September 26th, 1999
To the Chair, American Heart Association
Dear Sirs/Madams,
It is our great pleasure to join the AHA Second International Evidence Evaluation Conference at Dallas. We also than all of you who kindly take time to read our proposal for this conference.
Tesuo Hatanaka, MD, PhD
last updated; 990923
Contents
2. The current state of Advanced Life Support in Japan
3. Problems related to life support terminology
4. Striving for an increase in the citizen-initiated resuscitation rate
II. Our Comments on the ILCOR Advisory Statements
The association, from its formation on has held a deep interest in the way that cardio-pulmonary resuscitation (CPR) is performed in Japan, and has provided information to Japanese emergency medical workers regarding the global standardisation of resuscitation methods our translation of the ILCOR Advisory Statements. At the same time, we have stressed the necessity for a council to undertake the standardisation of resuscitation methods within Japan, and we are pleased to announce the creation of the Japanese Resuscitation Council in July 1999.
In this conference, we would like to cooperate with the representatives of the Japanese Resuscitation Council as much as we can, to discuss Japanese thinking on resuscitation, problem points and evidence, and in turn to report the findings of this conference to those involved in emergency medicine in Japan.
It is extremely important to prepare appropriate translated materials when one is to introduce new ideas and movements from other countries, and not merely in the medical field. Also, with the spread of the Internet, many of these resources are to be found on various academic related sites, making valuable and beneficial information available to those involved with resuscitation.
With the approve of the AHA, an Osaka group last year published the Japanese translation of "The Utstein Style" (originally published through the efforts of the AHA in 1991). Our association in turn has made this translation available on the Internet, at the AHA homepage.
http://www.americanheart.org/utstein/
AHA volunteers have nearly completed a high-grade Japanese translation as well as an Internet version of the ILCOR Advisory Statement (originally published in 1997), and this material has also been supplied as a discussion document to the Japanese Resuscitation Council. We have distributed printed copies of the Japanese version of the ILCOR Advisory, with the approval granted from ILCOR and the AHA, and we strongly hope that Japanese emergency medical workers will come to understand the spirit of ILCOR. We would also like to ask ILCOR and the AHA for permission to publish the Japanese version of ILCOR.
Moreover, we would like to translate the AHA Guidelines 2000, due to be published next year, and to provide Japanese emergency medical workers with comprehensive and easily understood resource materials in the shortest time span possible. Our association would therefore like to request translation and publication permission and rights regarding the AHA Guidelines 2000 as well as the ILCOR Advisory Statement.
The limits on advance life support that emergency medical technicians will be able to perform are currently under debate on a national level. However, there is no expectation of early defibrillation by first responders being introduced into Japan anytime soon. The Japanese Resuscitation Council is expected to create resuscitation guidelines for Japan based on the ILCOR Advisory Statement and the AHA Guidelines 2000; it is clear, however, that differing reports will and do exist. We, the Japanese emergency medical-related personnel attending this conference, feel it is necessary to explain this matter in detail.
a) The standardization of resuscitation rate evaluation
Roughly 15% of pre-hospital cardiac arrest patients in Japan receive resuscitation from lay citizen, and while we can see a steady upward trend in this, with less than 10% of patients being resuscitated by our citizen only a few years ago, it is still unsatisfactory considering the high literacy rate and low rate of infectious disease carriers in Japan.
However, if we compare citizen-initiated resuscitation rates among various countries and various regions within Japan, we can see that no appropriate evaluation index yet exists. We would like to propose, as part of the content of the Utstein Style, a comparison study of resuscitation rates on a regional, organizational and national level using, for example, eyewitness accounts of resuscitation of endogenous cardiac arrest patients. Publication of actual cardiopulmonary resuscitation (CPR) rates will act as a greater incentive to the citizens and instructors in that region than can be achieved simply by releasing self-satisfying figures, such as that several thousand people received resuscitation training.
b) Accumulating detailed data on citizen-initiated cardiopulmonary resuscitation (CPR)
At the Pittsburgh EMS, entries on citizen-initiated CPR, containing (assumed) information on time of onset, type of wound/disease, place of onset, existence of eyewitnesses and presence of citizen-initiated CPR, in addition to detailed records on advanced life support (ALS), are accumulated in a database.
By analyzing these detailed records, it is possible to determine the necessity of training and instruction in resuscitation techniques. For example, in the 202 atraumatic cardiac arrest cases in Pittsburgh in 1994, the witnessed resuscitation rate was 40.4%. The home is the most common place of onset but in turn the home has the lowest rate of initiated CPR, at just 26.6%. With this in mind, we must admit that it is vital to carry out resuscitation training among those citizens most likely to have to face cardiac arrest situations.
c) Evaluation of the risk of infectious disease and anti-contagion devices, the growth of compensation systems
As the ILCOR Advisory Statements point out, concerns regarding infectious diseases are currently very high, and many people may hesitate to perform mouth-to-mouth resuscitation, fearing the spread of the HIV virus. Also, it is a fact that some patients do have, i.e. the hepatitis virus and so it would be wise to use an anti-contagion device such as a simple mouth mask. We would like to therefore encourage the evaluation and improvement of anti-contagion devices through the use of the AHA Guidelines. On the other hand, we consider it worthwhile to perform infection follow-ups on citizens who have performed resuscitation techniques and to expand the compensation system to cover medical test expenses for those citizens.
d) Compulsory training in resuscitation techniques for public servants
In some countries and regions, training in resuscitation techniques is compulsory for police, firefighters and teaching staff. As this system helps to drastically increase public safety in public places, we would also like to encourage this through the use of the AHA Guidelines. As part of Japan's own system, introduced recently, it is compulsory for all drivers to take resuscitation training when they receive their driver's license. One must admit the inherent value in such a system, but it is still necessary to compare citizen-initiated resuscitation rates at regular intervals under a standardized formula in order to achieve some form of final evaluation.
b) Action for Choking Prior to Cardiac Arrest
In the ILCOR Advisory Statement, chest compression is recommended for choking. We agree that it is a simple and effective maneuvers especially for lay citizen once the victim suffers cardiac arrest. However, when the victim is not completely collapsed yet, isn't it deleterious for lay citizen to perform chest compression? We may need more evidences and data for it.
