is 1-2% (8)• The survival rate does not improve with the existence of emmergency

systems with advance life support (9) • The individual survival is dependent on the defibrillator availability in

4-5 minutes after onset of the event (10)

8. The public access defibrillation trial investigators. Public-access defibrillation and survival after out-of-hospital cardiac arrest. NEJM 2004; 351: 637-469. Stiell I et al. Advanced cardiac life support in out-of-hospital cardiac arrest. EJM 2004; 351: 647-5610. European Ressucitation Council. Part 2: Adult basic life support and use of automated external defibrillators. Resuscitation 2005; 67: s7-23

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• The early defibrillation has demonstrated to be critical in the survival improvement of SCD (11)

• Many victims of SCA can survive if bystanders act immediately while VF is still present (12)

• Early bystander CPR can double or triple survival from VF SCD (13, 14)

• CPR plus defibrillation within 3-5 minutes of collapse can produce survival rates as high as 49-75% (15)

• The recent technical improvements in the Automated External Defibrillators (AED) made possible it’s use by lay people.

Prevention of SCD in the community

11. Marenco J et al. Improving survival from sudden cardiac arrest: the role of the automated external defibrillator. JAMA 2001; 285: 1193-20012. Larsen MP et al. Predicting survival from out-of-hospital cardiac arrest: a graphic model. Ann Emerg Med 1993; 22:1652-813. Holmberg M et al. Factors modifying the effects of bystander CPR on survival in out-of-hospital arrest patient in Sweden. Eur Heart J 2001; 22: 511-914. Waalewijn RA et al. Survival models for out-of-hospital CPR from the perspectives of the bystander, the first responder and the paramedic. Resuscitation 2001; 51: 113-22 15. White R et al. Evolution of a community-wide defibrillation programme experience over 13 years using police/fire personnel and paramedics as responders. Resuscitation, 2005; 65(3): 279-83.

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What is an automated external defibrillator?What is an automated external defibrillator?

• It’s a small device, consisted of a computerized part that delivers

shock to victims of VF cardiac arrest. The device is attached to the

victim by adhesive pads or electrodes, which records and analyzes

the victims electrocardiogram rhythm, informs the rescuer if a shock

is needed and provides voice and audio prompts to guide the

rescuer through all steps of AED use. (16)

Automated external defibrillator

16. A.W. Diack, W.S. Wellborn, R.G. Rullman et al., An automatic cardiac resuscitator for emergency treatment of cardiac arrest. Med Instrum 13 (1979), pp. 78–81. Abstract-EMBASE | Abstract-INSPEC   | Order Document | Abstract + References in Scopus | Cited By in Scopus

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• Over the past two decades, automatic external defibrillators (AED) have been developed and improved to allow single rescuers to defibrillate victims of cardiac arrest rapidly.(17)

• The expansion of the role of defibrillation to both minimally trained first-responders (police officers, firefighters, security guards, flight attendants) and to trained laypersons who witness an arrest.(18)

• The placement of automated external defibrillators (AEDs) in such areas as airports, convention centers, sporting arenas, casinos, shopping malls, and large office buildings. (19)

• An organized and practiced response, with rescuers trained and equipped to recognize emergencies, activate the emergency medical services system, provide CPR, and provide defibrillation in situations where quickness is determinant. (20)

Automated external defibrillator programs

17. Becker S et al. Minimal instructions improve the performance of layperson in the use of semiautomatic and automatic external defibrillators. Critical Care 2005; 9: 110-1618. Davies C et al. A national program for on-site defibrillation by lay peolple is selected high risk areas: inicial results. Heart 2005; 91: 1299-30219. Zipes DP, Wellens HJ. Sudden cardiac death. Circulation. 1998;98:2334-2351

20. Lim S et al. Results of the first five years of the prehospital automatic external defibrillation project in Singapore in the “Utstein style”. Resuscitation, 2005; 64: 49-57 2.

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Improve outcome from sudden Improve outcome from sudden deathdeath ??

The efficacy is not overall stablishedThe efficacy is not overall stablished

Lay rescuer AED programsLay rescuer AED programs may:

• Provide an early recognition and correction of these dysrhythmias by lay rescuers;

• Increase the number of people who receive bystander cardiopulmonary resuscitation (CPR);

•Reduce time to defibrillation.(21)

21. Joseph V. Automatic external defibrillators: lessons from the past, present and future . Resuscitation 1999; 41: 219

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The main objective of this study is to evaluate whether

the utilization of the AED in the community in AED

programs reduces overall mortality of SCD and

increases quality of life of the survivors.

Objective

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Methods

• Systematic review of published articles

• Bibliographic research in medical databases: • PubMed’s • Scopus’

• Searching criteria: • from the earliest achievable date until December 2006. • Terms used: automated external defibrillator, public access

defibrillation, sudden cardiac arrest, out-of-hospital cardiac arrest, ventricular fibrillation or tachycardia

• Manual review of the relative articles of the articles included in the systematic review and manual review of cited references

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Query used to search PubMed:

("automated external defibrillator" OR "automated external defibrillator programs" OR "public access defibrillation" OR "out-of-hospital defibrillation")

AND

("Death, Sudden, Cardiac"[MeSH] OR "sudden cardiac arrest" OR "sudden cardiac death" OR "out-of-hospital cardiac arrest" OR "Ventricular Fibrillation"[MeSH] OR "ventricular fibrillation" OR "Tachycardia, Ventricular"[MeSH]OR "ventricular tachycardia")

NOT letter

Methods

Class- 12 1st year 2006/2007

Exclusion Criteria:

Initial tracing (exclusion): performed by one group, composed of three reviewers, according to the exclusion criteria mentioned below:

– Not being presented in English, French, Portuguese or Spanish;

– Not to be published in the last 20 years;

– Not aplicated to humans.

Methods

Class- 12 1st year 2006/2007

Inclusion criteria: • performed by one group, composed of three reviewers.

• Selection was made by consense of the three reviewers:

• Inclusion criteria: 1 - Being based on the systematic review’s theme – concerning studies published

about AED programs in the community.

2 – Articles that had information about survival rates at hospital discharge after implementation of AED programs or data that made possible it’s calculation.

3 – Articles that had information about quality of life of the survivors after implementation of AED programs or data that made possible it’s calculation

4 – Studies with a minimal number of 50 patients or programs with a duration of more than 6 months

5 – Studies about AED community programs with lay people, fire-fighters, police officers and paramedic involvement.

Methods

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• Projecto1 gantt.mpp

Gantt Gantt Diagram and Diagram and

FlowchartFlowchart