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INTRODUCTION
The value of early intervention in critically ill patients has long been recognized. As
early as the 1700s, scientists recognized the value of mouth-to-mouth respiration and the
medical benefits of electricity (1). In the modern era, advances in resuscitation began to
proliferate. In 1947, Claude Beck successfully resuscitated a 14-year-old boy through
the use of open chest massage and an alternating current (AC) defibrillator, the kind that
is used in wall outlets. In 1956, Paul Zoll demonstrated the effectiveness of closed chest
massage with the use of an AC defibrillator. In the late 1950s, Peter Safar, William
Kouwenhoven, James Jude and others began to study sudden cardiac arrest (CA) and in
1960, they demonstrated the efficacy of mouth-to-mouth ventilation and closed chest
cardiac massage (2). In 1961, Bernard Lown demonstrated the superiority of direct
current (DC) defibrillators, the kind provided by batteries. In 1966, J. Frank Pantridge
and John Geddes developed the worlds first mobile intensive care unit (MICU) in
Belfast, Northern Ireland, as a way to bring early advanced medical care to patients with
cardiac emergencies (3). In 1969, William Grace established the first MICU in the
United States in New York City (4). Subsequently, there were efforts in the United States
and throughout the world to emulate and build on this concept. In the late 1960s and early
1970s, paramedic programs were developed by Eugene Nagel in Miami, Leonard Cobb
in Seattle, Leonard Rose in Portland, Michael Criley in Los Angeles, and James Warren
and Richard Lewis in Columbus. In the 1980s, Mickey Eisenberg, Richard Cummins,
From: Contemporary Cardiology: Cardiopulmonary Resuscitation
Edited by: J. P. Ornato and M. A. Peberdy Humana Press Inc., Totowa, NJ
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Cardiopulmonary Resuscitation
and colleagues demonstrated the effectiveness of rapid defibrillation in Seattle, Washington (5), while Kenneth Stults demonstrated the same in rural Iowa (6). This growing
body of research demonstrated the importance of rapid care for victims of sudden CA
by showing that survival improved when basic life support (mouth-to-mouth ventilation
and closed chest compressions) was provided within 4 minutes and advanced life support (defibrillation, intravenous medications and fluids, and advanced airway management) within 8 minutes. Subsequent studies found that the benefits of advanced life
support were primarily the result of electrical countershock for patients in ventricular
fibrillation (VF). From these findings, a model of care called the Chain of Survival,
was first described by Mary Newman (7), and then by Cummins et al. (8), and eventually
adopted by the Citizen CPR Foundation, the American Heart Association (AHA) and
others. The Chain of Survival consists of four action steps that must occur in rapid
succession to provide the patient the greatest likelihood for resuscitation: early access
(call 911 or the local emergency number to notify the emergency medical services
[EMS] system and summon on-site help); early cardiopulmonary resuscitation (CPR;
begin immediately); early defibrillation; and early advanced care (transfer care to EMS
professionals upon their arrival at the scene).
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training and no formal medical background to provide the lifesaving intervention of early
defibrillation. AEDs are essential weapons in the current battle against sudden CA, and
so a brief review of their characteristics is in order.
The key components of an AED are as follow:
computer to perform ECG analysis,
battery,
capacitor,
defibrillation pads and connector cable, and
external shell with control buttons.
Although each manufacturers device varies slightly, they are relatively consistent in
their operation. Turning the device on typically initiates a series of verbal instructions.
The device prompts the user to attach the defibrillation pads to the patients chest. By
detecting a change in impedance, the AED knows when the pads have been attached. (In
devices in which the pads are not pre-attached, the device will prompt the user to attach
the connector cable to the AED.) Once the pads are placed on the chest, the device initiates
an electrocardiogram (ECG) analysis, typically evaluating two short segments of ECG
strip for morphology, rate, and nonphysiologic signals (artifact and interference). If
analysis of both of these segments agrees that a shock is indicated, the device charges the
capacitor and advises the user of the finding. When the capacitor is charged, the device
prompts the user to push the shock button. Some devices currently on the market will
warn the user to clear the patient, that is, make sure no one is touching the patient, and
then automatically deliver the shock, without requiring the user to push any buttons. The
AED automatically initiates reanalysis after a shock to determine if another shock is
needed; it will repeat this process for up to three consecutive shocks. After a third consecutive shock, the device will withhold analysis for 1 minute and prompt the user to do
CPR during that interval. In all cases, users are guided by voice prompts that transfer
decision making from the user to the computerized device.
