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Automated External Defibrillators in Public Areas :
The Evidence And Opinion
20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Nalinas Khunkhlai MD FRCPT(Emergency Med)Scientific chairman
Thai Resuscitation Council
Department of Emergency Medicine
and Narenthorn EMS Center,
DMS, MOPH
THAILAND
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Conflict of Interest statement :
None
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Cardiac arrest : By location
OHCA IHCA
Residential
~65%Public
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Survival rate?
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Cardiac arrest statistics : US
US OHCA survival Adult (%) Children (%) Overall (%)
Bystander witness + VFSurvival to discharge 28.4 57.1 28.4
- From survey , 79% Public knows what to do.
- 98% recognised for shock the heart back to normal.
- 60% familiar with CPR
- 60 % were treat by EMS ~40% bystander CPR with AED
- For EMS treat group : 23% VF
Circulation 2013 : 127; 000-000
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Cardiac arrest statistics : Asia
- Largest database came from Japan, Korea, Singapore and Taiwan.
- Bystander CPR rate varies among countries.
- Available OHCA data . For IHCA - very limited.
PAROS Investigators group.
OHCA AsiaBystander CPR
(%)AED (%)
Overall survival + CPC 1-2 (%)
Korea 42.4 0.3 3
Japan 40.2 0.7 2.8
Singapore 24.3 1.1 1.7
Malaysia 22.6 NA NA
Taiwan 19.8 NA 3
Thailand 15.8 0.3 1.7
UAE 10.5 0.8 3
Overall 38.3 0.6 2.8
Asian OHCA survival Adult (%) Children (%) Overall (%)
Bystander witness + VFSurvival to discharge Unknown
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Lesson learned from PAD program.
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
VictimRescuer AED
Out of hospital part
From chain of survival.
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
AED is good
Only when the
Rescuer can find them
!!!!
Lesson No.1= can’t find
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Resuscitation 84 (2013) 910-914
Philadephia : Located the AEDs.
- Philadephia : 1420 buildings Door-to-Door survey
- 12% of buildings report AEDs in place.
- Confirm by visualization and photo for 53%. ….
Others : employees refused access.
(Average 67% of buildings allow public access.)
- In the building with AED : need to contact at least 2 employees
(range 1-8) before take the AED for use.
- Average time to get AED 4 minutes (range 1-55)
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
AEDs were placed in the place which
mostly restrict access.
Resuscitation 84 (2013) 910-914
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Copenhagen 1994-2011 : OHCA in public places
- AEDs registered with Danish
AED Network,Denmark.
- Mark decrease accessibility
in evening and Night time.
and weekdays.
Malta Hansen et al. Circulation. 2013; 128:2224-2231
Lesson No.2 = can’t get
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Malta Hansen et al. Circulation. 2013; 128:2224-2231
Copenhagen 1994-2011 : OHCA in public places
- AEDs hardly access during non-weekday-daytime.
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Lesson No.3 = can’t plan
What data is need before the planing?
point of risk for OHCA
vs
Place for AED
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
PAD in Toronto :
GIS modelling to match cardiac arrest location
with possible AED sites
A.A. Siddiz et al Resuscitation 84 (2013) 904-9
- 15,786 OHCA non traumatic cases in Great Toronto.
- 1,754 (12%) arrest in public locations.
- 1,310 cases in Toronto Only.
- 44.4% Bystander Witness
- 38.1% Bystander CPR
- 5.3% Bystander AED
- 32.1% Shockable rhythm
- 12.2% Survival to hospital discharge
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
A.A. Siddiz et al Resuscitation 84 (2013) 904-9
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Best coverage calculation at 100 AEDs with 40% cases area coverage
A.A. Siddiz et al Resuscitation 84 (2013) 904-9
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
At Ratio 1 AED for 40 m.
- Increasing coverage from 15% to 20 % needs 70 AEDs
At Ratio 1 AED for 100 m.
- Increasing coverage from 15% to 20 % needs 15 AEDs
A.A. Siddiz et al Resuscitation 84 (2013) 904-9
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Lesson No.4= can I?
Previous MI
Should I have AED at home?
