26th ICIM in Kyoto
MIGAKU KIKUCHI 2002.05.30
Thank you, Dr. Davidson.
Dr. Davidson, Ladies and gentlemen,
Thank you for taking the time out of your busy schedules to listen to my presentation today.
We have been doing cardiopulmonary resuscitation education in Iwate for almost 10 years.
The effective strategy to save more people from sudden cardiac arrest out-of-hospital is strengthening the “chain of survival” in the community.
We should make an effort to educate combining early CPR with early defibrillation to the general population.
I would like to talk about the attempt in Iwate and the future direction of CPR.
As you know, Ichiro was awarded the American league MVP.
His batting average was .350 for Mariners in Seattle.
This, incidentally, was equal to the survival rate from sudden cardiac arrest in Seattle.
This is a poster that was used in Seattle.
It says that if you have to have a heart atttack, have it in Seattle.
In Seattle you have a greater chance of survival from sudden cardiac arrest.
The survival rate was 20% to 35%, which was very surprising at that time.
This slide shows distribution of mortality in patients with acute myocardial infarction who die within 30 days.
Slightly more than 50% of the patients who die will do so before reaching the hospital.
In most of those deaths, the presenting rhythm is ventricular fibrillation.
The major risk of VF occurs during the first 4 hours after the onset of symptoms.
Five hundred thousand Americans a year die from coronary artery disease, and of those, 250,000 die out-of-hospital.
Now we are here in Kyoto.
Iwate prefecture is in the northern part of Japan.
The capital city is Morioka and lies 500 kilometers north of Tokyo.
It is located at a similar latitude as Lisbon and Washington D. C.
Iwate is the second largest prefecture in Japan.
It’s roughly three quarters as large as the state of Massachusetts in the United States.
Iwate is rich with hot springs.
The Morioka area is encircled by Mountains like Mt. Iwate.
Mt. Iwate symbolizes the area and is sometimes called the Eastern Mt. Fuji.
At the heart of Morioka is the Rock-Splitting Cherry Tree.
Every spring, delicate cherry blossoms may be seen on this lovely tree.
Our Iwate Medical University and Critical Care Emergency Center is located nearby.
When transported to our Critical Care Emergency Center, this slide shows the causes of CPA.
In over 1,400 CPA Out-of-Hospital cases , internal CPA accounted for 64%.
Of those 909 internal CPAs, Sudden Cardiac Arrest accounted for 62%.
Of those 567 SCAs, acute myocardial infarction (AMI) either diagnosed or suspected accounted for 305 or 54%.
If half of the 222 unknown origin cases, including many Instant Deaths, were designated as AMI, they would account for about 70% of SCAs.
AMI is the leadng cause in CPA Out-of-Hospital.
We should make an effort to educate early CPR to the general population to save more people from sudden cardiac arrest out-of-hospital.
We set a goal for Iwate and focused on prehospital emergency care to improve as Seattle has done.
The Iwate CPR Propagation Committee was founded in 1993.
It is cooperated by the above organizations.
Paramedics inauguration in Japan started in 1991
In 1993 Iwate CPR Propagation Committee Foundation began standardized CPR training.
The trademark of the CPR movement is “Can You Rescue the Person You Love?”
This way of CPR is a little different from the present way
Before standardizing CPR, the Japan Fire Department and the Japan Red Cross respectively instructed CPR in a different way.
Nationwide, standardized CPR began in 2001, following the American Heart Association CPR and ECC guidelines for 2000.
In 1994, the CPR requirement for driver’s license and compulsory education in high schools started.
Until the year 2000 we have instructed a total of 250,000 plus people in CPR.
Currently we are at over 300,000 people.
The rate of bystander CPR to internal CPA transported to our institute increased 42% in 1998, which is three times as high as the national average.
While the survival discharge rate in SCA Victims increased only 14% at the maximum.
Now, I would like to give you some background about sudden cardiac arrest,
Three quarters of SCA occur in home with a witness.
Over 85% of SCA are caused by ventricular fibrillation (VF).
Electrical defibrillation is the only effective treatment for VF.
VF is time-dependent.
If not done quickly VF will deteriorate into asystole which cannot be treated.
As Dr. Pepe or Dr. Morley mentioned before, this graph shows probability of survival discharge after VF cardiac arrest and the interval between collapse and defibrillation
Survival rates after VF cardiac arrest decrease approximately 7% to 10% with every minute.