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Cardiopulmonary Resuscitation
The algorithms used to define shockable rhythms in AEDs have been continually
refined over the last 20 years and are now quite sophisticated and accurate. Several
evaluations have found their specificity to be close to 100%, which means that the device
will not shock ECG rhythms that would not be shocked by an advanced care provider
performing manual defibrillation. The sensitivity typically is 90 to 95% with most
misses being very fine VF (14,15).
Multiple models of AEDs are now available and new ones are entering the market on
a regular basis (Fig. 2). They include both new brands and upgraded models of existing
brands. To see the current models on the market, visit the National Center for Early
Defibrillation website (www.early-defib.org) (16).
A variety of AED improvements have been proposed recently. One concern is the
need to shorten the hands-off interval, during which chest compressions are withheld
(17).This interval consists of listening to prompts, applying defibrillation pads, AED
rhythm analysis, capacitor charging, and shock delivery and typically takes 60 to 90
seconds, even for proficient users. Another consideration is whether or not AEDs
should incorporate communication capabilities to automatically alert the local 911
center when and where a device is activated and/or allow the telecommunication officer
to speak with the user directly. Both options add additional cost, size, and weight to the
device. Thus, the dilemma is whether it is better to have the smallest, most portable,
lowest priced devices or to ensure rapid 911 notification and real-time user assistance.
A lower priced device could mean wider distribution of AEDs and hopefully more rapid
availability of a device, whereas an automatic connection would assist users in proper
use of the device and care for the individual and the additional benefit of ensuring
immediate dispatch of EMS.
An intriguing potential development is the incorporation of defibrillation success
prediction guidance. Callaway has demonstrated the ability of the scaling exponent, a
measure of the VF tracings geometric characteristics, to predict likelihood of conversion
to an organized rhythm (18). Others are evaluating the utility of frequency and amplitudebased analyses (19). The clinical relevance is that the AED could base the decision to
shock not just on the presence of VF but also on the likelihood of successful conversion.
For patients with low likelihood of conversion, basic and advanced life support could be
provided prior to defibrillation.
The most optimal defibrillation waveform remains unknown. Most new devices on the
market use biphasic waveforms rather than the previous standard, monophasic waveform. The biphasic waveform at a lower energy level seems to be at least as effective as
the higher energy monophasic and thus can decrease the size, weight, and cost of the
device. Whether a low-energy biphasic waveform or an escalating biphasic waveform is
more effective remains to be determined.
In summary, AEDs have become very simple and easy to use. A minimal amount of
training is required to become familiar with the device In fact, a study comparing untrained,
sixth-grade children and EMTs in the use of an AED illustrates just how easy these devices
are to use: untrained children were able to operate the AED successfully in a time that was
only 27 seconds longer than it took the EMTs to use the device (20).
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Fig. 2. Some automated external defibrillator models currently available. Courtesy of the National
Center for Early Defibrillation, University of Pittsburg (www.early-defib.org). (A) AccessAED
(Access CardioSystems); (B) Samaritan AED (HeartSine Technologies Inc.); (C) LIFEPAK
CRPlus (Medtronic Physiocontrol Corp.); (D) Fr2+ (Philips Medical Systems); (E) AED 10 (Welch
Allyn Inc.); (F) AED Plus (Zoll Medical Corp.).
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Cardiopulmonary Resuscitation
perform closed chest compressions, and provide ventilation and oxygenation. Because
victims in VF and VT have a much higher likelihood of survival than those with other
rhythms, reaching these victims and delivering defibrillation has been emphasized. AEDs
have provided an important means to achieve this goal.