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Home use of AED for Sudden cardiac arrest
Home Automated External Defibrillators Trial : HAT Investigators NEJM 2008; 358: 1793-804
- 7000 anterior MI , who were not candidates for ICD
- Control group = Call EMS + perform CPR
- AED group = Use AED + then call EMS + perform CPR
Primary outcome = death (any cause)
Control 6.5% vs AED 6.4%
HR AED 0.97
(95%CI 0.81 to 1.77 , p 0.77)
Home AED did not improve overall survival ,
compared to conventional resuscitation methods.
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Factors to make maximum benefit
from having AEDs
VictimRescuer AED
Register
maintain
easy access
quality control
in touch with local
emergency centre
High
‘possible victim’
traffic
High risk activity
(sports)
local officer as
response FR
volunteer rescuers
High density
Willing & knowledge
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
AED placement ? : the magic numbers
- High Incidence sites ?( ≥ 1 arrest per 30 sites in 1 year)
- Low Incidence sites ?( ≤ 1 arrest per 100 sites in 1 year)
- Places of high flow of possible victims ( ex. Airport / prison /
shopping malls )
- Places of high risk activities ; physical (sports center) or
mentally (casino).
Becker L. et al. Circulation 1998; 97:2106-9CB Lo. Hong Kong Med J (9) 2003; 114-8
Should analyse your area incidences
Strategic plan
before deploy.
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Current situation of PAD program in Asia
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Situation of PAD program in Asia
- Japan
- Korea
- Taiwan
- Singapore
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
NEJM 2010; 362:994-1004
- All-Japan Utstein Registry ; 2005 to 2007
- 312,319 adults OHCA
- Presumed cardiac + Bystander witness + Initial VF = 12,631 (4%)
- Of 12,631 OHCAs, 3.7% AED by Layperson.
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Temporal trend of
Public OHCA : Japan
1113
19
0
5
10
15
20
25
2005 2006 2007
OHCA : Bystander CPR+ witness + VF
Survival to hospital discharge with CPC1-2 (%)
2429
34
0
9
18
27
36
45
2005 2006 2007
OHCA : Receive AED shock
Survival to hospital discharge with CPC1-2 (%)
NEJM 2010; 362:994-1004
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
24
29
34
0
9
18
27
36
45
2005 2006 2007
OHCA : Receive AED shock
Survival to hospital discharge with CPC1-2 (%)
Time from collapse to 1st shock (min)
3.73.2
2.2
NEJM 2010; 362:994-1004
PAD Japan
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Murakami et al. J Am Heart Assoc. 2014; 3: e000533
OHCA outcomes after PAD era in Osaka
- Osaka, Japan. From 2005 through 2011.
- 9453 bystander witnessed OHCA.
- 9.5% occurred in public place
- Mean time from collapse to shock = 5 min
Trends in proportion of Public AED use by laypersons,
bystander witnessed OHCA
AEDs use from 2005 to 2011
2005 2011
Railway 0 41.2
Sports
facility0 56.5
Proportion of good CPC (%)
Sports
facilitySchool Railway
Public
building
51.6 41.9 28 23.3
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
PAD in Korea
Hyun Soo Chung Resuscitation 84 (2013) e95-e96
Using Digital Signage stand
with AED inside
Seoul , August 2011
Benefit :
- 1. cost : get money from
advertising.
- 2. user-friendly , easy to learn
- 3. more approachable to
small-scale communities
Ads
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Marcus EH Ong et al. Resuscitation 2008; 76,388-396
Singapore : PADS Phase I
Geographic information systems for planning
Public Access Defibrillation?
Distribution of OHCA were different
compare day time to night time.
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Singapore : Public Education / AED registry
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Taipei : Geospatial analysis of OHCA / 7-11 coverage
- Green dot = OHCA
- Purple dot = 7-11 location
- Orange dot = Fire station
Chung-Yuan Huang, Tzai-Hung Wen. Computational and Mathermatical methods in Medicine.
May 2014
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Taipei : Geospatial analysis of OHCA / 7-11 coverage
Chung-Yuan Huang, Tzai-Hung Wen. Computational and Mathermatical methods in Medicine.
May 2014
Comparison of coverable OHCA rates for different
AED service range when 7-11 is limit to 100 stores
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
VictimRescuer AED
Conclusion
PAD program returns the good survival
chance
Only with initial area assessment
continuous monitoring
and re-evaluation.
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20 th ASEAN Federat ion of Card iology Congress 2014, June 12th -15th, Kuala Lumpur, MY
Thank you