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Bringing Automated External Defibrillators (AEDs) into School Settings

Reprinted with permission courtesy of School Health Professional. Published in the October 18, 2000 issue. For subscription information, call 1-800-421-2795.

Heart Association Says Skip Pulse Check

Laypersons doing CPR should skip the pulse check, says the American Heart Association. The recommendation is part of a major revision of the organization's recommendations for CPR and cardiovascular emergencies.

The new emergency cardiovascular care guidelines cover a variety of topics such as CPR, automated external defibrillators (AEDs) and recommendations for emergency medical personnel. One of the major changes is the recognition that a pulse check is unreliable and a recommendation that no pulse check be done before bystanders begin administering chest compressions to an unconscious person.

The guidelines also place major emphasis on early defibrillation for ventricular fibrillation and AEDs as a tool to increase sudden cardiac arrest survival.

The full text of the guidelines is in the Aug. 22 Circulation: Journal of the American Heart Association available online at or at:

You're watching a varsity basketball game on a Friday night when suddenly a player collapses and goes into cardiac arrest. What are you prepared to do other than administering CPR (cardiopulmonary resuscitation)? What if you're not at the game; will someone else know what to do?

It's a scenario that's not as rare as you might think. Last year four students collapsed at sporting events in southern Wisconsin, says Becki Hirschy-Wolkenheim, RN, MS, a learning specialist with Children's Hospital and author of "Public Access Defibrillation in Schools."

"In 1999, we had four cases where teenagers collapsed, three of them died, all on a basketball court or playing pick up," she explained. One, Adam Lemel, a popular 17-year-old competitive athlete was taken to Children's after he went into cardiac arrest during a Friday night basketball game. Adam's death so moved cardiologist Dr. Stuart Berger that he started looking into the incidence of cardiac arrest among adolescents.

"While the incidence is 1 in 200,000, we had four incidences in 1999 in southern Wisconsin alone. We have since tracked five incidences in northern Illinois and one in Michigan. Either the problem is underreported ... or we are seeing more of this," said Hirschy-Wolkenheim.

Berger and a close friend of Adam's came to the local heart association looking to do something about the problem. The two joined forces with Hirschy-Wolkenheim and put together a program that trains students, faculty and staff about the acquisition and use of automatic external defibrillators (AEDs).

AEDs are medical devices with two electrodes that are applied to the chest. The device automatically senses the heart rhythm and determines whether a lifesaving electric shock is necessary. The AED prompts the user to deliver a shock and all the bystander has to do is press the "shock" button. Prompt bystander CPR combined with early defibrillation have produced survival rates exceeding 50 percent in some early defibrillation programs.

AEDs in high school setting make sense for a lot of reasons: the typical sudden cardiac arrest in an adolescent is often related to a congenital problem such as a transposed coronary artery that causes no symptoms - or mild symptoms that are easy to ignore.

Before and after school, community groups (including many older people at higher risk for cardiac arrest) use the school during athletic and social events. "With proper training of employees, the device will benefit far more people that just the kids," said Hirschy-Wolkenheim.

If AEDs were inexpensive, they'd probably be everywhere. "You get down to the final question, what is a life worth? If it's my kid, you go ahead and spend millions to put one on every wall in Wisconsin," said Hirschy-Wolkenheim.

On the positive side, AEDs are safe and easy to use. "This device is extremely safe. Studies have been done that show it's so simple to operate that 8-year-olds have been able to figure it out without training. That shows you how simple and reliable the device is," said Hirschy-Wolkenheim. A study published in "Circulation" found that sixth-graders with no training were able to correctly use AEDs, and use them at an only modestly slower pace (90 second versus 67 seconds) than trained EMTs (emergency medical technicians).

What about the potential for misuse? Can kids shock each other with AEDs? Nope, the device will not deliver a shock unless it detects a shockable rhythm, said Hirschy-Wolkenheim.

And AEDs work. "The reports coming back from the field via research is that we're looking at 60 percent and 70 percent survival rates compared to 20 percent for CPR," she said.

The key to a successful AED program is training and who better than the school nurse to do that training and to lead the effort to buy an AED? "It's a wonderful opportunity for school nurses to say, 'Here's a program we can get into and another case in point where we're really needed in schools.'"

"Public Access Defibrillation in Schools" is basically a cookbook with recipes for AED planning, purchasing and training. "We talked to schools and saw where they were getting stuck. We came up with what we think is a workable program. It tells them when you're planning to do this, follow these steps. When you're implementing this, follow these steps," with the emphasis on training," said Hirschy-Wolkenheim.

The guidebook supplements the AED training available from the local chapters of the Heart Association and the National Safety Council. It offers sample forms that will make sense to teachers and offers suggestions specifically for schools - for instance two of the prime populations to train are high school custodians and security guards because they're at school whenever the doors are open.

"We developed four training and practice role-plays specific to a high-school situation," said Hirschy-Wolkenheim. And while the book doesn't include college settings, it would be very easy to take the settings and modify them to fit post-secondary role-plays, she added.

So what does an AED cost? Right now, there are three FDA (Food and Drug Administration)-approved AEDs, which range in cost from about $2,500 to $4,000. Lithium battery packs and cases can add another $200 to the price tag. Hirschy-Wolkenheim doesn't recommend one AED over another, but she does recommend planning for hidden costs.

"It's not just buying the machine. You need safe storage and that doesn't mean locking it up in the principal's office. If you can only afford one device install it in the front entrance in an alarmed box, but not hard wired (meaning if you open the door an alarm will ring but it won't alert emergency responders)," she suggested.

Symptoms that Need Another Look

Here's a list of questions you can use to screen athletes for hidden cardiac problems:
  1. Have you ever had chest pain with exertion?
  2. Have you ever fainted with exercise?
  3. Do you have episodes of palpitations where your heart feels like it's jumping out of your chest?
  4. Do you experience shortness of breath with exercise?
  5. Does your family have a history of cardiac anomalies or cardiac problems?
The cost to train in Wisconsin is $50 per person. After receiving proper training, a school nurse or health education teacher can then train students, staff and faculty. "If you have your own internal training system, it's going to be much less expensive," said Hirschy-Wolkenheim.

The training you need may be specified by one of 40 state laws governing AEDs. This month, Congress is looking at two bills relating to CPR (cardiopulmonary resuscitation) and AEDs. H.R. 4506, the Teaching Children to Save Lives Act would provide funds to teach CPR to 6th-12th-graders. The second bill, the Cardiac Survival Act would cover AED use.

Once you've gotten an AED, take the next step, Hirschy-Wolkenheim urged. "We highly recommend that schools make CPR and AED training a mandatory requirement for high school graduation. They're life skills. There are a few school districts out there that are considering putting this into their health curriculum. We recommend that kids come out of high school knowing all about this," she concluded.

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