1. Early CPR matters; what about early defibrillation? First important to understand different cardiac arrest rhythms: Ventricular fibrillation – heart rhythm in chaos Ventricular tachycardia – heart rhythm very fast Ventricular fibrillation (VF) and ventricular tachycardia (VT) are both shockable rhythms – that is, they need defibrillation

2. Early CPR matters; what about early defibrillation? First important to understand different cardiac arrest rhythms: Pulseless electrical activity (PEA) – electrical recording can look normal, but no blood flow Asystole – also known as “flatline” – no electrical activity at all PEA and asystole are not shockable rhythms – defibrillation does not treat these cardiac arrest rhythms

3. Cardiac arrest heart rhythms summary ventricular ventricular pulseless asystole fibrillation tachycardia electrical activity Shockable rhythms; need to defibrillate VF and VT are very common for cardiac arrest in the home or in public places Non-shockable rhythms; do not defibrillate PEA and asystole are more for cardiac arrest among hospitalized patients

4. The importance of defibrillation Since VF and VT common in public, AEDs are crucial to save lives But finding them can be hard – no formal system in place for most places Terminal A Concourse Map A3 A5 A1 A4 A6 A2 A8 A10 A12 A7 A9 A11 Recent projects to locate AEDs – harnessing “social media”: Merchant and Asch, Circ Cardiovasc Qual Outcomes 2012

5. Survival is also dependant on rapid defibrillation 40 30 20 10 0 Should we have AEDs in our homes, like fire extinguishers? Large U.S. study showed no clear benefit from home AEDs Bardy et al, NEJM 2008 <1 2 3 4 5 6 7 minutes to defibrillation Survival to discharge For shockable rhythms,with each passing minute without a shock, survival falls Chan et al, NEJM 2008

6. Challenges to the widespread use of AEDs Poor public education around AED use; No uniform instructions for AEDs Cost of AEDs (most cost over $1000 per device) Some municipalities and states have rules supporting AEDs; some don’t Federal Law supports AEDs in Federal Buildings – but doesn’t specify how many Lingering concerns about liability by business owners

7. What other treatments exist beyond CPR and defibrillation? ACLS (advanced cardiovascular life support): Medications (epinephrine, amiodarone) Airway devices to provide rescue breaths Cardiopulmonary bypass machines (still experimental) Evidence for these other treatments is modest at best; CPR and defibrillation have the strongest scientific support

8. CPR in the workplace Friday, June 13, 2008 Tim Russert, TV correspondent, had cardiac arrest at work had known coronary disease suffered heart attack that quickly led to cardiac arrest Attempted resuscitation (CPR and defibrillation) failed Unknown how long until AED was applied Resuscitation in the media

9. CPR in the home Friday, June 25, 2009 Michael Jackson had cardiac arrest at his home; physician performed CPR Presumed respiratory arrest from drug overdose Attempted resuscitation (CPR and defibrillation) failed CPR performed in the bed – not a hard surface Resuscitation in the media

10. CPR in the workplace February 25, 1990 Terri Schiavo had cardiac arrest at home Was successfully revived by EMS team Suffered severe brain injury from the cardiac arrest event; after protracted legal battle, feeding tube was removed and she died on March 31, 2005 Resuscitation in the media

11. CPR in the workplace March 17, 2012 Fabrice Muamba had cardiac arrest while on English football field Was successfully revived after prolonged resuscitation efforts Brain injury was largely spared by the use of new treatment option known as “therapeutic hypothermia” Resuscitation in the media

12. Exciting time for cardiac arrest science and treatment Broad implementation of AED programs is increasing survival “Hands only” CPR removed barriers for bystander action Dispatcher assisted CPR is improving bystander action as well Realization by many that cardiac arrest is not hopeless – a shift of perception is occurring among healthcare providers Post-resuscitation therapies including therapeutic hypothermia and cardiac catheterization improving outcomes Photograph of recent survivor at Penn, honored along with one of her health care Rescuers – now home with her family

13. Upcoming Coursera lectures in this program Lecture 2:Rethinking CPR: quality of care and new ideas about training Lecture 3:Finding the AEDs – the role of social media Lecture 4:Therapeutic hypothermia and post- resuscitation care Lecture 5:Frontiers in resuscitation: reperfusion medicine and cardiac bypass Lecture 6:Survivorship and end-of-life issues after cardiac arrest