American Airlines follows Qantas's lead. FDA-designate

1
Friendly skies?

• Richard L Page MD
• Associate Professor of Internal Medicine
• Director, Clinical Cardiac Electrophysiology
• University of Texas Southwestern Medical Center
• Dallas, TX

2
In-flight cardiac care
Qantas success story
Qantas installed portable semiautomatic external
defibrillator devices (AEDs) in 1991 on all its
international Boeing 747 and 767 aircraft and at
major Qantas airport terminals. In the 65 months
after these devices were installed, 46 incidents
of cardiac arrest were treated, 27 in aircraft.
27 passengers went into cardiac arrest and were
treated with the AED on board the aircraft. 6 of
the 27 went into ventricular fibrillation (VF).
The defibrillator worked in 5 of the 6. Two of
them survived, apparently saved by the
defibrillators. 19 cases of cardiac arrest were
reported at the airports 17 of those went into
VF and defibrillation worked on all 17.
3
In-flight cardiac care
American Airlines follows Qantass lead
By July 1997, AEDs were deployed on all
international flights and certain domestic
over-water routes main flight attendants or
pursers were trained to use the defibrillators in
the event of an in-flight medical emergency. By
the end of 1998, all 649 Americans jet aircraft
had defibrillators on board, and all 24,000
flight attendants had been trained to use the
AED. 
4
FDA guidelines
AED indications

• FDA-designated indications for AED placement
• full loss of consciousness
• an absence of breathing, or
• absence of pulse

Physicians present can request that an AED be
used as a monitor because the device has a
monitor screen. If the device is used as a
monitor, it can then be placed outside of the
typical or more strict indications.
5
American Airlines study
204 cases of AED use

• In 69 of cases a physician was present.
• In 42 of cases loss of consciousness was
  documented.
• Rhythms associated with death were seen in 28 of
  the 204 patients
• 14 of the 28 had agonal rhythm
• VF was documented in 14 of the 204 patients
• shock was administered in 13 patients
• relatives of 1 terminally ill patient refused
  treatment
• In 2 cases where shock was administered, the EKG
  recording was not available for analysis, but it
  is likely that VF was present.
• Of the 15 patients who received shock for VF, 6
  (40) were discharged from hospital to lead full
  functional lives.

