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Pediatr Cardiol (2012) 33:402–406 DOI 10.1007/s00246-012-0158-2

REVIEW ARTICLE

Automated External Defibrillators and Secondary Prevention of Sudden Cardiac Death Among Children and Adolescents Joshua Kovach • Stuart Berger

Received: 29 July 2011 / Accepted: 16 August 2011 / Published online: 3 February 2012 Ó Springer Science+Business Media, LLC 2012

Abstract Sudden cardiac death is devastating at any age, but it is especially so among children and adolescents. This report discusses the outcomes for patients with out-ofhospital cardiac arrest (OHCA) and describes public access defibrillation programs in general and those directed at children and adolescents. In addition, the relatively new concept of cardiopulmonary resuscitation (CPR)–automated external defibrillator (AED) programs directed at schools is discussed. Although limited data are available, some of the preliminary data suggest improved OHCA outcomes associated with CPR-AED programs implemented in schools. These early data provide hope for the future potential reduction in the incidence of sudden cardiac deaths in the school setting, not only among children and adolescents, but also among adults. Keywords Automated external defibrillator Cardiopulmonary resuscitation CPR-AED program Out-of-hospital cardiac arrest Sudden cardiac death

Introduction This article is a review of public access defibrillation (PAD) in general and as it pertains to children and adolescents. The issues discussed include a review of PAD, its rationale and evidence for the pediatric population, and

J. Kovach S. Berger (&) The Herma Heart Center, Children’s Hospital of Wisconsin, The Medical College of Wisconsin, 9000 W. Wisconsin Ave, MS 713, Milwaukee, WI 53226, USA e-mail: [email protected] J. Kovach e-mail: [email protected]

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updated information with regard to existing PAD targeted toward children and adolescents.

Review of PAD and Out-of-Hospital Cardiac Arrest Data Historically, the mortality rate for out-of-hospital cardiac arrest (OHCA) has been very poor [2, 8, 24], with recognition that survival decreases by 10% for every minute that resuscitation is delayed [8, 34]. In reaction, a push was made toward improving response time through the development and implementation of PAD programs. In 2004, the outcomes of a PAD trial were published in the New England Journal of Medicine [20]. This multicenter trial showed a survival benefit for OHCA in adults at sites that had cardiopulmonary resuscitation (CPR) plus an automated external defibrillator (AED) as opposed to sites that had CPR alone. A cost-effective placement of AEDs was suggested for locations with one of the following criteria: one arrest every few years, at least 250 adults older than 50 years passing through the site during waking hours, a location with high-risk individuals present, or a location with a higher frequency of sudden cardiac arrests (SCAs). Such locations, as initially suggested by Becker et al. [3], might include airports, golf clubs, health clubs, large industrial areas, facilities for sporting events, casinos, shopping malls, and the like. The appropriate locations could vary depending on the specific community. Increasing efforts have been made across the United States to introduce resuscitation and PAD programs into high schools [12]. Screening programs for detection of underlying heart disease in student athletes that increases their risk for SCA remain imperfect [26]; and frequently, sudden arrest secondary to ventricular tachycardia or

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fibrillation during activity may be the initial presentation for this group [7, 25]. Although the sudden death of a student during competitive sports or other vigorous activity while on school grounds is certainly traumatic within a community, the relative incidence of sudden cardiac death (SCD) among children and adolescents remains low compared with its frequency among adults [27, 34]. Additionally, concern remains that defibrillation outcomes for children with SCA may be inferior to those for adults, although the particular underlying reason for this discrepancy remains unclear [10, 13]. However, schools also serve as community gathering places where adults at high risk for SCA may routinely be present. The American Heart Association (AHA) has put forth specific recommendations in their Emergency Cardiovascular Care Guidelines (2000) for sites that should benefit from AED placement [32]. These Guidelines recommend lay rescuer AED program development at locations that meet at least one of the following criteria: 1.

2.

3.

The frequency of sudden cardiac events poses a reasonable probability of AED use within 5 years of AED placement and training. Children or adults attend the school who are thought to be at high risk for SCA such as those with congenital heart disease, channelopathies, cardiomyopathies, or known cardiovascular disease. An emergency medical service (EMS) call to shock cannot be achieved reliably and consistently within 5 min of the SCA, whereas a collapse-to-shock response time shorter than 5 min can be achieved reliably by training of first responders and lay rescuers.

Subsequently, in 2003, the AHA released an update of their advisory statement regarding the use of AEDs for children, approving their use for children younger than 8 years but older than 1 year. To date, the safety of AEDs for children younger than 1 year has not been firmly established [31].

Rationale and Evidence for CPR and PAD Programs Targeted Toward the Pediatric and Adolescent Population In 2004, the AHA released a statement specifically providing recommendations for the development of a Medical Emergency Response Plan for schools that meet the aforementioned criteria as effective preparation for a cardiac arrest [21]. These recommendations described a number of elements necessary for successful implementation of such a plan: 1.

