Mandatory Arrhythmia Awareness in all CPR Classes

This year, like every year, more than 7,700 people age 35 and under will die suddenly of cardiac causes in the US and Canada. Roughly half of them will experience fainting episodes or exhibit other warning signs in the months, weeks and days prior to their death. If these sentinel events are recognized and acted upon a great number of at risk young people will not die.  Several of the diseases that underlie paediatric Sudden Cardiac Arrest are genetic, with a dominant gene transmission pattern, and therefore many asymptomatic first degree relatives might also be saved.

All properly taught certification level CPR training includes a discussion on Heart Attack and Stroke warning sign recognition and management. It is time to include a discussion on recognizing and responding to the warning signs of paediatric heart arrhythmia diseases in every CPR class with extra attention being given to the discussion for classes being taught to educators, coaches and any adults that are responsible for the well-being of children.

The basic warning signs of inherited heart rhythm disorders are as follows:

·        Fainting (syncope) or seizure during or shortly after physical activity, especially if it happens repeatedly

·        Fainting (syncope) or seizure resulting from emotional excitement, emotional distress, or auditory startle

·        Family history of unexpected sudden death during physical activity or during a seizure, or any other unexplained sudden death of an otherwise healthy young person

Other warning signs include; brown outs (near fainting); a strong sensation of palpitation or racing heart; extreme shortness of breath (new) with exertion - more so than other children.

The recommended response to all loss of consciousness fainting is to Call 911, even if the child quickly regains consciousness and “seems fine”. For both fainting and all other warning signs parents should be advised of the event, provided with information (a pamphlet or a link to a web page) on heart rhythm disorders and encouraged to consult a physician that is trained to recognize paediatric arrhythmia. 

Every CPR Training Agency, both not-for-profit and private, should be required by state or provincial law to include a discussion of the warning signs of Paediatric Inherited Heart Rhythm Disorders in every class.  Special attention should be given to the topic when the audience is educators, coaches or any other group that works directly with young people.  Already eight states have passed or are considering legislation that will make awareness training of paediatric heart rhythm disorders mandatory for coaches, sport officials and physical education teachers. We need every state and province to mandate this training as a required component of every CPR class.

The evidence to support the inclusion of Arrhythmia Awareness in every CPR class is abundant und unequivocal. The International Liaison Committee on Resuscitation (ILCOR) was asked to consider a recommendation to include Arrhythmia Awareness in all Basic Life Support training classes as part of the 2010 BLS Guideline Recommendations.  They chose a softer position regarding the follow-up by coroners of all potentially cardiac related deaths of young people. Even if ILCOR chooses to ignore the evidence state and provincial legislators can still choose to act in the best interest of at-risk young people.

Three Thoughts for CPR Instructors and Students

Every person that attends CPR training represents a potential life giving resource, like a bottle of water in the desert, their attendance cannot be squandered. The next time you teach or take a certification level CPR course it may be helpful to keep these three thoughts in mind.

1. Doing something is NOT better than doing nothing - Instructors give their students a free pass when they utter the dreaded "doing something......" line. In most of the classes that I teach some student knowingly expresses the "doing something" sentiment. I gently correct them and point out that CPR is only effective when it is performed properly. Poor CPR produces results that are exactly equal to, not better than, doing nothing.

The reason that people take four or five hours out of their busy schedule to take a CPR course is to acquire a toolkit for protecting the life of a person experiencing a significant cardiovascular event. The excellent science published over the past decade gives us a clear indication of what works and what doesn't work in cardiac resuscitation. CPR instructors must teach the methods that work and CPR students must endeavour to learn and perform those techniques to the best of their ability. Teaching and learning effective CPR is the only way to improve survival rates for cardiac arrest in our communities. We trivialize and demean the process when we tell students that "doing something is better than doing nothing"

2. You DO NOT have to break ribs to perform effective CPR - I cringe every time I hear this. It seems there is a legion of CPR instructors out there that hammer on the idea that if you're not breaking ribs you're not doing it properly, including professional responders that brag to their students "I've done CPR over a dozen times and broken ribs every time." I don't know where to begin with this one, it is just wrong on so many levels.
First of all the science is clear and unequivocal, the majority of survivors do not have broken ribs. More importantly our job as CPR instructors is to bring down the barriers to the public getting involved with a patient when they witness a cardiac arrest. Telling lay people that in order to help that person they will have to break their ribs has precisely the opposite effect. Effective CPR does not require breaking ribs, it is okay to speak to the possibility of broken ribs, but it should be put in proper perspective and the whole discussion should only take up a few seconds of class time. I ask all instructors to please stop with the broken rib bull, and I implore all students the next time your Instructor plays the broken rib card, call his bluff.

