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Cardiac Death in Children and Adolescents... Can We Prevent It?
By: Dr. Stuart Berger Introduction This article is based on Dr. Stuart Berger's presentation to the chapter presidents of the National Association of School Nurses on June 29, 2000. Dr. Berger is the medical director of the pediatric heart transplant program and the Heart Center at Children's Hospital of Wisconsin. He is also the medical director of Project ADAM™, section chief of pediatric cardiology in the department of pediatrics, and associate professor of pediatrics at Medical College of Wisconsin in Milwaukee. The presentation was sponsored by School Health Corporation, Medtronic Physio-Control, and Good-Lite. Adam Lemel was an outstanding athlete. At 17, he was a star basketball player and one of the best high school tennis players in Wisconsin. While playing basketball at a neighboring Milwaukee high school in January 1999, he collapsed during a time-out. Tragically, Adam was dying on the basketball court, and not until the paramedics arrived, was CPR begun. By that time, it was too late. Adam died. His autopsy revealed a rare condition known as arrhythmogenic right ventricular dysplasia (ARVD). One month later, Wilmot High School student Mark Barranco, 18, also experienced sudden cardiac death (SCD) while playing basketball. His autopsy revealed an anomalous left coronary artery. The following November, a Milwaukee Technical High School football player died of SCD while playing basketball with friends. And, in April 2000, two more Milwaukee-area deaths were attributed to SCD: a Marquette University senior and a visiting 12-year-old baseball player from Illinois. On autopsy, all three had hypertrophic cardiomyopathy. These events in Milwaukee occurred in just over a year's time. Seventy miles away, a 14-year-old Manitowac student, Craig Handl, collapsed while playing basketball at recess. This time, the cardiac arrest did not end in tragedy. Within three minutes, the emergency team arrived on the scene and began CPR. Within five minutes of Craig's collapse, the paramedics used an automated external defibrillator (AED) to "jump-start" his heart. They then defibrillated Craig's heart four more times. Craig not only survived, but he also made a full recovery. The medical team determined that his SCD was caused by long QT syndrome (LQTS). Since LQTS is a hereditary condition, Craig's family members were evaluated. His brother and father were also found to have LQTS. In order to prevent their premature deaths, internal defibrillators were implanted in all three family members. These cases make three points. First, although more common in adults, SCD can occur at any age-even in apparently healthy children and adolescents. Second, early intervention in SCD is essential. As was true in Craig's case, a combination of CPR and the use of AEDs can save lives. Third, some individuals who are at risk for SCD, like Craig's brother and father, can be identified to prevent their premature deaths.
What is SCD? SCD occurs when there is a total cessation of the heartbeat, often as a result of ventricular fibrillation. Ventricular fibrillation can result from lack of oxygen (ischemia) to the heart muscle or from a primary electrical disorder (arrhythmia). In either case, ventricular fibrillation leads to an ineffective quivering of the heart. Death quickly ensues if the heart's electrical impulses are not converted to an effective, blood-pumping rhythm. This "defibrillation" can be achieved with a machine called a defibrillator. A defibrillator administers an electrical shock that often "jump-starts" the heart into a normal rhythm. Survival depends on how quickly the defibrillator is used. Research demonstrates there is only an 8-10 minute window of opportunity for a successful rescue-and the greatest chance for survival occurs within the first three minutes. For each minute that passes without defibrillation, survival decreases seven to 10 percent. Who's
at Risk?
Many children and
teens at risk for SCD do not experience symptoms. The first sign or symptom
is the SCD itself.
Echocardiography (ultrasound) and directed electrocardiography (ECG) can identify some high-risk students. Even so, there is no test or combination of tests that will identify every student at risk for SCD-even if those tests are performed on every high school athlete.
AEDs: Lightweight and Easy to Use Although every at-risk student cannot be identified, the chance for survival can be improved. Schools can prepare for an SCD emergency with CPR and AED training. With the availability of AEDs in schools, time to defibrillation can be drastically reduced. Because rates of resuscitation from SCD are directly related to time to defibrillation, AEDs can enhance survival rates and reduce the risk of brain damage due to oxygen deprivation. Originally, defibrillators were large, heavy, and cumbersome. They required advanced skill and training, an understanding of EKG rhythms and knowledge of when to shock and how much current to use. Consequently, these older model defibrillators were found mostly in hospitals. Modern defibrillators, or AEDs, are much more versatile. They are lightweight and portable. They also have sensors that automatically make a "decision" whether or not to defibrillate. Voice prompts guide the rescuer through the process. Research studies have shown that modern AEDs are so easy to use that minimally trained sixth graders can correctly operate the device almost as quickly as emergency medical personnel. AEDs are now found in airports, casinos, golf courses, police cars, schools, shopping malls, sports arenas, and wherever large groups of people congregate. One manufacturer of portable AEDs is Medtronic Physio-Control. The pioneer of the industry, Medtronic Physio-Control offers AED machines that meet the requirements set by the American Heart Association, American Red Cross, and Consumer Products Safety Commission. AEDs in Schools: Destiny or Fantasy? School AED programs can save not only the lives of students, but also the lives of faculty members, parents, grandparents, and other school visitors or sports spectators. Additionally, these programs increase awareness of the issues, risks, and symptoms surrounding SCD-and the dire consequence of ignoring symptoms. AED training programs also include CPR instruction, which can be incorporated into high school curriculum and faculty education. With such life-saving potential, why are AED programs not available in more schools? Some school personnel may fear the liability of owning and operating AEDs. However, with the increasingly widespread availability of these machines, this concern may be shifting. Those without AEDs may be exposing themselves to legal risk. (Note: In September 2000, United Airlines agreed to pay $18 million in to a woman whose 37-year-old husband died on a plane that had not been equipped with a defibrillator.) Other school administrators may hesitate because of financial concerns (at the time this article was written, AEDs cost about $3,500 - they now cost between $2,500 and $3,000). Some schools have bought AEDs with the support of local corporations or donors. In other schools, parent associations have paid for defibrillator programs through fund-raising efforts. On the other hand, school officials simply may not be aware that AEDs can be placed in schools. Or, if they are aware, they may not know where to access information and resources that explain how to introduce these devices and programs into schools.
