(Circulation. 1997;96:2775-2777.)
© 1997 American Heart Association, Inc.
Articles |
Saving Lives in the Sky
From the Department of Medicine Cardiology, The University of Texas Health Science Center at San Antonio.
Correspondence to Robert A. O'Rourke, MD, Charles Conrad Brown Distinguished Professor in Cardiovascular Disease, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78284-7872.
Key Words: Editorials • fibrillation • death, sudden
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Introduction |
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 Top Introduction Arrhythmias in Sudden Cardiac...Public Access DefibrillationSudden Cardiac Death Among...The Qantas Cardiac Arrest...Cost ConsiderationsReferences |
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Sudden cardiac death is responsible for
300 000 to 400 000 deaths yearly
in the United States, depending on the definition used. When the
definition is restricted to death occurring <1 hour from the onset of
symptoms, patients included have a >90% incidence of an arrhythmic
death.1
Sudden cardiac death is commonly the initial manifestation of
coronary heart disease. It accounts for 50% of the mortality
from cardiovascular disease, which remains the main
cause of death in this country.2 Sudden cardiac death
rates in developed countries outside the United States are similar.
Approximately 75% of cardiac arrests occur at home, and about two
thirds are witnessed. The chances of surviving sudden cardiac arrest
are <10%, with most persons dying before reaching a hospital. Those
people who do survive a cardiac arrest have a good chance of living
many more years; 80% are alive at 1 year, and as many as 57% are
alive at 5 years.
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Arrhythmias in Sudden Cardiac Death |
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TopIntroductionArrhythmias in Sudden Cardiac...Public Access DefibrillationSudden Cardiac Death Among...The Qantas Cardiac Arrest...Cost ConsiderationsReferences |
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Ventricular fibrillation is the initial recorded rhythm in 40% to 70% of patients who have cardiac arrest, depending on the patient population and the time to first recording.3 4 Sustained ventricular tachycardia is the first rhythm documented in fewer than 2% of sudden death victims, but it is unknown how often it precedes and precipitates ventricular fibrillation. In 157 patients who were wearing an ambulatory ECG recorder at the time of their cardiac arrest, primary ventricular fibrillation was documented in 8%, ventricular tachycardia degenerating into ventricular fibrillation in 62%, and torsades de pointes in 13% of patients.5
Electromechanical dissociation and asystole are found in 30% to 50% of cardiac arrest patients, and their occurrence usually parallels the time interval from collapse to first monitoring of the rhythm, suggesting that it is a later manifestation of cardiac arrest.3 4 Not surprisingly, it is a more common finding in persons with unwitnessed cardiac arrests.
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Public Access Defibrillation |
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TopIntroductionArrhythmias in Sudden Cardiac...Public Access DefibrillationSudden Cardiac Death Among...The Qantas Cardiac Arrest...Cost ConsiderationsReferences |
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The most important determinant of successful cardiopulmonary resuscitation is the time interval from cardiovascular collapse to initial intervention. Because most patients are found to be in ventricular fibrillation, the time from onset to defibrillation is the key element in the acute management of the cardiac arrest victim. The chance of survival decreases 7% to 10% for each minute that defibrillation is delayed. The importance of early intervention is reflected in the "chain of survival" concept of emergency cardiac care systems: early access, early cardiopulmonary resuscitation, early defibrillation, and early advanced cardiac life support.6
Because early defibrillation appears to be the most important treatment in the chain of survival, in 1991 the American Heart Association challenged manufacturers to develop simple, low-cost automatic defibrillators for use by targeted groups and where large numbers of people congregate.7 At the AHA Public Access Defibrillation Conference of 1994, it was further recommended that an enhanced defibrillation strategy be extended to include defibrillation by minimally trained members of the public.8 Since then, considerable advances have occurred, and several manufacturers have developed small, lightweight, simple semiautomatic external defibrillators (AEDs) for use by the public.9 10 11 12
A second Public Access Defibrillation Conference entitled "Strengthening the Chain of Survival" was recently held by the American Heart Association in Washington, DC, from April 17 through 19, 1997; it was chaired by Dr Myron L. Weisfeldt. This conference addressed the present status of emergency medical services, the current technology of AEDs and optimal AED waveforms, training curricula for targeted responders in the use of AEDs, a clinical trial to evaluate public access defibrillation, regulatory considerations, and three levels of public access defibrillation (P.A. Bowser, coordinator, AHA Automatic External Defibrillation Task Force, personal communication). Level 1 applies to targeted, nontraditional first-responder defibrillation and includes defibrillation efforts by police and highway patrol personnel, lifeguards, security personnel, and airline flight attendants.