3. Count using numbers, 1 and 2 and 3 and 4 ....  NOT old Bee Gee's songs - The Stayin' Alive gimmick is an excellent tool for promoting Bystander CPR in 60 second Public Service Announcements, it is not an appropriate technique to teach to a student that has signed up for certification level CPR training. I've met hundreds of people that can't remember the name of "that song you're supposed to sing" but I've never had a student that can't remember how to count to 5.
When you count properly, 1 and 2 and 3 and 4 and 5 and 1 and 2 and 3 and 4 and 10 ...... many excellent things happen for the patient. With very little practice students can develop a cadence that will produce a rate of 100 bpm, plus or minus 5, virtually every time. Proper rate makes a huge contribution to survival. When you push down on "One" and come up on "And" work is distributed equally between the two critical functions of chest compressions, pushing blood out to the brain and internal organs and allowing the heart to refill with blood on the upstroke. This drives a nice even circulation pattern that helps keep vital organs oxygenated. Finally when you count out loud using numbers, not Bee Gee's songs, all of the people assisting you with the resuscitation know exactly where you are in the CPR cycle and can perform their tasks accordingly.

The four hours that you spend teaching and  learning CPR and other Basic Life Support skills represent an opportunity to give life to another human being, in all likelihood a co-worker, a family member or a friend. It is a kind of sacred trust and should be treated with the appropriate respect.

Teaching CPR to Adults versus Teens

I write this blog at my own peril. Whenever I promote this concept the push back is always intense, but I remain steadfast. That said I want to be clear right off the top I am not talking about a 90/10 deal but more of a 55/45 arrangement. I simply feel it would be beneficial to re-direct some of the universal enthusiasm for teaching CPR to teenagers toward teaching CPR to Adults. I don't believe teens should not be taught CPR, I just know that more adults should.

Adults hang with adults, teenagers hang with teenagers. I get it, it's not an absolute, but it is a fairly accurate generalization. There are not too many teenagers in a typical workplace. There are not too many teenagers at the gym at 11:00 pm when the senior men's league is playing basketball. There are not too many teenagers living in adult only condos and communities.

In the game of resuscitation the prize is increased survival to discharge for out-of-hospital cardiac arrest (OOHCA) and we need to build a team that can win now and win in the future. To win now we need adults to find a few hours in their busy schedule to learn CPR.

Adults experience the vast majority of cardiac arrest and they must take the majority of the responsibility for responding to cardiac arrest. Although teenagers are capable of performing appropriately during a cardiac emergency we cannot download the responsibility for saving our lives onto them. Think about all of the places where you spend significant blocks of time. Think of all the places where you are engaged in activity that may place you at increased risk for cardiac arrest. How often are there teenagers about?

In Ontario there is a well supported push to teach CPR to every grade nine student.  My thought is that yes we should teach CPR to every grade nine student - right after we teach CPR to every elementary and high school teacher, principal and support staff that work in our schools. If a student or a teacher collapses to the ground, VSA, in cardiac arrest, adults should not be watching helplessly and praying that a thirteen year old student steps up and saves the day. In Ontario cardiac arrest kills more than 9,000 people each year. I'm not sure that deferring improving that statistic until the current cohort of grade nine students comes of age is the best strategy. We need to be looking at much shorter term fixes.

Expecting young teens to perform CPR in a real life situation places an unfair emotional burden on them. I've listened to dozens of real life CPR stories: the storyteller speaks as if it happened yesterday even if it happened 15 years ago, their voice waivers and their eyes may fill with tears. Performing real life CPR is a traumatic experience that most people never forget. It seems a little weak and irresponsible to look to our children to fix the problem of historically dismal survival rates for out-of-hospital cardiac arrest.

Physically people weighing less than 120 lbs find it very challenging to perform effective chest compressions for more than a few seconds. I've evaluated CPR compressions performed by over 300 grade nine students on metered Laerdal manikins and the smaller kids are too fatigued to achieve an effective compression depth after only a few reps. Poor CPR is the equivalent of no CPR.  All of the research on improving survival to discharge rates for cardiac arrest  points to other solutions, none of the research suggests that teenagers are the answer.

The evidence is unequivocal, most cardiac arrest survivors benefit from an effective bystander intervention which includes quality CPR and/or the application of an AED. The communities with the highest survival rates for OOHCA are the communities with the highest rate of bystander intervention. Over the next ten years the communities that will enjoy the greatest improvement in survival rates for cardiac arrest are the communities that teach CPR to the greatest number of ADULTS.

Teaching CPR to thirteen year olds may pay dividends in 2025, in the meantime if you are over age twenty five recognize your civic responsibility and learn CPR this year.