Cardiac arrest.Defibrillation in our offices can saves lives

révention
en pratique médicale
Cardiac arrest
Defibrillation in our offices can save lives
A patient suffers a cardiac arrest (CA) in our office. We only have a few
minutes to save him. Are we able to intervene? How do we deal with
this situation?
In Montreal, from January 1999 to December 2001, 12 patients suffered CA in their physicians' offices or clinics.Two patients were successfully revived.In the first case, the clinic had a defibrillator; in the second,
ambulance technicians arrived on the scene in 6 minutes. For a physician to witness CA in his or her clinic is rare. Nonetheless, we are compelled to reflect on developments in cardiopulmonary resuscitation
that greatly simplify the procedure. The goal of this article is to inform
physicians, general practitioners and specialists of these new trends in
reanimation and of the consensus surrounding international norms.
Cardiac arrest and defibrillation
Cardiovascular diseases are the main
cause of death in the country and in
Quebec. More specifically, ischemic
heart disease is responsible for the
majority of deaths in our society:
19.5% of the population die of this disease.1 Although many of these people
previously suffered from angina or
myocardial infarction, the first manifestation of the disease results in death in
50% of victims. In Montreal and Laval,
an average of 1140 people die every
year following a cardiac episode. A
review of the literature shows that a vast
majority of cases of CA are caused by
ventricular febrillation (VF), a usually
fatal arrhythmia for which a simple and
effective treatment exists: defibrillation.
When used quickly, that is, within five
minutes of the victim collapsing, a
defibrillator can detect ventricular fibrillation in 70% to 90% 2 of patients.
When cardiac arrest victims receive
defibrillation within the first five minutes after they collapse, 38% to 65%
survive to be discharged from the hospital. Some victims of CA are struck
down in our offices. Having to wait for
the emergency medical technicians to
arrive before administering defibrillation reduces a patient's chances of survival to 3.5%. 3 The Dicaire report
(2000) called attention to this deficiency in the health and social services network, especially in medical and dental
clinics.
The most important factor for the survival of a victim with ventricular fibrillation is the time lapse before defibrillation is delivered. Survival rates of individuals suffering cardiac arrest decrease
by approximately 7% to 10% for each
minute that passes without defibrilla-
S e p t e m b r e 2 0 0 P4 r é v e n t i o n e n p r a t i q u e m é d i c a l e , J a n u a r y 2 0 0 5
1
tion.4 For this reason, all ambulance
technicians in Quebec have been
trained in defibrillation to ensure they
can deliver this treatment before transporting the victim to hospital. However,
even the most outstanding medical
emergency technicians in North
America rarely arrive on time to save a
victim of cardiac arrest. This is the reason why almost all emergency medicine groups agree on one point: the
treatment of CA must include rapid
access to defibrillation, and professionals
on site are in the best position to act
quickly.5, 6, 7, 8,9, 10 This holds even more
true when health professionals who are
with the victim are physicians on call.
Defibrillation is an accessible and
affordable treatment. Automated
external defibrillators (AED) with the
capacity to precisely diagnose treatable arrhythmia are now available.
Prices vary between $2500 and
$5000, and only a few hours of training are required to learn how to use
one. These devices can resuscitate up
to 65% of VF victims. Using an AED
is very simple, safe and effective, and
in some provinces, defibrillation is
no longer a medical act but rather a
first-aid procedure. In Québec, several companies and public places
expressed a desire that their first-aid
teams offer defibrillation together
with cardiopulmonary resuscitation.
An agreement has been reached with
the Collège des Médecins du Québec
to allow non-physicians to administer
defibrillation if they are given up-todate AED training, and if they are
registered with the medical directors
of pre-hospital services in their
regions.
AED devices
Automated External Defibrillators (AED)
are very simple defibrillators programmed
to guide users based on a systematic ABCD
approach. The device automatically analyses arrhythmia and then advises the operator
to administer a shock when defibrillation is
needed. Several models of AEDs have been
approved by Health Canada11. The effectiveness of AEDs in converting ventricular
fibrillation (VF) into a normal heart rhythm
varies between 90% and 100%, after a
series of one to three shocks. Their sensitivity
to ventricular fibrillation varies from 97%
to 100%, whereas their specificity fluctuates between 96% and 100%. A study of an
airline company who has made mandatory
the use of AED for all unconcious individuals
determined that the VF detection rate was
100%12. Moreover, the device detected regular cardiac activity and never proposed
defibrillation in patients who did not suffer
CA. There are no complications in 200
uses.
Physicians who are not very familiar with
treatment for patients in CA do not have to
be experts in ACLS (Advanced Cardiac
Life Support), or have sophisticated and
expensive defibrillator monitoring units in
their offices. In the rare but tragic event that
a patient is in cardiac arrest in a clinic, having
a AED gives the victim a real chance of
surviving. A number of patients regain consciousness if defibrillation is administered
within the recommended time frames. For
others, ongoing basic cardio-pulmonary
resuscitation with DEA analysis every
minute (the device guides the user throughout the procedure) constitutes the best treatment while waiting for emergency services
to arrive.
