Correspondence

The introduction of Public access defibrillation to a University community: the University of Virginia public access defibrillation program

To the Editor,

We undertook the addition of a public access defibrilla- tion (PAD) program at a large mid-Atlantic university. In our design of the system, we found little useful information to guide us in the development and construction our system. This letter addresses the issues and methodology of our approach to this important program.

Despite decades of research, education, and the flourishing of a vast array of treatment options, cardiovascular disease in its many variations continues to be the most common cause of death in the United States [1]. One particularly troubling aspect of cardiovascular disease is sudden death resulting from cardiovascular events; in fact, 75% of sudden death events are related to cardiac etiologies [2]. Of course, emergency medical services- and hospital-based strategies of management are of import, but we must also consider the treatment that can, and should, be provided before the arrival of professional medical care. This treatment includes cardiopulmonary resuscitation and Electrical defibrillation of the “shockable” cardiac arrest rhythms.

The dominant paradigm for management of sudden cardiac death over the past 4 decades, starting with the original 1974 American Heart Association guidelines for cardiopulmonary resuscitation [3], posited that the greatest chance of survival in cardiac arrest lay with more complex therapeutic interventions-involving not only the lay public but also medical personnel. This strategy, however, has been challenged recently, noting that the advanced interventions likely provide minimal benefit, whereas the more basic approach can provide the patient with the greatest chance in meaningful survival. For instance, the Ontario Pre-hospital Advanced Life Support investigators set out to determine whether the ACLS paradigm provided a Survival benefit in out-of-hospital patients with cardiac arrest [4]. Surprisingly, the study found that basic maneuvers (emergency system activation, cardiopulmonary resuscitation, and early defibril- lation) had a greater positive impact on survival than more

advanced maneuvers (parenteral access, administration of cardioactive medications, and placement of invasive airways). This article, among others, provides the justification to further the Public access defibrillation automatic external defibrillator (AED) approach to sudden cardiac death.

In establishing a PAD program in a university setting, planning, support, and funding are key elements for success; a number of factors must be considered in these important areas, including the following:

• University leadership involvement with active support
• Program funding
• Availability of appropriate personnel (coordinator, med- ical director, trainer, local site coordinator)
• Centralized program management
• Medical coordination and oversight
• Strategic placement of AED units with consistent methodology
• Awareness of local site issues (daily building function, artistic and historical considerations)
• Consistent AED type throughout system
• Quality assurance and debriefing
• Awareness of local and regional public safety agencies

A major factor in determining the success or failure of such an initiative is the early endorsement of Institutional leadership. Enlisting the assistance of senior leaders is of vital importance not only with respect to program funding but also concerning acceptance by the members of the university community. In addition, a particular organizational leader- ship structure is advised. The necessary positions include the following: medical director (medical oversight and quality control), program coordinator (program operation), local site AED coordinators (management of the individual AEDs), and cardiopulmonary resuscitation/AED training facilitator.

Selecting specific university buildings for the placement of AEDs during the process involved 3 main criteria and multiple additional considerations.

• Overall site considerations
  • High volume of persons
  • Significant presence of at-risk individuals

0735-6757/$ - see front matter (C) 2012

Correspondence

• • Potentially difficult or delayed access of public safety responders
  • Site-specific consideration
    • Located within an approximate 3-minute “foot response” area
    • Artistic and historical concerns
    • Nonobstructive to building function
    • Clearly visible to all patrons of building
    • Easily accessed by all patrons of building
    • Located adjacent to other “emergency equipment

Priority consideration was given to areas with high foot traffic volume, larger numbers of at-risk individuals, and areas with difficult and/or delayed emergency responder access. Once the buildings themselves were selected, the process of identifying specific sites within the building to place the AEDs began. Site visits were conducted to determine the best location and number of AEDs for placement within each building. Building functionality played a large role in specific site selection. Working with individual people experienced with the specific building dynamic (ie, workers, facility coordinators, etc) assisted significantly in determining where people congregate and identify high-traffic areas. We felt that AEDs should be placed in public areas that are accessible at all times of building operation; importantly, we felt that AEDs should not be placed in offices or parts of the building that will be locked and inaccessible at certain periods of building operation (eg, night and/or weekends). Finally, the AEDs should be placed in a highly visible location that is not obstructive and does not interrupt building flow. Ideally, the AED should be placed where the local workers and the public will regularly see it, think about it, and, as a result, know where to get it if the need arises. Some buildings may need more than one AED. This should be checked by physically testing whether a rescuer can go from the victim, to the AED, and back within 3 minutes. If this is found to be impossible, an additional AED was considered for that area of the building.