1. Single-Rescuer Adult Basic Life Support
a) Sequence of Action: When to Leave the victim and Go for Help.
For single-rescuers, the ILCOR statements advise to leave the
victim and go for help either when the victims is unresponsive
or he/she is not breathing. Some people may hope to know which
is better time to leave the victim and go for help. Would you
tell us the answer?
b) Volume and Rate of Ventilation: 9 seconds to perform 15
cardiac compressions
It is only a tiny mistake.
an inflation time of 1.5 to 2.0 seconds
an inflation/exhalation cycle of about 3 seconds.
a chest compression rate of about 100 per minute
It therefore takes 9 (not 12) seconds to perform 15 compressions,
allowing 6 seconds for the 2 rescue breaths.
Single-rescuer CPR should result in 8 breaths and 60 chest
compressions per minute.
2. The Universal Advanced Life Support Algorithm
a) Basic CPR and the Precordial Thump
We would like to ask you the reason or the evidence which had
you to change the evaluation status of the precordial thump. In
the ILCOR Statement.
AHA 1992 ILCOR
i. monitored cardiac not stated class I
arrest
ii. wittnessed arrest class IIb not stated
and defibrillator
is not available
iii. unwittnessed arrest class IIb* class IIb
or pediatric patients (class III?)
* In the note of the figure, you say that: For an unwittnessed
arrest and in children, the thump is a class IIb recommendation.
http://www.americanheart.org/Scientific/statements/1997/049705.html#figure
Is it really true?
3. Pediatric Resuscitation
a) Background: Age Definitions
At what ages do you usually draw lines between newly born, infant,
child, adolescent, young adult?
b) Pediatric BLS
In the second paragraph, you say that:
Care and attention to abdominal distention caused by insufflation
of gas into the stomach should be recognized and avoided.
Do you mean that such care and attention should be avoided?
c) Pediatric ALS: Dose of Epinephrine
In the second line, you say: Because the outcome of asystolic and
pulseless arrest in children is very poor and a beneficial effect
of higher doses of epinephrine has been suggested by some animal
studies and a single retrospective pediatric study,50-54 second
and subsequent intravenous doses and all endotracheal doses for
unresponsive asystolic and pulseless arrest in infants and children
should be 0.1 mg/kg (0.1 mL/kg of the 1:1000 solution) as a Class
IIa recommendation.
What are 'asystolic and pulseless arrest' and 'unresponsive
asystolic and pulseless arrest' ? When you say 'unresponsive',
do you mean that epinephrine is not effective or that a patient
does not respond to some stimuli?
d) Pediatric ALS: Automated External Defibrillators in Pediatrics
In the second lines you say: Early rhythm assessment for pediatric
prehospital arrest is not frequently reported or reliable.
Which is not reliable early rhythm assessment or reports of early
rhythm assessment?
e) Guidelines for the Newly Born: BLS for the Newly Born
In the fifth paragraph you say: 5.Assess responseGb.In addition
to the presence of a cry and spontaneous respirations, the response
may also be assessed by feeling for a pulse, although this may
be difficult in the newborn and should not distract the rescuer
from providing adequate ventilations.
Would you tell us the difference between 'response' and
'responsiveness'?
4. Special Resuscitation Situations
a) Asthma: Key Interventions to Prevent Arrest
In the 7th paragraph of 'Intravenous Beta-Agonists', you say
that: This is an "agent of desperation" that can also be tried
in cardiac arrest associated with asthma. What do you mean
by an "agent of desperation" ?
b) Asthma: Key Interventions to Prevent Arrest
In the last paragraph of 'Tracheal Intubation With Artificial
Ventilation', you say: A small series of asthmatic cardiac
arrests presenting to a pediatric emergency department revealed
that three of eight patients had undiagnosed pneumothoraxes that
may have precipitated the arrests. The authors recommend empirical
bilateral tube thoracostomies in asthmatic patients who have a
cardiac arrest, a recommendation shared by Safar.
Every body knows that Dr. Safar is a distinguished scientist
especially in Resuscitology. However, is it essential to have
his name in the ILCOR docments. Is'nt it better have his splended
papers as the references.
c) Trauma: ALS Modifications During Arrest
In the second paragraph of 'Circulation', you say that:
If fractured ribs and/or sternum are present, synchronize
ventilations and compressions at a ratio of 1:5.
Do you have good evidence for that?
Acknowledgements:
To close this document, we would like to thank the American Heart Association (AHA) for generously permitting us to join the Second International Evidence Evaluation Conference at Dallas. Through this document, we have tried to explain some important points unique to Japan. We hope that taking things in other countries consideration, the AHA will develop the new guideline to the global standard for cardiopulmonary Resuscitation.