The earliest clinical report of these devices is from Bellingham, Washington, by
Diack and Wayne et al. in 1979 (21). The device was designed to conduct current
between a combination oral airway/metallic electrode in the orophanynx and an electrode on the mid-anterior chest. The device underwent further development and modifications including the transition to more traditional electrode placement on the left and
right anterior chest. Soon thereafter, Cummins, Stults and others demonstrated safe and
effective use of these devices by Emergency Medical Technicians (7,22). In 1989,
Weaver reported that equipping firefighter/first responders in King County, Washington
with these devices would achieve a calculated survival improvement among patients in
VF from 19 to 30% (23). This report provided not only legitimacy to the new technology,
but also a call for their deployment among first responders throughout the country.
Although paid firefighters became first responders in many urban areas, this resource
was not available in many suburban communities. In these locations, police officers were
often the most likely first responders. White et al. in 1996 (24), and Mosesso et al. in 1998
(25), published reports demonstrating successful use of AEDs by police officers. White
found a heretofore never reported survival rate of 45% with roughly similar survival
whether shock was provided by EMS or police officers in Rochester, Minnesota.
Mosessos study in a suburban area near Pittsburgh, Pennsylvania, demonstrated a
marked improvement in survival if police attempted to defibrillate sudden CA victims
upon their arrival rather than waiting for EMS personnel (survival to hospital discharge
26 vs 3%, p = 0.027). Davis et al. reported that police officers in the Pittsburgh study were
able to use the device effectively with minimal errors (26). These studies also demonstrated the devices were safe and rarely malfunctioned.
The evolution of excellent 911 centers and of emergency medical dispatch (i.e., prioritized dispatch and pre-arrival instructions) has also facilitated more rapid deployment
to CA calls. Despite these advances, however, first responders and EMS personnel generally are unable to reach the scene and provide therapy within the very small window of
opportunity afforded to victims of sudden CA.
Therefore, it has been increasingly recognized that the only way to effectively provide
what might be called immediate defibrillation is to have the defibrillator on site and
accessible to the lay bystander. Air travel is one venue in which the need for immediate
defibrillation is overt and which the AED strategy has proven success. The nature of this
venue creates an exceptionally long time interval before traditional EMS is able to
respond. Therefore, Qantas Airlines took what at the time was a bold step to equip
nonmedical personnel, such as flight attendants, with AEDs (27). Subsequently, Richard
Page reported the American Airline experience (28). During a 2-year period, 200 (191 on
aircraft and 9 in terminal) arrests occurred. The Federal Aviation Administration (FAA)
has now mandated that all airlines with at least one flight attendant be equipped with an
AED and that the staff had to be trained in their use.
Determination of other appropriate venues for AEDs is still unfolding. Perhaps the
largest effort to address this question is the Public Access Defibrillation (PAD) Trial (29),
which is comparing survival at sites with teams trained in CPR only vs sites with teams
trained in CPR and AED use and equipped with AEDs. The trial found survival doubled
at sites with AEDs and that no patients were shocked inappropriately (29a). Researchers
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also hope to learn important information about effective response plan strategies and
retraining requirements. The PAD Trial chose locations that would have a reasonable
likelihood of CA by using the criterion of at least 250 people over age 50 present at the
site for 16 hours a day or 500 persons present for 8 hours per day. Response plans were
designed to initiate CPR immediately and apply the defibrillator within 3 minutes of the
individuals collapse.
Several studies have tracked the incidence of sudden CA by type of location. Linda
Becker found in Seattle that CA occurred most frequently at the airport, county jail, large
shopping malls, public sports venues, and large industrial sites. They developed a criterion of greater than 0.03 arrests per year for high-risk locations and found that sites
that met this criterion could be expected to use each AED once every 10 years (30). At
sites that did not meet these criteria, the defibrillator would be used rarely, and thus the
authors question the appropriateness of employing AEDs in those locations. Frank et al.
evaluated CA in Pittsburgh and found that no single location had a particularly high
incidence. The most common venues at which CA occurred were dialysis centers and
nursing homes (31).
