a b s t r a c t

Aim of the study: Automated external defibrillation (AED) and Public access defibrillation have become cornerstones in the Chain of survival in modern cardiopulmonary resuscitation. Most studies of AED and PAD have been performed in urban areas, and evidence is scarce for sparsely populated rural areas. The aim of this review was to review the literature and discuss treatment strategies for out-of-hospital cardiac arrest in rural areas.

Methods: A Medline search was performed with the keywords automated external defibrillation (617 hits), public access defibrillation (256), and automated external defibrillator public (542). Of these 1415 abstracts and additional articles found by manually searching references, 92 articles were included in this nonsystematic review.

Results: Early defibrillation is crucial for survival with good neurological outcome after cardiac arrest. Rapid defibrillation can be a challenge in sparsely populated and remote areas, where the incidence of cardiac arrest is low and rescuer Response times can be long. The few studies performed in rural areas showed that the introduction of AED programs based on a 2-tier emergency medical system, consisting of Basic Life Support and Advanced Life Support teams, resulted in a decrease in collapse-to-defibrillation times and better survival of patients with out-of- hospital cardiac arrest.

Conclusions: In rural areas, introducing AED programs and a 2-tier emergency medical system may increase survival of out-of-hospital cardiac arrest patients. More studies on AED and PAD in rural areas are required.

(C) 2014

1. Introduction

In North America, the incidence of out-of-hospital cardiac arrest (OHCA) is approximately 50 to 55 per 100 000 inhabitants per year [1,2]. Sudden cardiac arrest is caused by myocardial infarction in more than 60% of cases, with ventricular fibrillation (VF) in 50% to 80% of collapsed patients [3,4]. In urban areas with rapid bystander cardiopulmonary resuscitation (CPR) and public access defibrilla- tion (PAD), survival rates from cardiac arrest have improved substantially [5]. Most studies on automated external defibrillation (AED) and PAD have been performed in urban areas (eg, Maastricht, Netherlands, with a population density of 1975 inhabitants km^-2; Goteborg, Sweden, with 2562 inhabitants km^-2; and Copenhagen, Denmark, with 5985 inhabitants km^-2) [6-8]. Data are scarce in less densely populated rural and mountain areas such as the European Alps, with a population density of about 20 to 240 inhabitants km^-2,

* Corresponding author. Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria. Tel.: +43 512

504 80496; fax: +43 512 504 22450.

E-mail addresses: [email protected] (M. Strohle), [email protected] (P. Paal), [email protected] (G. Strapazzon), [email protected]

(G. Avancini), [email protected] (E. Procter), [email protected] (H. Brugger).

or Oregon, USA, with 15 inhabitants km^-2. It is unclear how to equip rural areas with AEDs and PAD. The aim of this review was to review the literature and discuss evidence regarding treatment strategies for OHCA-VF in rural areas.

1. Material and methods

A literature search of the Medline database was performed using the keywords automated external defibrillation (617 hits), public access defibrillation (256), and automated external defibrillator public (542) for articles published on or before July 18, 2014. A manual search of the references was performed to find additional articles. In total, 92 articles related to AED and PAD in rural areas were included in this nonsystematic review.

1. Results and discussion
   1. Collapse-to-defibrillation time is decisive for Survival and neurological outcome

Time from OHCA-VF to defibrillation is crucial for survival and neurological outcome. The defibrillation success and survival rate of OHCA-VF patients not receiving CPR rapidly decline in the first 5 to 10

http://dx.doi.org/10.1016/j.ajem.2014.08.046

0735-6757/(C) 2014

Table 1

Influence of emergency medical technician defibrillation programs within EMS on survival from OHCA

Studies (n = 1713) Design Survival to hospital P

discharge before and

after implementation of AED

		Before	After
Eisenberg et al, 1980 [38] (n = 154)	Prospective, historical controls	4%	19%	b.01
Stults et al, 1984 [39] (n = 95)	Prospective controlled	3%	19%	b.05
Olson et al, 1989 [40] (n = 566)	Prospective controlled	4%	6%	b.02
Sweeney et al, 1998 [41]?(n = 627)	Prospective controlled, crossover	5%	5%	.8
Gottschalk et al, 2002 [42]?(n = 103)	Prospective controlled	32%	22%	.29
Stotz et al, 2003 [43]?(n = 168)	Retrospective	24%	14%	.112

Studies on early defibrillation within the emergency medicine system. ED denotes early defibrillation.