AED training
Since defibrillation is a medical act, physicians have a vested interest in administering
it. Just as for any other medical act, it is our
professional responsibility to develop and
maintain our skills. Non-physicians must
undergo training to learn to use automated
external defibrillation devices. Individuals
already certified in cardiopulmonary resuscitation get 4 hours of training; for others,
the training period is longer but generally
lasts less than 8 hours. A yearly refresher
session is mandatory. AED training is readily available and inexpensive.
Public access programme
The Urgences-santé Corporation realises
that for every patient in distress, rapid
response and an ability to provide advanced
care are essential to the person’s survival.
However, for victims of cardiac arrest, the
evidence shows that care providers already
on site offer victims the best chance of survival. In light of this fact, Urgences-santé
has launched a public access programme to
defibrillation. The goal of the programme
is to facilitate logistical and medico-legal
procedures so that teams of care providers
can offer defibrillation in settings where
there is greater risk. Currently in Montréal,
over 40 groups of respondents who have
one or several AED are registered with
Urgences-santé. They are external to the
health care network.
For physicians who would like their clinics
to be safe places with access to defibrillation, Urgences-santé can provide AED
training to their staff, as it does for other
partners in the health care network.
Organisations offering training sessions
Health care network in Montréal and Laval
• Urgences-santé (514-723-5763)
www.urgences-sante.qc.ca/trousse/defibril.asp
General public and first-aid attendants
• Heart and Stroke Foundation of Québec (514-871-1551)
www.santeducoeur.org/ Soins.php
• The Canadian Red Cross Society (1-800-592-7649)
www.redcross.ca
• St. John’s ambulance (514-842-4801)
www.sja.ca/english/about_us
A recent survey has shown that only 11
of our 29 CLSCs have defibrillators.
What, then, is the situation in clinics and
polyclinics? In Montréal, as part of an
agreement reached with Urgences-santé,
over 40 non-medical teams offer defibrillation. More and more companies, fitness
centres (e.g. 14 Nautilus centres) and
public places are acquiring these devices
and training their non-medical staff to
use them. As physicians, we need to
reflect on this, since cardiac arrest is the
first cause of death in our society.
1 FMCC : Fardeau croissant des maladies cardiovasculaires et des accidents vasculaires cérébraux au Canada, 2003. Ottawa, Canada, 2003.
2 Holmberg et Holmberg. Incidence, duration and survival of ventricular fibrillation in out-of-hospital cardiac arrest patients in Sweden.
Resuscitation 2000; 44: 7-17.
3 Taux de survie d’Urgences-santé (1994-2003), ACR témoignés (FV, FV
disparues, asystolie, AESP) : 3,5 % auront congé de l’hôpital. Pour le
39 % qui encore en FV à l’arrivée des techniciens ambulanciers, ce
taux monte à 9 %.
4 Larsen MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting
survival from out-of -hospital cardiac arrest: A graphic model.
Annals of Emergency Medicine 1993; 22: 1652-1658.
5 ILCOR: Circulation 2000; 102(suppl. I).
6
7
8
9
10
11
ERC: Resuscitation 1998; 37: 91-94.
AHA: Circulation 1998; 97: 1309-1314.
FMCC: Canadian Journal of Cardiology 1998; 14(1): 31-32.
ACEP: Annals of Emergency Medicine 1999; 33(3): 371-372.
ACMU: Canadian Journal of Emergency Medicine 2001; 3(4): 269-270.
Cardiac Science PowerHeart, FirstSave, Medtronic Physio-control
Lifepak 500, Lifepak CR-plusPhilips HeartStart FR2+, HeartStart
OnSite Welch Allyn AED 10 and AED 20 Zoll AED-Plus.
12 Page et al. NEJM 2000; 343: 1210.
révention
en pratique médicale
A publication of the Direction de santé publique
de Montréal in collaboration with the Association
des médecins omnipraticiens de Montréal as part of the
Prévention en pratique médicale programme, Information
component, coordinated by Doctor Jean Cloutier.
Editor-in-chief and texts: Dr. Isabelle Samson
Editor: Deborah Bonney
Graphic design: Manon Girard
Translation: Sylvie Gauthier
Contributors: Urgences-santé
Consultant: Dr. Martin Juneau,
Montréal Heart Institute
1301 Sherbrooke Street East, Montreal, Quebec H2L 1M3
Telephone: (514) 528-2400
http://www.santepub-mtl.qc.ca
email: [email protected]
ISSN (printed version): 1481-3742
ISSN (on-line version): 1712-2945
Legal deposit — Bibliothèque nationale du Québec, 2004
Legal deposit — National Library of Canada, 2004
Agreement number: 40005583
Association
des Médecins
Omnipraticiens
de Montréal
Prévention en pratique médicale, January 2005