Although the concept of deploying AEDs at various public locations is just beginning
to unfold, there are already questions being raised regarding the potential impact of such
a strategy. This is because 57 to 75% (32,33) of CAs occur in private residences. Thus,
only one-quarter to one-third of CAs can even be treated by a public access defibrillation
strategy. Several studies have calculated that public access defibrillation programs,
even if they achieve a high survival rate, will have only minimal impact on the overall
survival in communities (34). This has led some to suggest that the ultimate venue for
on-site defibrillators may be the home. The concept raises a number of issues including
how often arrests at home are witnessed, the feasibility of family members using the
AED in the crisis situation and the cost of placing AEDs in every home (35). A study
exploring these issues is the Home Access Defibrillation Trial by researchers at the
University of Washington. Nevertheless, a number of successful programs and models
providing on-site defibrillation have been reported and a number of important program
components have been identified.
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Cardiopulmonary Resuscitation
3000 were trained; users of the airports were alerted to the fact that AEDs were available in multiple ways: public service videos that repeatedly played in the waiting areas,
pamphlets, and news media. In the initial 2 years of the study, 21 persons experienced
nontraumatic CA; 18 out of the 21 cases were in VF. Eleven of the 18 (a remarkable
61%) survived. In five of these cases, persons who had no training or experience in the
use of AEDs and no official duty to respond used the AED. This study suggests that
there is benefit in making AEDs available to the general public.
When designing response plans, the goal is to provide access to defibrillation as
quickly as possible. All aspects of the program should be designed to facilitate this goal.
How this is achieved often is based on site-specific issues, but should include the components described in the next section, which is based in large part on a comprehensive
guide by Newman and Christenson (37).
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Seek Funding
Sometimes the costs of AED programs are incorporated into agency budgets. In many
cases, however, outside funding is needed. There are many sources for AED program
funding. Organizations and individuals will be more likely to contribute if your task force
either forms a nonprofit 501(c)3 organization or aligns with one, so that contributions are
tax deductible. For funding sources, see www.early-defib.org.
Select Device
Many AED models are on the market. Some issues to consider include ease of use,
compatibility with other devices in use in the service area, maintenance, ongoing manufacturer support, appropriateness for specific venue and expected users, and price. For
device options, see www.early-defib.org.
Conduct Training
AED training generally takes about 2 to 4 hours, including CPR training. Refresher
training should be conducted periodically and is available through on-line programs. Many
experienced AED program coordinators recommend brief (i.e., as little as 10 minutes)
refresher training every 3 months. Several organizations provide nationally recognized
quality programs in CPR and AED use. For training options, see www.early-defib.org.
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Cardiopulmonary Resuscitation
239
citizens were invited to also partake in training and many did so. The first community save
was of a man in his mid-40s on the 11th fairway during a golf tournament. Responders
on bikes arrived with the AED and defibrillated successfully.
All three stages of the AED program initiated by MCHD were met with great enthusiasm by the media, public, and participators, alike. Even groups that were long-standing
political adversaries of MCHD supported the hospital and its use of funds for this effective, lifesaving initiative. Additional support came from a wide variety of sources including government agencies, homeowners associations, businesses, civic associations, and
grants.
To ensure continued quality management of the Montgomery County Hospital Program, all participants in the program follow the single protocol designed by the EMS
medical director. A full-time program coordinator was hired to oversee deployment of
AEDs and the initial and ongoing training activities for 450 lay responders and 15 community sites.
A total of 134 AEDs have been deployed within Montgomery County. The success of
the program is illustrated clearly in the 28 pictures of survivors that hang on the MDHD
Wall of Fame.
Site Assessment
The goal should be that a responder and the AED arrive at the individuals side within
3 minutes of system activation. Thus, site assessment must evaluate time to respond to
various locations at the site and potential obstructions, such as entries with restricted access
that might delay response. Occupancy and visitation rates also should be evaluated.