* Studies in areas where the response time of the ALS team before introduction of the AED program was a few minutes.

minutes after collapse [9]. Other studies also report a steep decline in survival [10,11], which underlines that a response time shorter than 5 minutes has the biggest impact on positive outcome [11-17]. In a British study, patients with OHCA-VF witnessed by a physician had a survival rate of about 60% when the outpatient clinics where they collapsed were equipped with AEDs [18]. The response time was also decisive for survival: the hospital discharge rate was about 60% with a response time of less than 4 minutes and about 18% with a response time of more than 4 minutes. Automated external defibrillation studies with long call-to- defibrillation intervals (eg, N 10 minutes) have not demonstrated a substantial increase in the overall survival rate [19].

Short response times after OHCA-VF are also essential for good neurological outcome. In Amsterdam, survivors of OHCA-VF had less neurological impairment and loss of autonomy when the collapse-to-CPR and collapse-to-defibrillation times were shorter [20,21]. Another study reported that Life expectancy and quality of life were similar in patients who had survived OHCA-VF compared to a matched population [22].

Whereas early studies suggested a benefit of CPR before defibrillation [23-27], recent studies do not support these findings [28-33]. Thus, current CPR guidelines do not recommend a specific CPR interval before defibrillation but highlight the importance of efficient and Continuous chest compressions with as short as possible hands-off time until successful defibrillation [25,34,35].

Early defibrillation programs in urban areas within emergency medical services

Emergency medical services (EMSs) have different structures. A single-tier EMS consists of an Advanced life support team that is called to an emergency; a 2-tier system consists of Basic Life Support (BLS) and ALS teams that are dispatched according to medical information and needs. Other systems have a nontransporting first responder team whose members are BLS or ALS trained and a transporting unit that is dispatched simultaneously. Two-tier systems

may be more cost-effective because less qualified personnel and less equipment are needed to provide a good standard of care [36]. In a review, survival from OHCA-VF ranged from 3% to 33% but was higher with a 2-tier compared to a single-tier system [37]. The greatest improvements in survival from OHCA-VF were reported in areas where no preclinical defibrillation was available before these programs were introduced [38-40]. However, the advantage of a 2- tier system could not be replicated in areas where the response time of an ALS team had been fast (within minutes) before the program was introduced [41-43]. As a result, both the American Heart Association and European Resuscitation Council recommend that BLS teams should be equipped with AEDs [44]. Studies reporting outcomes after early defibrillation in urban areas within an EMS are listed in Table 1.

Early defibrillation programs in urban areas outside EMS

In some 2-tier systems, BLS AED is performed by BLS First responders trained in the use of AEDs, for instance, fire brigade members and police officers. These first responders perform contin- uous CPR and apply AED until the arrival of an ALS team. A 2-tier system outside the EMS can shorten call-to-defibrillation time; and it may improve outcome if the call-to defibrillation time is reduced to a few minutes, especially in areas where an ALS team is not rapidly available [3,15,45-50]. Some studies did not report improved outcomes because call-to defibrillation time could not be sufficiently reduced (eg, b 10 minutes). Studies reporting outcomes after early defibrillation in urban areas outside an EMS are listed in Table 2.

Public access defibrillation

Public access defibrillation is defined as the installation of AEDs in public places (eg, airplanes, airports, casinos). Introduction of PAD in densely populated or heavily frequented areas can increase preexisting

Table 2

Influence of AED programs outside the EMS on survival from OHCA

Studies (n = 7942) Design Responders Controls Survival to hospital P

discharge before and after implementation of AED

				Before	After
van Alem et al, 2003 [3] (n = 469)	Prospective controlled, randomized, crossover	Police, firefighters	EMS	15%	18%	.33
Stiell et al, 1999 [15] (n = 6331)	Prospective controlled, interventional	Firefighters, EMT-D	EMS	4%	5%	.03
Myerburg et al, 2002 [45] (n = 420)	Prospective controlled	Police	EMS	9%	17%	.05
Kellermann et al, 1993 [46] (n = 431)	Prospective controlled, crossover	Firefighters	EMS	10%	14%	NS
White et al, 1996 [47] (n = 84)	Retrospective	Police, EMT-D	EMS	43%	58%	.2
Mosesso et al, 1998 [48] (n = 207)	Prospective interventional, historical controls	Police	EMS	6%	14%	.1

EMT-D denotes emergency medical technician with AED skills; NS, nonsignificant.

