Tuesday, August 28, 2007

Should Defibrillators Be In Schools?

Just in time for the back-to-school season comes this report on the epidemiology of cardiac arrest in our schools.

The report adds much to our knowledge of the epidemiology of sudden death in schools from two large counties near Seattle, WA, USA. Of 3773 episodes of cardiac arrest in a public domain over 16 years, 97 arrests occurred in 671 schools but only 12 of these occurred in children.

The incidence of sudden death among (adult) school staff was 25-fold greater than that among students. Given the additional contribution of other adults not employed by the school, greater than 90% of cardiac arrests in schools occurred among adults. The finding supports the assertion that school-based CPR and AED programs would benefit faculty and staff members, as well as visitors to the school who, because of their age, are at greater risk of cardiac arrest than the students.

And while some doctors are in favor of expanding CPR and AED distribution, others are not:
"It is estimated that over 350,000 individuals die of sudden cardiac arrest in the U.S. each year," said Dr. Gregg C. Fonarow, a professor of cardiology at the University of California, Los Angeles. "Improved cardiac arrest recognition and emergency activation, early CPR, and early defibrillation, including the use of AEDs, can significantly increase the chances of surviving sudden cardiac arrest."
This study provides important community-based data on the incidence, circumstances and outcome of cardiac arrest in the school setting, Fonarow said. "This study found that half of the student cardiac arrests were not associated with physical exertion or sports participation, and student risk was similar for elementary school, middle school, high school and college," he said.

The majority of cardiac arrests in schools occurred among adults, Fonarow noted. "The finding supports the assertion that school-based CPR and AED programs would benefit not only students, but faculty, staff members, as well as school visitors, and provides important data for considering increasing CPR training and the availability of AEDs in the school setting," he said.

Another expert disagrees. The very rarity of cardiac arrests at schools makes having AEDs available unnecessary, he said.

"Any cardiac arrest in a student, especially if it occurs on school grounds, gets a lot of media attention," said Dr. Byron Lee, an associate professor of cardiology at the University of California, San Francisco. "This has led some to call for AED in every school."

However, because cardiac arrest at schools is extremely rare, and only a minority of cardiac arrests occurs in the students, "it seems unlikely that putting an AED in every school would be cost-effective," Lee said.
But what was remarkable in this study was the unusually high success rates of public access defibrillation by lay rescuers. From the study:
Seven of the school-based cardiac arrests received lay-rescuer defibrillation. Survival to hospital discharge among cardiac arrests was 39% in school settings (46% for initial rhythm of ventricular fibrillation) compared with 27% in other public locations.
These data, in my view, make a compelling case for the wide availability of public access defibrillation. It is survival to discharge from a hospital that matters, and there is nothing that will improve survival in that setting better than a beating heart. The chest thumping of CPR, while helpful temporarily, only mildly improves the chance of survival following cardiac arrest until the coordinated contraction of the heart can be restored with defibrillation.


Reference: Katayoun Lotfi BS, Lindsay White MPH*, Tom Rea MD, MPH, Leonard Cobb MD, Michael Copass MD, Lihua Yin MBA, Linda Becker MA, and Mickey Eisenberg MD, PhD. "Cardiac Arrest in Schools," Circulation 2007 doi:10.1161/CIRCULATIONAHA.107.698282

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