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Cardiopulmonary Resuscitation
with the medical advisor and approved by top management. It should address the following components:
Identification and training of the response team
Specific roles of team members
AED placement
Internal and external (911) notification systems
Response system function during operational hours
Periodic AED drills
Postevent review and feedback.
Select Device
There are a variety of different AED brands and models on the market. The various
models should be evaluated for a good fit in a particular setting based on site-specific
issues including storage conditions and personnel who will be using the device. For
device options, see www.early-defib.org.
Conduct Training
Personnel designated to respond should receive formal training in both basic CPR and
use of the AED. This generally can be accomplished in 3 to 4 hours of training initially
with retraining conducted in a very brief fashion every 3 to 6 months. Formal retraining
is recommended every 2 years. There are a number of organizations that provide nationally recognized quality programs in CPR and AED use. Additionally, there are also
private companies that provide training. (For information, see www.early-defib.org.) If
resources allow, one should consider opening training to all occupants of a site even if
they are not part of the formal response team.
Device Installation
Device placement depends on the response plan. If the plan provides for delivery of
the AED by designated individuals, such as a security team, then deployment should
enable these personnel to have immediate and direct access to the device at all times.
Whenever possible, devices should be deployed in such a way that they are also readily
accessible to other occupants and visitors to the building to increase the likelihood of
timely use. There are a number of brackets and enclosed cases designed for wall mounting
of devices. These can be armed with alarms, both audible and visual, and can be connected to either an on-site communication center or the local 911 call center. Signage
indicating the location of the device should be installed to enable it to be visible down
hallways from a distance. The NCED suggests using a standard symbol for AEDs (Fig. 3).
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Fig. 3. Symbol for AEDs promoted by The National Center for Early Defibrillation.
response plan. One such strategy is to place signage and pamphlets at entryways and
lobbies of buildings on the availability of AEDs and how to activate the on-site response
team when applicable.
Continuous Evaluation
The on-site AED program should be assessed on a regular basis to ensure its effectiveness, especially the timeliness of response. After every event, the program coordinator
and medical consultant should evaluate individual responses and use of the AED. Feedback should be provided both to individuals and to the entire response team. Regular
reminders about when and how to activate the response team should be provided to all
building occupants.
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Cardiopulmonary Resuscitation
volunteered to lead an evacuation of the building in the case of fire. The duties of the fire
marshals were expanded to lead in the use of an emergency response involving the AED
and their title was changed to emergency response marshals. This group, along with some
additional volunteers, was trained in CPR and AED through the AHA Heartsaver AED
course. They have been recertified every 2 years and receive shorter refresher training
every 6 months.
The Hillman security system is used to activate the on-site response plan. Security
buttons existed throughout the company under desks and near phones. Pressing one of
these buttons alerts the guard at the front lobby security desk when and where an emergency occurs. The guard, in turn, calls 911, retrieves an elevator and guides the emergency medical technicians to the patient. After hours when no guard is on duty, the
marshal places the call directly to 911. If alone, he or she can use a speed dial number to
activate the public announcement broadcasting system and call any employee in the
building to come and help.
All the components of the AED program are contained in a comprehensive policies and
procedures manual. The manual includes information such as the placement of the AEDs;
the names of the emergency response marshals; the procedures for calling for help; an
explanation of how to perform CPR and use the AED that they had purchased for the
company; checklists for the maintenance of the device, procedures for the reporting any
event involving the AED to the medical director; and answers to frequently asked questions about AEDs.
The program was registered with the State of Pennsylvanias Emergency Medical
Services Institute, and coordinated with the local ambulance service to help ensure seamless transfer of care. It was established that if the AED is ever used, the medical director
will be contacted within 24 hours to review the response, together with the data stored in
the AED, for the purpose of quality improvement. Although tested in a successful mock
drill, the program has, fortunately, not been put to the test in a real situation. Hillman
Company employees can rest assured, however, that if a CA event does occur, the on-site
emergency response plan should ensure rapid and effective treatment.