Table 3

Public access defibrillation programs outside the EMS and survival from OHCA-VF

Studies (n = 16 580)	PAD locations	Responders	Survival to hospital discharge
Folke et al, 2009 [8] (n = 1274)	Copenhagen, Denmark	Volunteers	13.9%
O’Rourke et al, 1997 [13] (n = 46)	Qantas aircrafts	Air crew members	26%
Valenzuela et al, 2000 [16] (n = 105)	Casinos, USA	Casino officers	53%
Caffrey et al, 2002 [51] (n = 26)	Chicago airports, USA	Volunteers	56%
MacDonald et al, 2002 [52] (n = 53)	Boston Airport, USA	Firefighters, EMS	21%
Page et al, 2000 [53] (n = 200)	US airline	Flight attendants	40%
Culley et al, 2004 [54] (n = 50)	Seattle, King County, USA	Volunteers	50%
Hallstrom et al, 2004 [56] (n = 235)	USA	Volunteers	23% vs 14% CPR only (P = .03)
Kitamura et al, 2010 [60] (n = 12631)	Japan	Volunteers, EMS	37.2% PAD (survival at 1 mo)
Wassertheil et al, 2000 [87] (n = 28)	Stadium, ANZAC Parade, Australia	Volunteers, EMS	71%
Capucci et al, 2002 [88] (n = 354)	Piacenza, Italy	Volunteers	44% vs 21% EMS (P = .046)
Davies et al, 2005 [89] (n = 172)	UK airports, railway stations	Volunteers	28%
Cappato et al, 2006 [90] (n = 1394)	Brescia, Italy	Volunteers, EMS	1.4% vs 4.4% after PAD (P = .04)
Hanefeld, 2010 [91] (n = 12)	Bochum, Germany	Volunteers	50%

survival rates to hospital discharge by up to 50% [54]. The achieved survival rates can be as high as 55% [13,16,51-53]. In a large PAD study, bystanders were trained in either CPR or CPR with defibrillation; survival was 14% in the CPR group and 23% in the CPR with defibrillation group (P = .03) [55,56].

It has been suggested that automated external defibrillators should be positioned in any area where an ALS team cannot arrive in less than 5 minutes and where at least 1 OHCA-VF is expected to occur over a period of 5 years [55,57]. Suitable locations for AED include airports, factories, nursing homes, marinas, schools, shopping malls, sport arenas, and train stations [55,57,58]. Automated external defibrillators have also been recommended for places where more than 250 persons older than 50 years gather [59]. In Japan, a national PAD program decreased mean collapse-to-defibrillation time from 3.7 to 2.2 minutes (P b .001), increased the number of defibrillations administered by laypersons, and increased the number of patients surviving with minimal neurologic impairment from 2.4 to 8.9 per 10 million inhabitants (P = .01) [60]. As a result of these retrospective studies, some authors proposed locations deemed suitable for installing an AED [7,61-65] and stated that cost- effectiveness should be assessed before starting a PAD program [66,67] and first responders should be regularly trained. Studies on PAD are listed in Table 3.

Early defibrillation in rural and mountain areas

The chance of surviving OHCA-VF is higher in dense urban areas than in rural areas [68]. The 2000 European Resuscitation Council guidelines state that early defibrillation should be standard for EMS “except in sparsely populated and remote settings, where the frequency of cardiac arrest is low and rescuer response times are excessively long” [69]. However, some studies have found data