When defibrillation is delayed, survival rates decrease to approximately 50% at 5 minutes, approximately 30% at 7 minutes, less than 10% over 9 minutes.
It shows how important early defibrillation is to survive.
Defibrillation must be delivered within minutes of cardiac arrest in order to have the best chance of success.
Time is key for survival from SCA.
Accordingly, Guidelines 2000 emphasizes value of early defibrillation especially.
Early Defibrillation is a high priority goal.
No. 1 Defibrillation should be done within 5 minutes for prehospital.
No. 2 AED is placed where there is reasonable probability of SCA occurring once every 5 years.
No. 3 Education in CPR and AED use for BLS responders is an acceptable, safe and useful recommendation.
As a call-to-shock time within 5 minutes cannot be reliably achieved with conventional EMS services, the importance of public access defibrillation should be emphasized.
The AED is the key to making this possible.
The “chain of survival” concept represents the sequence of four events to optimize a person's chance of surviving a cardiac arrest.
The four links of the chain are early access, early CPR, early defibrillation and early advanced cardiac life support
Defibrillation was once provided only by advanced practitioners.
With the introduction of automated external defibrillators, responders not trained in rhythm recognition were able to defibrillate.
With the inclusion of AED use as a basic life support skill, BLS encompasses the first 3 links in the chain of survival.
Now we should notice that defibrillation is included in BLS
As you see, early CPR and early defibrillation are done by the same layperson.
There are various kinds of AEDs.
In Japan, yellow, blue and red types are approved.
All AEDs are portable and easy to use.
AEDs are sophisticated, computerized devices that are reliable and simple to operate.
It’s not necessary for the AED operator to be skilled in rhythm recognition.
It’s easier to use than a mobile phone.
The only “4 universal control steps” of AED operation are;
1st. POWER ON the AED
For example, some AED models power up automatically when the device is opened, others push a button.
2nd. ATTACH pads anteriorly and laterally
3rd. Automatically ANALYZE the patient’s heart rhythm
4th. PRESS the shock button
AEDs advise the operator by screen messages and voice prompts when a shockable rhythm is detected.
Laypersons can administer this lifesaving intervention with minimal training.
AEDs have Non-rechargeable batteries and do daily self tests and are virtually maintenance free
Non-trained 6th grade children were trained for only15 seconds and told what pads and a shock button are.
The interval between AED pad attachment and defibrillation on a CPR dummy were observed.
Trained professionals in Seattle could do it in 67 seconds, 6th graders could do it in 90 seconds.
That’s only 23 seconds difference between the specialist and elementary school student.
Dr. Bardy, one of whom researched this, said that he felt relieved even if he had a heart attack, because he had instructed his son in AED use”.
PAD programs consist of 3 steps in the United States.
The 1st step is nontraditional responders use.
The 2nd step is targeted responders.
The 3rd step is residential use.
PAD program is going by steps.
This slide shows AED is used by nontraditional responders
They have used AEDs successfully.
In Rochester, Minnesota early defibrillation by police and paramedics was done in the community.
The Survival to hospital discharge from SCA rose to 49%.
Of the victims who were first shocked by police, 58% survived.
American Airlines has also equipped AEDs
Flight attendants were trained for 4 hours and AEDs were used in 200 cases.
Of all the VF victims, 40% survived.
Of the victims on airplanes, 55% survived to hospital discharge.
Also, AEDs were equipped at Las Vegas casinos and used by security guards trained for 2 hours.
When defibrillation was achieved within 3 minutes or less from time of collapse, the highest survival rates were obtained.
These survival rates are 74% and the best to date.
In the next step, AED is used by targeted responders like these.
AEDs are located in the above areas.
For example in Chicago O’Hare Airport, the largest airport in the world, AEDs are located next to the restroom.
A person present at the scene of the cardiac arrest brings the AED to the victim and then defibrillates
9 out of 11 SCA cases were saved in the first 6 months of installation.
The overall survival rate was 80%.
Former President Clinton called for expanded use of AEDs
He said, “More than 600 Americans die from sudden cardiac arrest everyday, but as many as 20,000 lives a year could be saved by the increased availability of AED.” “It’s time for national government to help bring AEDs to public places all over America.”