School Nurses: Key to Implementation School nurses are key to the success of AED programs. Just as school nurses oversee school-wide screening programs for hearing, vision, and other health issues, they are ideally suited to take the lead in developing AED programs. Interested school nurses can begin by obtaining available AED program resources. Local heart associations and manufacturers of AEDs, such as Medtronic Physio-Control, are valuable sources of information. They can provide guidance, direction, and support. They can answer logistical questions, such as how many defibrillators a school needs and where they should be placed. For example, a sprawling high school or college campus may need several AEDs-one near the gymnasium, another in the administrative offices, another in the student union. Distributors, such as School Health Corporation, offer not only AEDs, but also step-by-step resource booklets. One such booklet is Public Access Defibrillation in Schools-Project ADAM™. (The Project is named for Adam Lemel, the high school student who died of SCD in January 1999.) Written by the staff members of Children's Hospital of Wisconsin, the booklet includes worksheets and check lists to prepare for an AED program. It's important to involve principal players early in the planning process. These should include a physician, representatives from the local emergency medical system, area hospital, and local corporations as well as school administrators, board members, and faculty. Because each state has its own legislation regarding the operation and maintenance of AEDs, it is also important to become familiar with state laws and to review them with legal counsel. Generally, local heart associations, AED distributors or manufacturers can provide this information. Once a commitment has been made to establish an AED program in the school, approximately 10-20 key people should be trained in CPR and the use of the AED. In addition to school nurses, this group might include athletic trainers, coaches, teachers, referees, custodial staff, and others. Ongoing education and training is essential. Mock drills will increase the likelihood that schools will be prepared for SCD at anytime. Summary: AEDs in Wisconsin When Adam Lemel died in 1999, he left behind friends, family members, and a future. To ensure that Adam's death was not in vain, childhood friend David Ellis joined forces with Children's Hospital of Wisconsin to initiate Project ADAM™ (Automatic Defibrillators in Adam's Memory). Their shared vision includes the following goals:
Today, Project ADAM™ has successfully introduced AEDs into several Wisconsin schools. School nurses have played an integral role in these cases. (See sidebar.) It is their hope that sudden cardiac death will be a topic that students simply study in health class-not an event they witness in their schools.
Sidebar: Making A Difference: The Gift of an AED Program By: Karen Smith, R.N. Karen Smith is Coordinator of Nursing Services and Special Activities at Pewaukee School District, Pewaukee, Wisconsin. There are times in life when you realize you can really make a difference in students' lives. When Registered Nurse Pam Marlin, Health Room Aide Fran Holloway, and I decided to pursue the dream of an AED program in our school district, we knew this was one of those times. Our administrators, teachers, and community members were very supportive, and the kids were absolutely fascinated with the technology. The first step we took was to lay the groundwork. We found the ideas in Public Access Defibrillation in Schools: Project ADAM™ guided us through this process. We shared these Project ADAM™ materials and newspaper articles on AEDs with our administrators and insurance carrier. Next, we invited Pediatric Cardiologist Stuart Berger, M.D., to speak to our administrative team, insurance carrier, athletic department personnel, and health teachers. After Dr. Berger's in-service, Pam, Fran, and I went for AED instructor training. About the same time, we heard that the local Masons were looking for a philanthropy project, so Pam, Intensive Care Physician Rainer Gedeit, M.D., and I headed for the Masonic Lodge to present an in-service. Within a few months, the Masons gave us a check for $4,000. At the same time, we developed crisis plans with our local emergency medical system. How would we handle a rescue in the day, evening, or weekend? How would we transfer the defibrillator to the hospital with the patient? (The AED holds crucial information about the SCD event, such as rhythm strips, numbers of shocks and corresponding joules.) Because we believe education is key, we set up a booth at our annual blood drive. We presented in-services to all staff members at our four schools, distinguishing between cardiac arrest and myocardial infarction and demonstrating how a defibrillator works. With the help of juniors and seniors in our health volunteer program, we educated our 600 high school students about cardiac arrest and AEDs. As a result of these educational efforts, we received some unexpected benefits: the National Honor Society purchased the AED case, drama students donated half their play proceeds to our project fund, and parents and grandparents called to offer their financial support. We also spoke to our parent teacher organization and the Booster Club; both groups made significant contributions. Along with education, we provided AED training for key personnel, including custodians, coaches, teachers, and our health room staff. Finally, we enhanced the health curriculum. We added CPR and AED demonstration to the tenth-grade this year. Next year, we'll add AED training and certification in tenth grade. In the eleventh and twelfth grade, we'll re-certify students. The education continues through the summer when we'll open AED training to high school students whom we missed (because we started with the tenth grade) and to community and staff members. What a tremendous gift and opportunity we have as school nurses: to be able to educate an entire community, reduce the risk of sudden cardiac death, and send children out into the world who know how to save lives.
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