opposing this advice (Table 4); on San Juan Island, USA, survival of OHCA-VF was 43% with a 2-tier system, which is comparable to similar studies in urban areas [70]. In Ketchikan, AK, USA, survival increased from 15% to 38% (P = .03) using AEDs [71]. In 2 further studies performed in rural US communities with BLS- and AED- trained paramedics, survival increased from about 3% to 18% [39,72]. In Galicia, Spain, the survival rate from VF was 12%; but overall survival from OHCA was only 2.3% due to the low incidence of Shockable rhythms upon arrival of an EMS team. In this setting, time of activation and response of the EMS were slow (15-minute median collapse-to-crew arrival time), negatively affecting the incidence of VF and survival [19]. In a Swedish retrospective analysis of more than 14 000 cardiac arrests, OHCA survival in rural areas was not significantly different from survival in urban areas (4.8% vs 5.5%). The conclusion was to place AEDs closer to patients of small communities, allowing fire brigades and other first responders to shorten the time to defibrillation [73]. Similarly, the Italian government issued a regula- tion that obliges organizers of sporting events to have AEDs and trained personnel available on site [74].

Mountain regions have strong seasonal fluctuations in population with resulting fluctuations in the incidence of OHCA-VF. In small communities, the response time of a BLS or ALS team to OHCA-VF is usually more than 5 minutes. The Medical Commission of Mountain Emergency Medicine suggests that AEDs should primarily be installed in ski areas in the winter and in mountain huts near cable cars or popular hiking trails The location is determined by the sport type, risk factors of the general participant, and environmental conditions [75,76]. In some remote American and European mountainous regions, first responders (eg, mountain rescuers, fire brigade members, ski lift officers) have been trained in BLS and AED to reduce call-to-defibrillation time. A survey reported that AEDs have been widely implemented by mountain rescue

Table 4

Influence of AED programs on survival from OHCA in rural areas

Studies (n = 1121)	Design	Location	Responders	Controls	Survival to hospital discharge before and after introduction of AED programs	P
					Before After
Colquhoun, 2002 [18] (n = 259)	Retrospective	GP office; Cardiff, UK	GP with AED	GP	12.5% 63% unwitnessed witnessed	NR
Stults et al, 1984 [39] (n = 95)	Prospective, controlled	Rural communities; Iowa, USA	EMT-D	EMT	by GP by GP 3% 19%	b.05
Killien et al, 1996 [70] (n = 78)	Retrospective	Island community; San Juan Island, USA	EMT-D/paramedic	EMT	NA 43%	NR
Kriegsman et al, 1998 [71] (n = 71)	Retrospective	Rural community; Alaska, USA	EMT/paramedic	EMT	9% 20%	NR
Vukov et al, 1988 [72] (n = 63)	Prospective, controlled,	Rural communities; Minnesota, USA	EMT-D	EMT	4% 17%	NR
Colquhoun, 2006 [92] (n = 555)	crossover Retrospective	GP office; Cardiff, UK	GP with AED	GP	NA 27%	NR

GP denotes general practitioner; NA, not applicable; NR, not reported.

services worldwide [77], and some mountain rescue backpacks are now equipped with AEDs [78].

The literature on AED use in mountain and remote areas is limited, and only few case reports of patients with favorable outcomes have been published [79,80]. In these settings, the probability to rescue a hypothermic patient in OHCA is high; and the chance of survival at hospital discharge is higher compared to normothermic patients (27% vs 50%) [81,82]. Administration of up to 3 shocks is recommended, with further dosing guided by the Clinical response, when core temperature is less than 30?C [83]. High-altitude base camps such as Mt Everest or Aconcagua also have seasonal fluctuations in the population, easy tourist access, and a daily population up to more than 1000 [84]. Visitors to these areas should be assessed for risk of coronary heart disease and seek individual pretravel advice to reduce the incidence of sudden cardiac arrest. An effective chain of survival in such base camps would include AEDs [76,85]. Mechanical CPR could be helpful if no helicopter rescue is available and terrestrial rescue is technically difficult or rescue time is more than 30 minutes [86].

1. Conclusions

Only few studies exist on out-of-hospital defibrillation in rural areas, but most show a better outcome from OHCA after implementation of AED and PAD. Automated external defibrillation and PAD programs can only be successful if implemented into the chain of survival of a 2-tier EMS. An ALS team should be available within a reasonable time. Public access defibrillation and first responders trained in AED could represent a cost-effective alternative to additional ALS teams. More studies on AED and PAD in rural areas are required.

Acknowledgments

The authors do not have any institutional or commercial affiliations that might pose a conflict of interest regarding the publication of this manuscript. There is no other conflict of interest related to this manuscript.

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