Lastly, local public safety agencies, including police, fire, and emergency medical services entities, were made aware of all phases of the plan. Furthermore, they were informed of the various AED locations and the specific type of unit such that equipment compatibility could be addressed prospectively.

Medicolegal issues are a very important portion of PAD consideration for all parties involved. In fact, concern for liability is the most frequent stated reason for both individual rescuers as well as various owner-leaders to avoid involve- ment in such events and programs. Such concerns must be considered from several different perspectives, including the individual rescuer, the “owner” of the AED and location of the unit, the AED coordinator/trainer, and the medical director. All states in the United States have some form of “good Samaritan” legislative protection. The reader is referred to the American Heart Association’s resource entitled “American Heart Association: AED Legislation-

241

Good Samaritan” [5]. Medicolegal specifics vary from state to state, yet the common theme is protection from legal liability for a rescuer who uses an AED in attempted appropriate fashion without “gross negligence or willful and wanton misconduct.” Furthermore, the National Cardiac arrest survival Act provides legal protection for the rescuer; this act was initially intended to offer immunity from liability for individuals in states without Good Samaritan legislation. Program coordinators and medical directors of AED, similar to the “acquirer and enabler of a PAD project,” experience variable protection from civil prosecution from state to state [5]. With respect to legal issues, the involved person (the individual rescuer, owner-leader, program coordinator, and medical director) should consult his/her legal counsel for advice and guidance in this important area of PAD implementation and operation.

Peter Whitney-Cashio MD

Melissa Sartin BA Department of Emergency Medicine University of Virginia School of Medicine Charlottesville, VA 22908, USA

William J. Brady MD Department of Emergency Medicine University of Virginia School of Medicine Charlottesville, VA 22908, USA

Center for Emergency Preparedness University of Virginia Medical Center Charlottesville, VA 22908, USA

E-mail address: [email protected]

Kelly Williamson MD

Department of Emergency Medicine

Northwestern University Chicago, IL 60611, USA

Kostas Alibertis CCEMT-P Gilbert Somers EMT-P, RN

Center for Emergency Preparedness University of Virginia Medical Center Charlottesville, VA 22908, USA

Robert E. O?Connor MD, MPH Department of Emergency Medicine University of Virginia School of Medicine Charlottesville, VA 22908, USA

doi:10.1016/j.ajem.2011.07.015

References

1. Lloyd-Jones D, Adams R, Carnethon M, et al. For the American Heart Association Statistics Committee and Stroke Statistics Committee: heart disease and stroke statistics-2009 update. Circulation 2009;119: e21-181A.

242 Correspondence

1. Brady WJ, Sochor M, O’Connor R. Cardiorespiratory arrest. In: Adams, Barton, Collings, et al, editors. Emergency medicine. Philadelphia (Pa): Elsevier; 2012.
2. American Heart Association. Standards for cardiopulmonary resuscita- tion (CPR) and emergency cardiac care (ECC). J Am Med Assoc 1974; 227:S833-68.
3. Stiell IG, Wells GA, Field B, et al, for the OPALS Study Group. Advanced cardiac life support in out-of-hospital cardiac arrest. New Engl J Med 2004;351:647-56.
4. American Heart Association. AED Legislation-Good Samaritan. www.americanheart.org.

The effect of light-emitting diodes on intubation with Vital View plastic Laryngoscope blade during a simulated resuscitation^?