An effective communication system throughout the campus to permit rapid contact and coordination with EMS from any location

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2. 3. 4.

5.

Development of a coordinated response plan among school staff and local EMS Implementation of safety features to reduce risk and prevent injury Instruction and training of school staff and students in the administration of first aid and CPR, including provision of necessary equipment Implementation of an AED program in schools that meet the criteria listed earlier. The AED program should include medical provider oversight, training in CPR and AED use for identified first responders, coordination with EMS, appropriate device maintenance, and ongoing quality improvement.

In 2007, Rothmier et al. [30] reviewed the data from schools in the state of Washington. Of the 407 high school principals polled, 118 (29%) responded and 64 (54%) had AED programs. Their data estimated the probability of AED use in a Washington high school to be 1 in 154 schools per year. However, only 25% of the responding schools coordinated AED implementation with an outside medical agency, and only 6% coordinated an Emergency Action Plan (EAP) with local EMS. These authors speculated that this poor compliance with the AHA guidelines likely was a result of reliance on donated funds for AED implantation and a lack of funding to generate a true EAP. In 2007, a follow-up study by Lofti et al. [23] was performed in the state of Washington to assess the epidemiology of cardiac arrest in all school settings, with a special focus on school AEDs. The study was focused on Seattle and King County between 1990 and 2005. During this study, 97 cardiac arrests occurred in schools (0.4% of all arrests and 2.6% of public location arrests). Of these cardiac arrests, 12 occurred among students, 33 among faculty and staff, and 45 among adults not employed by the school. The data of Lofti et al. [23] showed that overall, school-based cardiac arrests occurred in 1 of 111 schools annually, with 1 arrest per 8 colleges per year, 1 arrest per 125 high schools per year, and 1 arrest per 200 preschools/middle schools per year. On the basis of these data, the estimated annual incidence of SCA was 0.18 per 100,000 person years among students and 4.51 per 100,000 person years among faculty and staff. By 2005, 18% of the schools in Seattle and King County had AED programs. In this population of schools, overall survival after SCA was 39%, and nearly 80% of the patients with SCA in this study presented with documented ventricular fibrillation or tachycardia.

The Wisconsin Experience In southeastern Wisconsin, a series of SCD and SCA episodes over an 11-month period in 1999 led to an interest in

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primary and secondary prevention aimed toward SCA. The episodes in five previously asymptomatic teenagers resulted from arrhythmogenic right ventricular dysplasia, left coronary artery arising from the right sinus of ValSalva, and hypertrophic cardiomyopathy in the three patients who died and from left coronary artery arising from the right sinus of ValSalva and long QT syndrome in the two patients who survived after the episode or episodes of SCA. Project ADAM (automated defibrillators in Adam’s memory) was born out of the aforementioned initial interest and concern, starting in November 1999. The goals of Project ADAM are three-fold: (1) education with regard to warning signs, such as important symptoms and pertinent family history, (2) advocacy for high school student education and CPR training before graduation, and (3) establishment of CPR-AED programs in the schools of Wisconsin state. Project ADAM, based at Children’s Hospital of Wisconsin, has attempted to achieve its educational goals via meetings and powerpoint presentations aimed at various groups including students, teachers, school nurses, parents, coaches/athletic directors, school nurses, physicians, and other health care professionals. A Project ADAM manual has been developed that describes a step-by-step approach outlining how individual schools might go about organizing and establishing a school CPR-AED program. To date, Project ADAM CPR-AED programs have been placed in more than 800 schools within Wisconsin state, representing approximately 30% of all the state schools. A survey was sent recently to all schools in the state to gather updated and detailed information from the sites, including updated numbers. In addition, affiliated Project ADAM sites have been established in several other states including Georgia, Florida, Pennsylvania, Illinois, Washington, Alabama, and Texas, with several other states interested in or close to becoming affiliate sites. Several of the affiliated Project ADAM programs are based at regional children’s hospitals. In 2009, J. Wilson (personal communication) did a preliminary review of high schools in the state of Wisconsin via an online survey. He found that 59% of the high schools responded to the survey and that 93% of these had school CPR-AED programs. Survival after an episode of SCA in a high school that had a CPR-AED program was 46%, modestly higher than the poor OHCA survival rate for children and adolescents reported in the literature [10, 13]. Additional important data for southeastern Wisconsin include data from the Milwaukee Public School (MPS) system, the largest school district in the state of Wisconsin. The MPS system has a total of 207 schools including 121 elementary schools, 58 middle schools, 12 high schools, 7 combined middle and elementary schools, and 2 schools with elementary through high school grades. All the Milwaukee public schools (100%) have CPR-AED programs.