SUMMARY
Although sudden CA remains a leading cause of death in the Western world, the advent
of AEDs is allowing a new assault on this stealth, silent killer. These devices allow lay
bystanders and nonmedical emergency responders to provide defibrillationthe only
known effective therapy for VF. AEDs are safe and effective, easy to use and difficult to
misuse, require low maintenance, and are becoming less costly. A growing number of
communities and specific venues have reported successful early defibrillation programs.
Public access defibrillation is a critical component of the optimal intervention strategy
for combating sudden CA.
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ACKNOWLEDGMENTS
The authors would like to thank Chrysia Melnyk for her superb assistance with the
preparation of this manuscript.
REFERENCES
1. Eisenberg M. Life in the Balance. Oxford: Oxford University Press, 1997.
2. Page JP. The Paramedics. Morristown, NJ: Backdraft Publications, 1979.
3. Pantridge JF, Geddes JS. A mobile intensive care unit in the management of myocardial infarction.
Lancet 1967; 2:271.
4. Grace WJ, Chadborn JA. The mobile coronary care unit. Diseases of the Chest 1969; 55:452455.
5. Eisenberg MS, Bergner L, Hallstrom A. Cardiac resuscitation in the community: importance or rapid
provision and implications for program planning. JAMA 1979; 241:19051907.
6. Stults KR, Brown DD, Schug VL, et al. Prehospital defibrillation performed by emergency medical
technicians in rural communities. N Engl J Med, 1984; 310:219223.
7. Newman M. Chain of Survival takes hold. JEMS 1989; 14(8):1113.
8. Cummins RO. Ornato JP. Thies WH. Pepe PE. Improving survival from sudden cardiac arrest: the chain
of survival concept. A statement for health professionals from the Advanced Cardiac Life Support
Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation
1991; 83:18321847.
9. Lombardi G, Gallagher J, Gennis P. Outcome of out-of-hospital cardiac arrest in New York City: The
Prehospital Arrest Survival Evaluation (PHASE) study. JAMA 1994; 271:678683.
10. Becker LB, Ostrander MP, Barrett J, Kondos GT. Outcome of CPR in a large metropolitan area where
are the survivors? Ann Emerg Med 1991; 20:355361.
11. Callaway CW. Improving neurologic outcomes after out-of-hospital cardiac arrest. Prehosp Emerg Care
1997; 1:4547.
12. Spaite DW, Valuenzuela TD, Meislin HW, Criss EA, Hinsberg P. Prospective validation of a new model
for evaluating emergency medical services systems by infield observation of specific time intervals in
prehospital care. Ann Emerg Med 1993; 22:638645.
244
Cardiopulmonary Resuscitation
13. Nichol G, Laupacis A, Stiell IG, et al. Cost-effectiveness analysis of potential improvements to emergency medical services for victims of out-of-hospital cardiac arrest. Ann Emerg Med 1996; 27:711720.
14. Herlitz J, Bang A, Axelsson A, Graves JR, Lindqvist J. Experience with the use of automated external
defibrillators in out of hospital cardiac arrest. Resuscitation 1998; 37:37.
15. Macdonald RD, Swanson JM, Mottley JL, Weinstein C. Performance and error analysis of automated
external defibrillator use in the out-of-hospital setting. Ann Emerg Med 2001; 38:262267.
16. National Center for Early Defibrillation, University of Pittsburgh, Pennsylvania. http://www.earlydefib.org
17. Yu T, Weil MH, Tang W, et al. Adverse outcomes of interrupted precordial compression during automated defibrillation. Circulation 2002; 106:36872.
18. Callaway CW, Sherman LD, Mosesso VN, Jr., Dietrich TJ, Holt E, Clarkson MC. Scaling exponent
predicts defibrillation success for out-of-hospital ventricular fibrillation cardiac arrest. Circulation 2001;
103:16561661.