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Sudden Cardiac Death Among Airline Passengers |
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TopIntroductionArrhythmias in Sudden Cardiac...Public Access DefibrillationSudden Cardiac Death Among...The Qantas Cardiac Arrest...Cost ConsiderationsReferences |
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The number of lives lost due to cardiac arrest in commercial aircraft each year has been estimated to be as high as 1000 per year in International Airlines Transport Association (IATA) carriers.13 14 15 The incidence of sudden cardiac death in airplane passengers has likely been underreported due to the lack of mandatory reporting procedures.
The need for better data was underscored in a Chicago Tribune special report, "Code Blue: Survival in the Sky," published on June 30, 1996.14 Based on available data from foreign and US airlines, the Chicago Tribune estimated the number of passenger deaths aboard US carriers to be between 114 and 316 a year, not including sick passengers who died after being taken from the airplane. Most of the latter deaths were also likely due to cardiac arrest. This report also compared the relatively few drugs and scarcity of other medical equipment available aboard US airlines with the more extensive medical kits available on other international airlines.
Few airlines have equipped some or all of their aircraft with AEDs and trained selected aircraft personnel in the use of AEDs for the treatment of ventricular defibrillation, the usual initial arrhythmia in patients with sudden cardiac death; these few airlines include Qantas, Virgin Atlantic, and Air Zimbabwe, the latter of which is equipped with AEDs only on aircraft bound for London or Frankfort. In October 1996, the US Food and Drug Administration approved the use of AEDs for commercial aircraft. Recently, American Airlines bought 300 AEDs for use on "over water" aircraft and began an airline cardiac arrest program similar to that first initiated by Qantas.16 Hong Kong–based Cathay Pacific Airlines plans to equip all of its 60 aircraft with AEDs in the near future.
In the past, most US airline management believed that a fast landing is
"the best thing for the patient" who is severely ill. This makes
no sense for victims of sudden cardiac death considering that the time
to defibrillation is the main predictor of a successful outcome in
patients with sudden cardiac arrest and that 10% fewer patients will
survive for each minute of delay in initiating electrical shock when
ventricular defibrillation occurs. Diversion is an
unsatisfactory alternative for patients with cardiac arrest because
even under ideal conditions, an emergency landing from cruising
altitude takes 
20 minutes—longer if weather, air traffic, and other
factors are less than perfect—and 20 minutes is too long to wait for a
defibrillator.
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The Qantas Cardiac Arrest Program |
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TopIntroductionArrhythmias in Sudden Cardiac...Public Access DefibrillationSudden Cardiac Death Among...The Qantas Cardiac Arrest...Cost ConsiderationsReferences |
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In this issue of Circulation, O'Rourke (no relation to this author) et al13 report the first 65 months' experience of the Qantas Airline Cardiac Arrest Program. AEDs were installed in the major international Australian terminals and in each of the 55 aircraft by August 1992, and all flight service directors were trained to operate the device and supervise the management of cardiac arrest. Approximately 4000 cabin crew were trained in the rapid initiation of cardiopulmonary resuscitation for the victim of sudden cardiac death. Further supervision was available through volunteer physician responders en route on Qantas aircraft or remotely by Qantas medical staff in Sydney. Recently, each aircraft was supplied with an extensive Qantas medical kit that contains all the facilities for advanced cardiac life support by traveling medical practitioners who volunteer and wish to use them.