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Since the inception of Project ADAM in 1999, 12 lives saved in southeastern Wisconsin can be directly attributed to Project ADAM. Six of the lives saved have involved children and adolescents (mean age, 14 years), and six have involved adults (mean age, 54 years). There are several important lessons to be learned from these examples of aborted SCA.

Additional National Data The potential outcome benefits associated with school CPR-AED programs was published by Drezner et al. [14] in 2009. These authors reported on the effectiveness of emergency response planning for SCA in United States high schools with CPR-AED programs. This study was a cross-sectional analysis in which a representative from each school in the United States was asked to complete a comprehensive survey to assess its emergency response planning and to profile the details of any AED used in an episode of SCA. A total of 1,710 high schools with an onsite CPR-AED program responded and were analyzed further. Of the schools that responded, 83% had an established emergency response plan for SCA. Interestingly, only 40% of the schools practiced and reviewed that plan on an annual basis. Also of interest, CPR training varied among the staff (coaches 80%, school nurses 75%, administrators 64%, and teachers 49%); as did the degree of AED training (coaches 72%, schools nurses 71%, administrators 63%, and teachers 45%). In the same study [14], 36 (2.1%) of the 1,710 schools reported a case of AED use for an episode of SCA during the assessment period from July 2006 to July 2007. Of the 36 SCA victims, 22 were older nonstudents (spectators, teachers, staff, coaches, officials) with a mean age of 57 years, whereas 14 were high school students with a mean age of 16 years. For 35 of the 36 SCA cases, witnesses were present, and 34 of the 36 SCA cases received bystander CPR. A school’s AED was deployed in 30 of the 36 cases. Multiple shocks were administered in 12 of the cases. Interestingly, the survival to hospital discharge after SCA in high schools that had a CPR-AED program in this study was 64% (9 of 14) for student athletes, 64% for nonstudents (14 of 27), and 64% overall (23 of 36). Again, this is significantly better than the very low survival rate reported in the literature for OHCA among children, adolescents, and adults. Although this study had certain limitations, the results compare favorably with outcomes in other PAD studies including OHCA survival for AEDs in casinos (48%) [33], airlines (36%) [29], airports (52%) [5], and National Collegiate Athletic Association Division I Universities (54%) [11]. The study of Drezner et al. [14], the largest


investigation of emergency planning and AED use for SCA in U.S. high schools, demonstrated a high survival rate for both students and nonstudents. Despite the current recommendations for development of resusciation programs in schools, a number of significant barriers remain. The most frequently cited barrier to program development remains the financial burden of implementation. Although findings have shown school-based AED programs to be cost effective in the past [4], school programs function within significant budget constraints. Even when schools in the Boston area were provided with an AED to help jump-start their program, development beyond this initial device remained limited, with budget constraints as the most cited reason [16]. Even with the purchase of an AED for school use, the analysis of AED program implementation in Washington state by Rothmier et al. [30] found that adherence to AED guidelines often is incomplete, particularly the coordination of health care providers with EMS services. Although legal liability was a concern in the past, state and federal Good Samaritan laws in all 50 states and the Cardiac Arrest Survival Act have provided limited immunity for individuals responding to an arrest [17].

Other AED Uses and Methods In addition to the school setting, use of AEDs in home settings have been reported, including the application of wearable AEDs for children as secondary prevention of SCD. These applications have been limited to patients at risk for ventricular tachycardia or fibrillation in whom implantable cardioverter-defibrillator (ICD) implantation at the time may not have been possible. A few studies have evaluated home AED use for adult patients [15, 22], and AEDs currently are being developed for home AED applications [28]. To date, only a few reports have described ventricular tachycardia or fibrillation treated successfully in an infant using a home AED [1, 9, 19]. Additionally, two studies to date have investigated the use of wearable AEDs in pediatric populations [6, 18]. Neither study included an appropriate shock administered to a patient, so device efficacy for children cannot be reliably established. However, only one patient reported an inappropriate shock, and one patient had therapy failure secondary to device–device interaction [6]. The compliance rate varied between the two studies, so the risk of device unavailability during SCA remains unclear. Although pediatric application of wearable AEDs is considered off-label use by the Food and Drug Administration, these devices may represent an additional option for patients whose risk for SCA remains unclear and may

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not completely warrant ICD implantation or patients for whom ICD implantation is not feasible at the time.

Conclusions and Summary In summary, SCA among children and adolescents in the school setting remains an issue of high public concern, with increasing support for the development of early CPR-AED programs to ensure rapid response and resuscitation. School-based CPR-AED programs can start from grassroots origins, can save the lives of both children/adolescents and adults, and can gain momentum, with ascent to the national scene. It is hoped that further implementation of school CPR-AED programs, including the development and adoption of lay public CPR education, will result in timely intervention and the saving of many more lives.

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