19. Jekova I, Deshanova J, Popivanov D. Method for ventricular fibrillation detectin in the external electrocardiogram using nonlinear prediction. Physiol Meas 2002; 23:33745.
20. Gundry JW, Comess KA, DeRook FA, Jorgenson D, Bardy GH. Comparison of nave sixth-grade
children with trained professionals in the use of an automated external defibrillator. Circulation 1999;
100:17031707.
21. Diack AW, Welborn WS, Rullman RG, Walter CW, Wayne MA. An automatic ardiac resuscitator for
emergency treatment of cardiac arrest. Medical Instrumentation 1979; 13:7883.
22. Cummins RO, Eisenberg MS, Litwin PE, Graves JR, Hearne TR, Hallstrom AP. Automatic external
defibrillators used by emergency medical technicians; a controlled clinical trial. JAMA 1987; 257:
16051610.
23. Weaver WD, Hill D, Fahrenbruch CE, et al. Use of the automatic external defibrillator in the management of out-of-hospital cardiac arrest. New Engl J Med 1988; 319:661666.
24. White RD, Aspin BR, Bugiosi TF, Hankins DG. High discharge survival rate after out-of-hospital ventricular fibrillation with rapid defibrillation by police and paramedics. Ann Emerg Med 1996; 28:480485.
25. Mosesso VN, Davis EA, Auble TE, Paris PM, Yealy DM. Use of automated external defibrillators by
police officers for treatment of out-of-hospital cardiac arrest. Ann Emerg Med 1998; 32:200207.
26. Davis EA, Mosesso VN. Performance of police first responders in utilizing automated external defibrillation on victims of sudden cardiac arrest. Preshosp Emerg Care 1998; 2:101107.
27. ORourke MF, Donaldson E. The first five years of the Qantas cardiac arrest program. J Am Coll Cardio
1997; 29:404.
28. Page RL, Joglar JA, Kowal RC, et al. Use of automated external defibrillators by a US airline. N Engl
J Med 2000; 343:12101216.
29. Public Access Defibrillation Trial Investigators. PAD Trial study design and rationale. Resuscitation
2003; 56: 135147.
29a.Ornato JP, et al. The Public Access Defibrillation Trail. American Heart Association, Late-Breaking
Clinical Trials Plenary Session VII, November 2003, Orlando, FL.
30. Becker L, Eisenberg M, Fahrenbruch C, Cobb L. Public locations of cardiac arrest: implications for
public access defibrillation. Circulation 1998;97:21062109.
31. Frank RL, Rausch MA, Menegazzi JJ, Rickens M. The locations of nonresidential out-of-hospital
cardiac arrests in the City of Pittsburgh over a three-year period: implications for automated external
defibrillator placement. PEC 2001;5:247251.
32. Cobb LA, Fahrenbruch CE, Walsh TR. Influence of cardiopulmonary resuscitation prior to defibrillation
in patients with out-of-hospital ventricular fibrillation. JAMA 1999;281:12201222.
33. Litwin PE, Eisenberg MS, Hallstrom AP, Cummins RO. Location of collapse and its effect on survival
from cardiac arrest. Ann Emerg Med 1987;16:669672.
34. Pell JP, Sirel JM, Marsden AK, Ford I, Walker NL, Cobbe SM. Potential impact of public access
defibrillators on survival after out of hospital cardiopulmonary arrest: retrospective cohort study. BMJ
2002;325:515520.
35. Newman MM, Mosesso VN, Paris PM. AEDs in the home: a position statement from the National
Center for Early Defibrillation. National Center for Early Defibrillation website <http://www.earlydefib.org> Accessed: January 2002.
36. Caffrey SL, Willoughby PJ, Pepe PE, Becker LB. Public use of automated external defibrillators. N Engl
J Med 2002;347:12421247.
37. Newman MM, Christenson JM. Challenging sudden death: a community guide to help save lives.
Carmel, IN: Catalyst Research and Communications, Inc., 1998.