During the study period, there were 27 episodes of sudden death on
aircraft and 19 in the major Australian international terminals
attended by Qantas staff. The monitor defibrillator was used on all 46
of these persons and in 63 other acutely ill persons for monitoring
purposes. As might be anticipated, all 19 episodes of cardiac arrest
occurring in terminals were witnessed compared with just 16 of the 27
(59%) occurring on aircraft. In 8 cases, passengers could not be
aroused from sleep, and 7 of these were found to be in asystole. Not
surprisingly, 17 of the 19 patients (89%) with cardiac arrest
occurring in terminals were found to be in ventricular
fibrillation compared with only 6 of the 27 airborne passengers with
cardiac arrest; each of these 6 had a witnessed arrest. Successful
defibrillation was accomplished in 5 of the 6 airborne patients with
ventricular fibrillation, and the aircraft was diverted
expeditiously to its destination. Two of the 6 patients were long-term
survivors (2 years), with no residual neurological impairment.
Defibrillation was initially successful in 16 patients with ventricular fibrillation in terminals, and 4 of the l7 (24%) were long-term survivors. Thus, 23 of the total number of 46 persons with cardiac arrest were found to be in ventricular fibrillation. It is highly likely that the others were initially in ventricular fibrillation that degenerated into asystole.
The report by O'Rourke and associates indicates the importance of having AEDs available in airport terminals for the early ventricular defibrillation of patients who have cardiac arrest while visiting the terminals or while passengers in transit. The greater success rate in the treatment of victims of sudden death in airline terminals, where they are frequently witnessed events and there is a shorter time interval to defibrillation compared with cardiopulmonary resuscitation attempts in airborne passengers, is extremely important. A strong case can be made for requiring the presence of an AED and other medical equipment necessary for successful cardiopulmonary resuscitation in all major airline terminals based on the experience of the Qantas Airline Cardiac Arrest Program.
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Cost Considerations |
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TopIntroductionArrhythmias in Sudden Cardiac...Public Access DefibrillationSudden Cardiac Death Among...The Qantas Cardiac Arrest...Cost ConsiderationsReferences |
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In the Qantas Airline Cardiac Arrest Program, the available monitor-defibrillator device functioned well, and shocks were delivered appropriately to all patients with ventricular fibrillation and to none with sinus rhythm, idioventricular rhythm, or asystole. In response to the Public Access Defibrillation initiative of the American Heart Association, several manufacturers have developed smaller, lightweight simple defibrillators for use by the public, and the number and type of available devices are rapidly evolving. In the future, the price, weight, and complexity of these devices will likely continue to decrease; the current much reduced price is $3000 to $4000 for each AED.
The cost of supplying each aircraft and terminal with AEDs, of maintaining the equipment, and of providing additional medical supplies for advanced life support after defibrillation has been an obstacle to the more widespread use of AEDs on IATA. Additional expense also is required to train aircraft personnel in the use of AED and in maintaining that expertise. However, as indicated by the Qantas Cardiac Arrest Program experience, the monies saved by not diverting aircraft for the care of victims of sudden death who were pulseless and had no treatable arrhythmia could amount to many millions of dollars.
Also, based on the Federal Aviation Administration current valuation of $2.7 million for each human life, it has been estimated that the American Airlines AED program need save only one or two lives over the next 5 years to justify the cost of installing and maintaining AEDs and providing the expanded medical kits. The added cost per passenger would be less than 2¢ per flight over the same 5-year period.17 This certainly is an inexpensive approach to a major problem when one considers the airport tax used at many airline terminals throughout the world.
On May 16, 1997, the Honorable Barbara Kennelly of Connecticut introduced legislation to promote greater safety in commercial aviation with the introduction of the Airline Passenger Safety Act (HR 1670). This legislation would require commercial flights to carry adequate medical supplies and equipment to deal with in-flight medical emergencies. This bill would require air carriers to establish steps to be taken in the event of an emergency. It would also require airlines to carry AEDs and require each member of the flight crew to be trained in cardiopulmonary resuscitation and the use of an AED. This new legislation would also mandate that the air carriers describe what happened and what actions were taken to assist the passenger in the event of an in-flight medical emergency and report the incident to the Secretary of Transportation so the public can be fully aware of the number of in-flight medical emergencies that occur each day. Also included is a "Good Samaritan" provision that exempts from liability trained airline staff, physicians, and other medical personnel who step forward to offer assistance during an in-flight medical emergency. As previously stated, the US Food and Drug Administration has already approved the use of AEDs for commercial aircraft (as of fall 1996).
