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- Article #3-

Case Studies and Commentary

NOTE:
Number in article is a LINK to footnote

As a disclaimer, it should be remembered that each case is fact specific. Would the outcomes have been different, is unanswerable. What is answerable is what was done by the responding personnel and the kind of equipment which was available in response to the emergency. Had emergency response equipment, e.g., an AED and emergency oxygen been readily available, opinions can be given as to the outcome (see liability). The following is an opinion on some of the cases.

Cases Where Oxygen Was Not Used

1.) SCHOOL
A child in an Alabama school suffered a cardiac arrest (2003). The school district had acquired 40 AED's but opted not to purchase emergency oxygen equipment that would have accompanied the AED. Newspaper articles reported CPR was given as the student was shocked three times over a period of 8-10 minutes but did not resuscitate. EMS arrived, medication was given and the child was successfully defibrillated. The concern now is one of irreversible brain damage because of the delay.

Not reported, but obviously, one of the major differences between the defibrillation method of the EMS and that employed by the school was in the use of oxygen. It is known that the more hypoxic the victim, the harder it is to defibrillate. Also, what was not stated in the article is whether the student was initially breathing at the time of emergency and whether the student then went into cardiac arrest.

Incidentally, the school district reported a successful defibrillation on another student the same week. As stated earlier each case is different. Perhaps the blood oxygen content was sufficiently high to achieve successful defibrillation without supplemental oxygen. Presumably, oxygen post defibrillation was given by EMS; there was no apparent neurological damage for failure to provide oxygen post defibrillation, only time will tell.

2.) SCHOOL
A student attending school in central PA collapsed in class after recess (2002). Newspaper articles reported the school nurse gave CPR but the student did not become conscious. A defibrillator was brought from the high school but defibrillation was not successful. Not much is known from the newspaper reports, but CPR with supplemental oxygen would have been better.

3.) SCHOOL
2 children from Delaware and one from New Jersey died from an attack of asthma. Newspaper reports indicated CPR was given. Administration of oxygen may have prevented these deaths.

4.) O'HARE AIRPORT
O'Hare was, it is believed, the first airport to install public access AED's. O'Hare opted not to incorporate emergency oxygen with their AED's allegedly because they had an EMS unit on site and would arrive within 3 minutes. Their report for the first two years, in operation, has been published. 1 O'Hare reported that 26 patrons were treated, 4 did not have cardiac arrest, 2 had seizures, 1 shortness of breath. In those cases, the defibrillator was used as a monitor. 18 victims were in ventricular fibrillation. 11 were given CPR and successfully defibrillated; 7 individuals did not defibrillate, i.e., 39%. All survivors were given CPR and one for 10 minutes between episodes of ventricular fibrillation before eventually being resuscitated. Relevant to response time, it was reported that HeartSave trained personnel standing next to a defibrillator took at least two minutes to ready the patient and the equipment.

Commentary on O'Hare report. First, what cannot be overlooked is that 39% of the victims did not successfully defibrillate and of those that did, some required several shocks. Whether early administration of oxygen with CPR instead of mouth to mask CPR would have made a difference is conjecture, but it is known that CPR provides a low concentration of oxygen to the victim. Victims that are hypoxic are not easy to defibrillate. Second, the patrons who were monitored with the defibrillator would have been better off with oxygen. Third, oxygen in the first two minutes necessary to ready the equipment, retrieve the CPR mask, and the victim may have averted a cardiac arrest in the case where the victim is not yet in cardiac arrest. The lay responder does not know the exact situation until the AED advises whether or not to " Shock". A better plan is to have the combination unit with oxygen readily available.

5.) PITTSBURG AIRPORT
A prominent university basketball coach suffered a heart attack in the airport. The airport has public access AED's stored in a single cabinet. Oxygen is not available with the AED's. Oxygen is available only on arrival of EMS. In the case of a heart attack, the defibrillator is of no value. Did the lack of oxygen in the time interval between the heart attack and arrival of oxygen aggravate the injury?

6.) FITNESS CENTER 50+ male suffered apparent heart attack and passed out. CPR administered. EMS arrived in about 10 minutes and successfully defibrillated. Brain dead. Oxygen was not administered prior to EMS arrival.

Contrast The Following Cases Where The Facilities Maintained
The Combination Unit And The Victim Benefited From The Oxygen.

1.) MALL
Female staff member at a JC Penny lost consciousness, O2 administered. Defibrillator did not fire. Became conscious with O2 and the victim transferred to hospital. Victim Survived.

2.) SYNAGOGUE
Elderly male collapsed during service of apparent cardiac arrest. Oxygen administered CPR and Defibrillator fired. Victim received an internal defibrillator at hospital and lived.

3.) COMMERCIAL PILOT
Suffered an apparent heart attack while practicing in a simulator. The pilot passed out. When O2 was administered the pilot revived. The pilot suffered from a hemorrhage, not a heart attack. Had the pilot been in ventricular fibrillation, the outcome may have been different, thus showing the necessity of the combination unit.

4.) MALL
88 year-old female passed out, recovered, and passed out again. O2 administered, no pulse; defibrillator prepped. The women recovered on O2; defibrillator did not fire. Episodic ventricular
tachycardia.

The above cases are but a few illustrating that in an emergency the lay responder needs to be able to address not only the cases of ventricular fibrillation by the use of an AED, the lay responder needs to address other types of emergencies, such as, respiratory difficulty or to prevent the victim from critically deteriorating during post defibrillation and that includes the administration of oxygen.

Footnote:

1.) Public Use of Automated External Defibrillators, Sherry L. Caffrey et al, N. Engl. J. Med., Vol. 347, No. 16 October 17, 2002 p1242-1246. Back to Article