Richard L Page MD, presented at the 21st Annual
Scientific Sessions of the North American Society
of Pacing and Electrophysiology (NASPE),
Washington, DC
6
American Airlines study
AED effective and safe
A 40 resuscitation from VF compares favorably
with any EMS system. In many cases, the device
was placed on passengers with fatal rhythms, and
often without full loss of consciousness but in
no case did the AED recommend or deliver shock
inappropriately. Even in the isolated environment
of the aircraft the device worked well for VF and
was safe even if used when VF was not present.
7
Using the AED
Idiot-proof technology
Remove the adhesive backing and place the 2
electrical patches (not paddles) on the bare
chest. Turn the device on. The device reads the
heart rhythm and gives both a verbal and a
display recommendation to shock if ventricular
fibrillation (VF) is detected. If a shock is
recommended, the person operating the AED will be
instructed to stand back and push the flashing
red button to deliver the shock. The AED will
not deliver a shock if it does not detect
VF. After the shock, the device re-analyses the
electrograms and determines whether another shock
is recommended.
8
American Airlines study
Reliable shocks
In 204 AED uses, the device never inaccurately
recommended a shock, and never failed to detect
VF that required a shock. In most uses, after
tracking the heart rhythm, the device determined
no shock was required. All but 1 patient was
shocked out of VF with a single shock. The only
case that didn't convert with a single shock
converted with a second shock.
Robert C Kowal MD, presented at the 21st Annual
Scientific Sessions of the North American Society
of Pacing and Electrophysiology (NASPE),
Washington, DC
9
Shockable rhythms
Differences between airlines
AED can terminate VF, but survival is effected by
the condition of the heart and the time the
patient has been down. A flat line or agonal
rhythm may imply that the patient was in arrest
long before it was recognized or that the heart
is so sick that it can't be resuscitated
patients who persistently came out in an agonal
rhythm died. American Airlines had more
shockable rhythms than Qantas, possibly because
of the duration of the flights. On the longer
Qantas flights, where more people were found in
agonal or slow rhythms, it is more likely that
passengers are assumed to be asleep, when they
may be dead. This lack of recognition may account
for the higher percentage of slow heart rhythms
seen on airlines than in public places where
people are moving around.
10
Children vs EMTs
Study design
With the use of a mock cardiac arrest scenario,
AED use by 15 6th grade children was compared
with that of 22 emergency medical technicians
(EMTs) or paramedics. The primary endpoint was
time from entry at the cardiac arrest scene to
delivery of the shock into simulated ventricular
fibrillation. The secondary endpoint was
appropriateness of pad placement. All
performances were videotaped to assess safety of
use and compliance with AED prompts to remain
clear of the mannequin during shock delivery.
Gundry JW, et al. Circulation 19991001703-1707
11
Children vs EMTs
Study results and conclusions
Electrode pad placement was appropriate for all
subjects. All remained clear of the patient
during shock delivery. The speed of AED use by
untrained children was only modestly slower than
that of professionals. The difference between
the groups is surprisingly small, considering
that the children were untutored first-time
users. These findings suggest that widespread
use of AEDs will require only modest training.
Gundry JW, et al. Circulation 19991001703-1707
12
Survival statistics
Response time key to survival
Every day more than 600 Americans died from
cardiac arrest. Chance of survival is reduced by
10 for every minute of waiting. All too
frequently, by the time the paramedics arrive and
defibrillation is performed it is too late to
save the patient. Any reasonable individual can
probably obtain enough information from the AED
instructions to administer treatment, which would
be better than waiting for emergency
assistance. According to estimates by the
American Heart Association, 30 of Americans
suffering from cardiac arrest could be saved by
immediate treatment with AEDs.
13
Cardiac Arrest Survival Act
The House of Representatives passed a bill in
1999 that directs the Department of Health and
Human Services to develop guidelines for
installing AEDs in federal buildings, and
granting legal immunity to those who use
them. President Clinton proposed a new Federal
Aviation Administration (FAA) rule that would
require all commercial airplanes with at least 1
flight attendant to carry an AED on international
and domestic flights.
http//thomas.loc.gov/cgi-bin/bdquery/z?d106h.r.0
2498
14
Immunity for AED users
The Cardiac Arrest Survival Act of 1999 provides
that any person who provides emergency medical
care through the use of a defibrillator, any
person who maintained, tested, or provided
training in the use of the device, any physician
who provided medical oversight of the device, and
the person who acquired the device (if specified
conditions have been met) is immune from civil
liability for any personal injury or wrongful
death resulting from the provision of such care,
unless the person engaged in gross negligence or
willful or wanton misconduct under the applicable
circumstances.
http//thomas.loc.gov/cgi-bin/bdquery/z?d106h.r.0
2498
15
Chest compression vs CPR
A Seattle study conducted between 1989 and 1998
looked at 520 episodes of cardiac arrest. In a
randomized manner, telephone dispatchers gave
bystanders at the scene of apparent cardiac
arrest instructions in either chest compression
alone or chest compression plus mouth-to-mouth
ventilation. Complete instructions were delivered
in 62 of episodes for the group receiving chest
compression plus mouth-to-mouth ventilation and
in 81 of episodes for the group receiving chest
compression alone. Instructions for compression
required 1.4 minutes less to complete than
instructions for compression plus mouth-to-mouth
ventilation. Time to response by emergency
services averaged 4 minutes, and all units were
equipped with automated defibrillators.
Hallstrom A, et al. N Engl J Med 2000
3421546-1553
16
Chest compression vs CPR
Results
The rates were higher in the group receiving
instructions on chest compression alone, although
the differences were not statistically
significant. Outcome was similar for both types
of instructions, but chest compression alone may
be the preferred approach for bystanders
inexperienced in CPR.
Hallstrom A, et al. N Engl J Med 2000
3421546-1553