Medical Device Daily Executive Editor

Over the past five years, automated cardioverter defibrillators (AEDs) have been widely deployed in a variety of high traffic, high-stress venues, including schools. But according to Jonathan Drezner, MD, associate director of Hall Health Sports Medicine at the University of Washington (Seattle), in many schools — especially at the high school level — too often these life-saving devices may be located in a nurse's offices, locked in a cabinet or nowhere near the court or field.

So, not much use when a response of three to five minutes is necessary and the results of AED shock after that are much-diminished.

Drezner recently headed a study group that has issued a report providing guidelines for deployment and use of AEDs, and the provision of CPR, for scholar/athletes. The report, titled "Inter-Association Task Force Recommendations on Emergency Preparedness and Management of Sudden Cardiac Arrest in High School and College Athletic Programs: A Consensus Statement," which appears in this week's issue of Heart Rhythm, the journal of the Heart Rhythm Society (Washington).

Drezner told Medical Device Daily that there have been various studies and recommendations concerning the use of AEDs in schools, but that the new consensus guidelines pull these together and offer an important emphasis — that an AED on site at a school is only half of the job of providing defibrillation.

"The other half is management," Drezner said, in commenting on the report's key elements.

"Most colleges," Drezner says, "do have AEDs at selected athletic venues, and they have an emergency plan." And colleges are "fine-tuning" those plans.

But, he adds, "the high school level is something entirely different. As many as half of all high schools may have an AED located on the school grounds, but often without an accompanying emergency plan."

The AED, he says, may be somewhere in the nurse's office or some other place hard to get to, especially during after-hours events. "And," he asks rhetorically, "do they truly know who knows where the AED is, the mechanism for getting it, is it immediately accessible?"

He concludes that while there has been broad coverage emphasizing the value of AEDs, there has been no equivalent emphasis on the need for an emergency plan in high school settings, largely, he surmises, because the AEDs often have been donated. Schools "get the equipment but no emergency plan along with it."

The report cites a variety of statistics concerning sudden death in athletes and — perhaps rather surprisingly —that there are roughly 110 deaths per year, "or about one death every three days in the United States."

These of course, are not all the result of heart problems. The report cites studies indicating that the incidence of sudden cardiac death (SCD) in high school athletes is 1 per 1000,000 to 1 per 200,000. And the estimated incidence of SCD in college-age athletes ranges from 1 per 65,000 to 1 per 69,000.

The report notes that a majority of such deaths are the "sentinel event" of a serious heart problem, meaning no early symptomatic signals of trouble. And it adds that there is no "mandatory national reporting or surveillance system [so that] the true incidence of SCA/SCD in athletes is unknown, and prior reports may have underestimated the actual occurrence of SCA/SCD in young athletes."

And it further says that there currently is no recommendation for screening asymptomatic athletes via electrocardiography or echocardiography recommended by the American Heart Association (Dallas) "because of the poor sensitivity, high false-positive rate, poor cost-effectiveness, and total cost of implementation."

Drezner told MDD that a critical barrier for reporting of SCD and quick use of an AED is that onlookers may not immediately identify cardiac arrest as the cause when a young athlete collapses and do not respond appropriately.

"Up to one-third of athletes who collapse will have some seizure, a lack of activity for a brief moment that can be mistaken for exhaustion, fatigue." But, he says, if a collapse happens and "that person is unresponsive, assume it's cardiac arrest — until proven otherwise."

That assumption means that the AED should be immediately located and immediately turned on so that it is ready for use. And Drezner notes that the state of this technology has been shown as fail-safe, that is, only delivering a shock if the device determines that the problem is an electrical arrhythmia of the heart and a shock would help.

Drezner says that about 90% of all colleges now have AEDs but he calls the estimate for high schools "a moving target." From 25% to 50% of high schools have them, but this varies widely by state "and the resources of the school and the community the school is in."

He says the need is much less in elementary schools and venues such as park district facilities, but it is still important from a public safety standpoint.

But his persistent theme is AED availability, not just acquisition of the device.

"Plan out where you should keep [the AED], who will be the responders, decide if you need more than one AED, make it available near an athletic facility or in a remote area, develop a team of responders, encourage schools and institutions to train coaches in using the device and recognizing cardiac arrest, he said."

He also encourages practice drills similar to fire alarms and training students in AED use — "empower them so that they know where the AED is." And he notes studies indicating that even untrained young people can effectively put an AED to work, only somewhat more slowly than a trained responder.

Drezner says that the report was developed by a group that included representatives from 15 national societies. And while there was "a lot of discussion and the hardest thing to tackle was age range, target audience, the athletes, athletics in general," the report was hammered out in a fairly short time, compared to most such efforts — only about a year.

The recommendations will now be disseminated by the participating associations and through their journals.

He says the next research targets will be in monitoring more precisely the prevalence of AEDS in schools and the "level of emergency planning that exists."

In the meantime, he says the development of the report keeps him personally on the alert.

"When I walk by the youth baseball field, I wonder, are the people aware of what would be the time it takes to provide AED and resuscitation? The need for placement of AEDS at recreational fields, community centers, parks — that hasn't been formally addressed yet."

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