This slide shows the PAD program has improved survival rate.
The average of most cities around the world is less than 10%.
As mentioned before, early defibrillation by EMT made the survival rate improve to 26%
If done by these three here, the survival rate will reach 60% to 80%.
Clearly the earlier the defibrillation, the better the outcome.
Time is the only critical component and AED is the independent predictor of survival.
Common sense dictates residential AED use is expected to improve survival rates dramatically.
Currently, In Japan AED usage is not permitted by all medical staff
And this is a big problem. (with a sigh)
Only doctors and paramedics are permitted.
While flight attendants are allowed to use it, nurses and EMTs are not.
Moreover access to the defibrillator is only in restricted areas, even in hospitals.
There are many barriers to the ”chain of survival” in early defibrillation in both in-hospital and out-of-hospital.
The growth of PAD is exponential.
We believe PAD will spread in Japan in the near future.
Responder permitted AED use will cause interaction, cooperation, and reinforcement of each other in the above areas.
Authorization to attach and operate a defibrillator, should be expanded to all medical responders.
EMS protocols should be modified to allow EMSs to use AEDs without consulting a physician.
And we should break down barriers and revise some laws, if necessary.
On this basis, the next 3 steps like those in the United States should be followed.
These two maps are drawn on the same reduced scale.
This area here is the Morioka Fire District and this is the Tokyo Fire District.
As you can see, the Morioka Fire District is as large as the Tokyo Fire District.
When Compared the Morioka Fire District with the Tokyo Fire District, the Tokyo Fire District has 3 times as many EMTs, 50 times more paramedics, 40 times more ambulances with defibrillators, and 20 times more critical care emergency centers.
The Morioka Fire District staff and equipment are also extremely low.
This district, like Iwate, is a large and sparsely populated country area, and emergency medical service personnel are insufficient, and the time needed to transport patients is prolonged.
Can you imagine if these people were not allowed to use of this technology?
What If …?
firefighters retained control to push extinguisher buttons
barriers were not removed by firefighters and government
laypeople could not use extinguishers
the public had no access to extinguishers
the public was not allowed to purchase extinguishers
Would you guess firefighters and fire extinguishers would be replaced by physicians and AEDs?
One could make this fire extinguisher analogy for AEDs.
Common sense dictates that public access to AED will improve the survival rate of SCA.
We should use AEDs like fire extinguishers which are widespread in Japan, particularly in Iwate.
Accordingly, we should involve, and continue the public access defibrillation in the Iwate CPR propagating program and the movement.
We should make an effort to educate combining early CPR with early defibrillation and deploy AEDs in appropriate places.
We have named the Iwate PAD propagation movement “1,000 (one thousand) AEDs Equipment in Iwate”.
To do so would take the above 4 steps.
First step is for traditional responders in-hospital
Every medical staff can use AEDs and every clinic and every floor of the hospital have AEDs.
AEDs equipment is the key to defibrillate in the interval collapse to 1st shook within 3 minutes in-hospital arrest.
Second step is for traditional responders out-of-hospital.
AEDs are also used by paramedics and EMTs in every ambulance.
Third step is for non-traditional responders.
Last step is for targeted responders.
We should be aware that the general public could display the skills for CPR with an AED.
This next slide shows the Dawn of “1,000 (one thousand) AEDs Equipment in Iwate, where AED equipment will be installed in 9 institutes in these areas.
We are instructing general practitioners and ICU nurses, and every general practitioner and every nurse should have the skills in CPR plus use in an AED.
Enlightening and training medical stuff in advanced cardiovascular life support is as indispensable as public education for pre-hospital CPR and defibrillation.
ACLS providers, which include cardiologists, should also be aware that each person must display the skills in 1-rescuer adult CPR plus use in an AED.
I enjoyed making this poster, that is along similar lines as the one you saw at the start of my presentation.
Iwate, Good Scenery, the Best Hot Springs, Wonderful Food, Friendly People and a Greater Chance of Survival From Heart Attacks!
In Japanese, “Onsen nara Iwate-ken e iko. Itsu-dokode taoretemo dareka ga tasukete kureru-kara.“
I would like this to come true and make a difference.
I hope that my presentation was both informative and interesting for you.
I’m now ready to answer any questions that you may have, and If possible in Japanese, please.
Again, thank you for your time.