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.
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.
One ultimate objective within the ILCOR/AHA Guidelines and in particular with regards to Advanced Life Support is the decision on whether or not to perform early VF/VT diagnosis and early defibrillation. Defibrillation by first respoders using automated external defibrillators (AEDs) and advanced life support used by paramedics as in various other countries are seen as emergency medical systems in line with this objective.
However, a very large gap remains between pre-hospital care in Japan and that in the West. For example, Japanese emergency medical technicians (EMT) are not permitted to perform end-tracheal intubation or to provide any medical substances to the patient other than lactated Ringer's solution. Also, only medical doctors and emergency medical technicians are permitted to use automated external defibrillators, while defibrillation by first responders (police, security, lifeguard, airline attendants, train station personnel, volunteer medical personnel, personnel trained in the use of AEDs as emergency medical personnel in the workplace or rural areas), as exists in various other countries, is not even a consideration for other Japanese emergency medical workers or government administration.
Japanese medical workers offer two reasons for this. One is that although Japan is no larger than the state of California, it has a population of over 120 million people. The majority of those 120 million live in the 30% of Japan that is flat, and there are plenty of medical institutions within that 30%. Consequently, the majority of people in Japan are transported to a medical institution on average within six minutes of a call to the emergency medical system. As part of this situation, there exists a great deal of concern regarding the fact that advanced life support by emergency medical technicians outside hospital in Japan may result in delays in transport to medical institutions.
The second reason is that when electrocardiogram (ECG) evaluation is performed on patients in cardio-pulmonary arrest outside the hospital, the incidence of VF/VT is extremely low. Even in Japan though, investigations on the out-of-hospital patients in cardio-pulmonary arrest with the Utstein style have started to appear. However, according to these investigations, the incidence of VF/VT in observed cardiopulmonary arrest cases is only about 15%. This is almost the same as VF/VT incidence in children in various countries. In Japan, with its low incidence of VF/VT, the majority opinion is one that there is no point in changing the law to allow first responders to perform early defibrillation.
The thoughts of this association do not necessarily follow the opinions as given above. Firstly, it is unsatisfactory that Japan's citizens possess a pre-hospital care system that is vastly inferior to that in highly populated areas in other countries. Secondly, in a country such as Japan where no system exists for first responders to perform early defibrillation, ECG evaluation upon arrival of the emergency medical technician or patient arrival at the hospital, combined with delays in ECG evaluation, at first glance raises the possibility of lowered VF/VT frequency. As one background factor for this, is necessary to do comparative research following the adjustment of time required for a "call to ECG assessment".
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.
It is to be expected that thanks to its universal character, AHA resuscitation guidelines will be applied not just in America but on a global scale. Regarding terminology, there are many examples that reflect the current state of emergency medical care in America while no corresponding terminology exists in Japan. If possible, we would like detailed explanations and definitions for this terminology.
We would also like to know how the following electrocardiogram (ECG) terminology in used, what difference in meaning exists and in the case of corresponding words possessing the same meaning, which is more appropriate.
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.
a) The incidence of Cardiopulmonary Arrest Induced by Airway Obstruction by the Foreign Bodies is very high in Japan
The incidence of airway obstruction by the foreign bodies is not known precisely in the world. However we have an impression that the incidence is very high in Japan. This year we performed an investigation granted by the Disaster and Fire Prevention Agency in Japan. We investigated 819 patients who were transported by the ambulance and we found that incidence of airway obstruction by the foreign bodies have been 6.9/100,000 of population/year. The incidence of cardiopulmonary arrest induced by airway obstruction by the foreign bodies is 2.1/100,000 of population/year, and is as high as the incidence of out-of-hospital VF/VT in Japan. Rice cake was the most frequent cause of airway obstruction (19% of all), while meat shared only 5%.
As rice cake is very adhesive in the oral cavity, pattern of asphyxia by it and the action for choking needed should be quite different from the airway obstruction by meat in the western countries. In the ILCOR Advisory Statement, the abdominal thrust maneuver is eliminated from the teaching of BLS. However, it will be essential for us to state several options of actions in our guidelines and to continue accumulating evidences for etiology and treatment of airway obstruction by foreign bodies.
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.
Mouth-to-mouth and nose ventilation is recommended as the optimal method for delivering breath for infant up to 1 year of age. However, some recent investigations have shown that mothers can not seal over nose and mouth of the babies of their own for rescue breathing. We also have reported similar data on Japanese mothers and infants. If mothers breathe mainly through the mouth, it is not easy to inflate thelung, because infants are obligatory nasal breathers. Moreover, if mothers keep their mouth fully open during breathing, it is often hard to adjust blowing air volume.
The only problem for mouth-to-nose ventilation is that infant manikins for training of this method is not commercially available. Recently, we developed an airway kit which enables the infant manikin to be ventilated through the nose. We will be able to show the remodeled manikin during the coffee breaks on request.
1. Single-Rescuer Adult Basic Life Support
2. The Universal Advanced Life Support Algorithm
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.
I. General Guidelines
1. Translation of the AHA Guidelines 2000 and ILCOR Advisory, provision of information on the Internet
http://www.americanheart.org/utstein/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
5. Airway Obstruction by the Foreign Bodies in Japan
6. Mouth-to-Nose Ventilation for Infants
II. Our Comments on the ILCOR Advisory Statements
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.
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?