As the number of aircraft equipped with AEDs increases, the group of airline flight attendants trained in first-responder defibrillation increases, and the medical supplies necessary for advanced life support are provided on more aircraft, many more airborne victims of sudden cardiac death will be defibrillated successfully. Thus, "Saving Lives in the Sky" will become a major airline achievement rather than just an unusual experience reported by the few airlines currently involved in cardiac arrest programs.
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Acknowledgments |
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The author wishes to acknowledge Richard Kerber, MD (Division of Cardiology, University of Iowa) for his constructive criticism.
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Footnotes |
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The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.
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References |
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TopIntroductionArrhythmias in Sudden Cardiac...Public Access DefibrillationSudden Cardiac Death Among...The Qantas Cardiac Arrest...Cost ConsiderationsReferences |
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1. Goldstein S. The necessity of a uniform definition of sudden coronary death, witnessed within 1 hour of the onset of acute symptoms. Am Heart J. 1982;103:156-159.[Medline] [Order article via Infotrieve]
2. Kannel WB, Cupples LA, D'Agostino RB. Sudden death risk in overt coronary heart disease: the Framingham Study. Am Heart J. 1987;113:799-804.[Medline] [Order article via Infotrieve]
3. Green HL. Sudden arrhythmic cardiac death: mechanisms, resuscitation and classification: the Seattle Perspective. Am J Cardiol. 1990;65:4B-12B.[Medline] [Order article via Infotrieve]
4. Weaver WD, Hill D, Fahrenbruch CE, Copass MK, Martin JS, Cobb LA, Hallstrom AP. Use of the automatic external defibrillator in the management of out-of-hospital cardiac arrest. N Engl J Med. 1988;319:661-666.[Abstract]
5. Bayes de Luna A, Coumel P, Leclercq J. Ambulatory sudden cardiac death: mechanism of production of fatal arrhythmia on the basis of data from 157 cases. Am Heart J. 1989:117;151-159.
6.
Cummins RO, Ornato JP, Thies WH, Pepe PE.
Improvement in survival from sudden cardiac arrest: the `chain of
survival' concept. Circulation. 1991;83:1832-1847.
7.
Cobb LA, Elistam M, Kerber RE, Melker R, Moss AJ,
Newell L, Paraskos JA, Weaver WD, Weil M, Weisfeldt ML. Report of the
American Heart Association Task Force on the Future of
Cardiopulmonary Resuscitation. Circulation. 1992;85:2346-2355.
8.
Weisfeldt ML, Kerber RE, McGoldrick RP, Moss AJ,
Nichol G, Ornato JP, Palmer DG, Riegel B, Smith SC Jr, for the
Automatic External Defibrillation Task Force. Special Report: American
Heart Association report on the Public Access Defibrillation Conference
December 8-10, 1994. Circulation. 1995;92:2740-2747.
9. Crewdson J. Finally, the right tools to save lives in the air. Chicago Tribune, December 26, 1996.
10. Fritsch J. Cardiologists say portable defibrillators can save time and lives. The New York Times, April 16, 1997.
11. White RD, Asplin BR, Bugliosi TF, Hankins DG. High discharge survival rate after out-of-hospital ventricular fibrillation with rapid defibrillation by police and paramedics. Ann Emerg Med. 1996;28:480-485.[Medline] [Order article via Infotrieve]
12.
Kerber RE, Becker LB, Bourland JD, Cummins RO,
Hallstrom AP, Michos MB, Thies WH, White RD, Zuckerman BD. Automatic
external defibrillators for public access defibrillation:
recommendations for specifying and report arrhythmia
analysis algorithm performance, incorporating new
waveforms, and enhancing safety. Circulation. 1997;95:1677-1682.
13.
O'Rourke MS, Donaldson E, Geddes JS. An airline
cardiac arrest program. Circulation. 1997;96:2849-2853.
14. Crewdson J. Code blue: survival in the sky. Chicago Tribune, Special Report, June 30, 1996.
15. Friend T. Cardiac equipment on planes could save hundreds. USA Today, November 17:1, 1994.
16. McKenas DK. First do no harm: the role of defibrillators and advanced medical care in commercial aviation. Aviat Space Environ Med. 1997;68:365-367.[Medline] [Order article via Infotrieve]
17. Crewdson J. 1st airline in US adds heart rescue equipment: defibrillators could save scores of lives. Chicago Tribune, November 17, 1996.
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