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(Circulation. 1997;95:2183-2184.)
© 1997 American Heart Association, Inc.

Articles

Early Defibrillation

An Advisory Statement From the Advanced Life Support Working Group of the International Liaison Committee on Resuscitation

Walter Kloeck, MD, Working Group Chair¹; Richard O. Cummins, MD, ILCOR Cochair²; Douglas Chamberlain, MD, ILCOR Cochair³; Leo Bossaert, MD³; Victor Callanan, MD⁴; Pierre Carli, MD³; Jim Christenson, MD⁵; Brian Connolly, MD⁵; Joseph P. Ornato, MD²; Arthur Sanders, MD²; Petter Steen, MD³

Key Words: AHA Medical/Scientific Statements • cardiopulmonary resuscitation • defibrillation

	The Concept of Early Defibrillation

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Most adults who can be saved from cardiac arrest are in ventricular fibrillation (VF) or pulseless ventricular tachycardia. Electrical defibrillation provides the single most important therapy for the treatment of these patients. Resuscitation science therefore places great emphasis on early defibrillation. The greatest chances of survival result when the interval between the start of VF and the delivery of defibrillation is as brief as possible. To achieve the earliest possible defibrillation, the International Liaison Committee on Resuscitation (ILCOR) endorses the concept that in many settings nonmedical individuals should be allowed and encouraged to use defibrillators.

ILCOR recommends that resuscitation personnel be authorized, trained, equipped, and directed to operate a defibrillator if their professional responsibilities require them to respond to persons in cardiac arrest. This recommendation includes all first-responding emergency personnel, in both the hospital and out-of-hospital settings, whether physicians, nurses, or nonmedical ambulance personnel. The widespread availability of automated external defibrillators (AEDs) provides the technological capacity for early defibrillation by both ambulance crews and lay responders.

	Early Defibrillation by Ambulance Personnel

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ILCOR urges the medical profession to strive to increase the awareness of the public and of those responsible for emergency medical services (EMS) of the importance of early defibrillation by ambulance personnel. In some locations healthcare professionals will need to encourage medical and regulatory authorities to initiate changes in regulations and legislation. Leaders of EMS systems may need to overcome obstacles that include nonenabling legislation, economic priorities, unsuitable EMS structure, lack of awareness, inadequate motivation, and tradition.

ILCOR recommends that early defibrillation programs by nonmedical ambulance personnel be operated with control systems that

Set written policies and guidelines based upon or similar to those already developed by major resuscitation organizations.

Establish a training and quality maintenance program that ensures a high level of supervision.

Place the program under the direction and responsibility of a physician or the direct representative of a physician acting on his or her behalf.

Use only AEDs (except for fully trained paramedics, who may use manual defibrillators by local agreement).

Require that all defibrillators contain internal recording capabilities that permit documentation and review of all clinical uses of the AED.

	Early Defibrillation by First Responder in the Hospital

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The concept of early defibrillation applies not only to the out-of-hospital setting but also to in-hospital resuscitation efforts. ILCOR strongly encourages the development of early defibrillation programs for nonphysician in-hospital responders. ILCOR recommends that these programs comply with the following guidelines:

Regularly train all hospital staff who may need to respond to a sudden cardiopulmonary emergency in basic life support (BLS).

Establish and encourage AED training as a basic skill for healthcare providers working in settings where advanced life support (ALS) professionals are not immediately available.

Extend training and authorization to use conventional defibrillators or AEDs to all appropriate nonphysician staff, including nurses, respiratory therapists, and physician assistants.

Reduce the time from collapse to defibrillation by making conventional defibrillators or AEDs readily available in strategic areas throughout a facility.

Document all resuscitation efforts accurately by recording specific treatment interventions, event variables, and outcome variables. The in-hospital Utstein guidelines¹ provide a recommended Standard Reporting Form for in-hospital cardiopulmonary resuscitation (CPR).

Collect and review the patient variables, event variables, and outcome variables contained in the in-hospital Utstein guidelines set of uniform data elements.

Establish an interdisciplinary committee with expertise in CPR to assess the quality and efficacy of a facility's resuscitation efforts.

	Early Defibrillation by First Responder in the Community2 3

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A first responder is defined as a trained individual acting independently with a medically controlled system. In the community this may include police, security officers, lifeguards, airline cabin attendants, railway station personnel, volunteers who render first aid, and those assigned to provide first aid at their workplace or in the community and who are trained in the use of an AED.³

Establish acceptance, support, and coordination by responsible community medical and EMS authorities.

In some specific situations consider combining training programs for bystander defibrillation with training in BLS, with careful monitoring of results.

Arrange for review of all clinical applications of an AED by a medically qualified program coordinator or a designated representative.

Plan for critical program evaluation at two levels: individual clinical uses and overall EMS system effects.

Use only AEDs; practical considerations render manual defibrillators inadvisable for lay use.

Continue innovations to produce simple, lightweight, economically priced, and highly reliable AEDs.

	Early Defibrillation and the Chain of Survival Concept

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Early defibrillation addresses only part of the problem of sudden cardiac death. Early defibrillation initiatives will succeed only when implemented as part of the chain of survival concept. The links of the chain of survival include early recognition of cardiopulmonary arrest, early activation of trained responders, early CPR, early defibrillation when indicated, and early ALS. The chain of survival concept, while originally described in the context of out-of-hospital cardiac arrest, is equally valid for in-hospital resuscitation. Establishment of early defibrillation within a strong chain of survival will ensure the highest possible survival rate for both out-of-hospital and in-hospital events.

	Footnotes

 
¹ Resuscitation Councils of Southern Africa

² American Heart Association

³ European Resuscitation Council

⁴ Australian Resuscitation Council

⁵ Heart and Stroke Foundation of Canada.

`Early Defibrillation' was approved by the American Heart Association Science Advisory and Coordinating Committee in February 1997.

A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Avenue, Dallas, TX 75231-4596. Ask for reprint No. 71-0110. To purchase additional reprints: up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 214-706-1466, fax 214-691-6342, or To make photocopies for personal or educational use, call the Copyright Clearance Center, 508-750-8400.

	References

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1. Cummins RO, Chamberlain D, Hazinski MF, Nadkarni V, Kloeck W, Kramer E, Becker L, Robertson C, Koster R, Zaritsky A, Bossaert L, Ornato JP, Callanan V, Allen M, Steen P, Connolly B, Sanders A, Idris A, Cobbe S. Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: the in-hospital `Utstein style.' A statement for healthcare professionals from the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, the Australian Resuscitation Council, and the Resuscitation Councils of Southern Africa. Circulation. 1997;95:2213-2239.[Free Full Text]
   
2. Weisfeldt ML, Kerber RE, McGoldrick RP, Moss AJ, Nichol G, Ornato JP, Palmer DG, Riegel B, Smith SC Jr. Public access defibrillation: a statement for healthcare professionals from the American Heart Association Task Force on Automatic External Defibrillation. Circulation. 1995;92:2763.[Free Full Text]
   
3. Weisfeldt M, Kerber RE, McGoldrick RP, Moss AJ, Nichol G, Ornato JP, Palmer DG, Riegel B, Smith SC Jr. American Heart Association Report on the Public Access Defibrillation Conference, December 8-10, 1994: Automatic External Defibrillation Task Force. Circulation. 1995;92:2740-2747.[Free Full Text]
   

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