To the Editor,

Recently, laryngoscope handles retrofitted with light- emitting diodes (LEDs) (Vital View II fibre optic laryngo- scope handle; Vital Signs, Inc, Totowa, NJ) became commercially available for a dedicated plastic single-use blade (Vital View laryngoscope blade; Vital Signs, Ltd, West Sussex, UK). One of major features of LEDs illumination is the bluish-white color, which could have beneficial impact on the performance of intubation [1]. This manikin study compared intubation performance using a combination of Vital View II fibre optic laryngo- scope handle and a blade (VV-LED laryngoscope) with a combination of metal reusable laryngoscope blade with halogen bulb light handle (conventional laryngoscope) during cardiopulmonary resuscitation in a randomized, controlled, cross-over fashion.

Nineteen anesthesiologists intubated trachea of a man- ikin (ALS Skill Master; Laerdal Medical Japan, Tokyo, Japan) with 2 laryngoscopes in random order in the following 3 scenarios in the order of (a) a control scenario;

(b) chest compression scenario, where Continuous chest compressions were applied; and (c) chest compression with difficult airway scenario, where cervical collar was applied during chest compression (Fig. 1). At the end of each scenario, anesthesiologists were asked to rate the subjective difficulty of intubation on a 5-point rating scale (intubation difficulty scale), defined as (1) very easy, (2) easy, (3) moderate, (4) difficult, and (5) very difficult. Simulta- neously, they evaluated glottic visualization in 5 grades according to the Cormack and Lehane classification and percentage of Glottic opening scale as follows: class I, full view of the vocal cords; class II, partial view of the vocal cords; class III, only epiglottis visible; class IV, neither epiglottis nor glottis visible. Class II was divided into

2 subclasses: IIa was defined as more than 50% of the

^? Source of support: None.

vocal cords visible, and IIb was defined as up to 50% of the vocal cords visible [2,3]. The time elapsed to intubation was also measured.

There was no difference in performance of intubation between the 2 laryngoscopes in the control or chest compression with difficult airway scenarios. The VV- LED, however, provided significantly easier intubation than the conventional laryngoscope with improved glottic visualization in the chest compression scenario (median intubation difficulty scale was 2 using the VV-LED and

3 using the conventional laryngoscope, respectively) (Figs. 2 and 3). Time elapsed to intubate was not significantly different between the devices in all scenarios (Table 1).

Victims requiring emergency intubation cannot be thoroughly examined in advance. To avoid the possible transmission of infectious microbes, various types of plastic single-use laryngoscopic blades have been developed and are recommended for use [4]. However, the intubation provider might be reluctant to use of these plastic laryngoscopic blades because several of these blades are significantly less efficient compared with metal blades, probably because of insufficient rigidity [5,6]. Previously, the Vital View laryngoscope blade with halogen bulb light handle is reported to be comparable with a conventional laryngoscope in glottic visualization and the success rate of intubation during rapid sequence induction [7]. We found that neither glottic visualization nor intubation difficulty differs between the VV-LED laryngoscope and the conventional laryngoscopes in the control scenario. There- fore, the results indicated that illumination by LEDs would not have any significant effect on intubation especially in the scenario of an easy airway without chest compression. Interestingly, the VV-LED laryngoscope provided easier intubation during chest compression compared with the conventional laryngoscope. Possible explanation for our results could be the color of the LEDs illumination during intubation. A previous study showed that the intubation provider preferred the bluish-white color of the light [1]. Measurement of the spectral irradiance of the light from the laryngoscope blade demonstrated that irradiance in the blue/green region of the spectrum (400-550 nm) was prominent with LEDs illumination [8]. We assumed that this characteristic of the VV-LED laryngoscope facilitated identification of the glottis during chest compressions. On the other hand, difficulty of intubation using the VV-LED laryngoscope was similar to that of the conventional laryngoscope in the chest compression scenario with difficult airway. Cervical immobilization with a hard collar would cause difficult intubation as a result of reduction of cervical spine flexion and mouth opening. In such a clinical setting, laryngoscopy requires greater force than usual to align anatomical axes against cervical immobilization. The plastic blade of the VV-LED laryngoscope would transmit force less effectively than the reusable metal blade. Therefore, we assumed that the benefit obtained from the