Clinical Pearls & Morning Reports
Published December 4, 2019
Physicians have a role in helping to make the lay public aware of the importance of bystander contribution to favorable outcomes for people with out-of-hospital cardiac arrest. In addition, although physicians are not directly involved in bystander response to cardiac arrest, they should know how to support these resuscitation efforts, encourage appropriate education for lay providers, and advocate for placement of automated external defibrillators (AEDs) for public access. Read the review article here.
Q: How often is bystander cardiopulmonary resuscitation (CPR) provided in cases of out-of-hospital cardiac arrest?
A: Unfortunately, bystander CPR is provided in fewer than half of cases; AEDs are used even less often, in no more than 25% of appropriate patients, even though they are frequently available in public places. It is estimated that only approximately 2.4% of the U.S. population undergoes CPR training each year.
Q: Describe one of the primary reasons that bystanders do not provide CPR in out-of-hospital cardiac arrest.
A: One of the primary reasons for infrequent bystander intervention in out-of-hospital cardiac arrest is that lay rescuers may fail to recognize cardiac arrest. Cardiac arrest may be mistaken for syncope or seizure. Educational efforts should be targeted at helping the lay public understand that persons with cardiac arrest can initially have seizurelike activity or abnormal respirations and that every effort should be made to minimize delays in initiating care.
A: While instructions are being relayed by telephone, the dispatcher can alert others in the community about the cardiac arrest through text messaging and other smartphone-based applications. This approach notifies lay responders who have voluntarily agreed to join these digital response efforts of an occurrence of out-of-hospital cardiac arrest in their immediate vicinity, provides information about the arrest and location, and, in some cases, alerts them to the presence of adjacent public-access AEDs. Although this is a new strategy, early investigations are promising; studies have shown increased frequency of early CPR and associated improved survival and functional status among survivors. This strategy is formally supported by the American Heart Association. The dispatcher may have the ability to send an AED to the scene by drone. This approach is still investigational, but early system modeling suggests that an AED can arrive at the scene considerably earlier by drone than by standard emergency medical services (EMS) vehicle, with the time to arrival at the scene of the cardiac arrest reduced by 6 minutes in urban settings and by 19 minutes in rural settings.
A: Although AEDs offer many benefits, there are challenges to their use by lay providers. Studies suggest that even in regions in which active efforts have been made to position public-access AEDs widely, less than 10% of out-of-hospital cardiac arrests occur within 100 m of an AED. Furthermore, many AEDs that are installed in the community are located inside buildings such as schools, business offices, and sports facilities that are not accessible to the public during evenings, at night, or on weekends. In addition, when the ability of untrained laypersons to operate AEDs was evaluated, substantial variation in ability was observed. Both graphical and audible directions for defibrillator pad placement are important. Finally, although AED use is potentially lifesaving, operating an AED may cause the bystander to be distracted from performing CPR.