4. No t a c h y c a r d i a - - u n l e s s t h e r e are o t h e r lifethreatening problems, these patients are not admitted or monitored. If a patient arrives symptom-free in the emergency dep a r t m e n t with a history of anticholinergic or tricyclic ingestion, then following standard procedures, we encourage observation for six hours to see if any absorption occurs with s u b s e q u e n t onset of symptoms. Too often, asymptomatic patients are "medically cleared" and sent to the psychiatric service only to absorb the drug and require major therapy a few hours later. As in any inges'tion, when the history and symptoms disagree, and the patient is asymptomatic, it is conservative to observe the patient and determine if problems Will develop prior to discharge. With these indications and precautions in mind, physicians in emergency departments should be able to approach the use of physostigmine and associated care on a rational basis. Barry H. Rumack, MD JACEP, Consulting Editor 1. Rumack BH: Anticholinergic poisoning: treatment with physostigmine. Pediatrics 52:449-451, 1973.
Filtering Emergency Blood Transfusions I N THIS ISStrE OF JACEP (p 510) Drs. Olcott and Lim report their study of the effect on fresh platelets of ultrapore filters which are used to remove microaggregates from stored blood. They found t h a t these filters remove 20% to 40% of the platelets present in freshly drawn blood. They conclude that the use of such filters is probably deleterious when transfusing m a n y units of fresh blood to actively bleeding t r a u m a victims. Can these findings be translated into appropriate policy at the time of an emergency transfusion? It would be helpful to know the answer to the question, "When does one use the filter?" These facts are unquestioned: Ultrapore filters remove aggregates of platelets and white blood cells that form in stored bank blood. Such aggregates lodge as microemboli in lung capillaries causing pulmonary hypertension, the so-called '~shock-lung" phenomenon. This is ameliorated by filtering the particles from stored blood at the time of transfusion. Platelet adhesiveness is increased and platelet-leukocyte aggregates form, in vivo, in response to hypotension. Further, platelets store serotonin. W h e n their serotonin is released, it increases platelet adhesiveness. To complicate the picture a bit more, platelet aggregation enhances release of platelet serotonin. Though armed with such information, issues involving platelet function remain muddy. It is not clear w h a t is the impact of transfusing fresh platelets to patients in surgical shock on the f o r m a t i o n and embolization of endogenous platelet-leukocyte aggregates. While e x a m i n i n g complex laboratory matters, it is easy to lose~sight of the administrative problems t h a t affect medical decisions in important ways.
Page 542 Volume 5 Number 7
The bleeding p a t i e n t is so c o m m o n an emergency visitor t h a t one can rarely recall a day of bloodless pa. tient care. Paradoxically, the replacement of shed blood in the hospital e m e r g e n c y d e p a r t m e n t is uncommon, even in busy t r a u m a centers. Emergency receiving units t h a t treat victims of major hemorrhage generally initiate volume replacement with electrolyte solutions and colloid materials. The laboratory studies necessary to safely de. liver type specific blood take time. Patients requiring immediate surgical intervention to arrest hemorrhage are often rushed to the operating room while receiving infusions of volume expanders rather t h a n blood. Very few hospitals have a frequent demand for fresh blood and few have the capability to collect, store and test it prop. erly. In Orange County, Califoynia, with a population ap. p r o a c h i n g two million people, there are 38 hospital emergency departments, not one of which has total blood banking services. Fresh blood,~nonetheless, is generally available, though not without a small delay. Almost all institutions have blood storage units and some rotate preserved units with the Red Cross Blood Bank and other hospitals to maximize availability of limited supplies. Since platelet function is not preserved in cold storage, these procedures do not a u g m e n t supplies of truly fresh blood. In dire emergency, other sources are at hand. Emer. gency departments frequently m a i n t a i n a file containing the blood type of hospital personnel. Such lists m a y als0 i n c l u d e t h e blood t y p e s of a m b u l a n c e personnel, firefighters, police officers and paramedics who can be called upon to donate blood in response to unusual de. mand. Blood obtained by this means, t h o u g h fresh, is subject to the delay of collection, cross matching, and testing for hepatitis-associated antigen. Hepatitis testing t a k e s a b o u t six hours. If m a t c h i n g s t u d i e s are abbreviated, hepatitis screening deferred and donor exam. ination omitted, the recipient incurs various transfusi0n risks minimized by the comprehensive blood banking system. In m o s t e m e r g e n c y d e p a r t m e n t s t h e r e will be shortcomings in the system of supply, distribution, stor. age and preservation of blood. These shortcomings must be weighed against the problems created by attempting to obtain fresh blood from donors on short notice. Autotransfusion devices provide access to what may be the freshest blood of all, the patient's own shed blood. This blood must be filtered and would not obviate the need to obtain platelets from b a n k sources. It may be very difficult to predict initially the extent of future blood demands of the patient. Collins ~ has recently reviewed the numerous problems t h a t arise with massive transfusion. In addition to platelet problems, micro' aggregates, mismatch and transmission of disease, the list includes altered hemoglobin affinity for oxygen, coagulation abnormalities, acid-base imbalance, citrate toxicity, hypothermia, impaired red cell deformability, elevated potassium and a score of others. In facilities with comprehensive blood banking services offering very fresh blood on short notice, plateletpheresis
July 1976 , . , ~ P
ch~ique§ p e r m i t large q u a n t i t i e s of fresh p l a t e l e t s to be ~pplied for infusion. Thus, carefully screened b a n k blood 0uld be t r a n s f u s e d t h r o u g h a f i l t e r a n d p l a t e l e t s pC,~lPi e d v by a s e p a r a t e u n f i l t e r e d infusion.
ft0
~he i s s u e of t r a n s f u s i n g fresh as opposed to s t o r e d l00d, where the l a t t e r m a y be supplied as the s u m of ashed r e d cells, frozen p l a s m a and fresh platelets, reains unresolved. U n t i l it is, it will be well to keep filrs readily at h a n d in the e m e r g e n c y d e p a r t m e n t . Stanley R. Gold, MD, J A C E P Editorial Board l. Collins JA: Problems associated with the massive transfusion Ifstored blood. Surgery 75:274-295, 1974.
~lind Defibrillation by Basic EMTs IWENTY-TWO YEAR OLD G.S. pointed with pride to his edentials - an A d v a n c e d R e d Cross First A i d Card, a .auffeur s hcense, ecent completion o f an E m e r g e n c y edical Technician ( E M T ) curriculum and m a n y Saturty night viewings o f Emergency! He had six months o f xperience with a private ambulance company that stood , at professional football games. Their vehicle was outfit'with a new monitor-defibrillator because the N F L reires this in case a doctor needs it on the field, a consid~tion apparently resulting from the Detroit Lions' Chuck ughes' death in 1971. The vendor o f the apparatus had ~pplied some operating instructions and a manual. '
"
r
While the ambulance was being processed through a arwash in preparation for its appearance in that S u n lays game, G.S. was in some manner investigating the lefibrillator w h e n it d i s c h a r g e d . Upon h e a r i n g two thumps (the m a c h i n e on G.S. a n d then G.S. on the loot), the driver p r o m p t l y turned on the red light and sign, extricated the ambulance from the washatorium a n d Fpedto a nearby hospital where, two minutes later, G.S. ~asnoted to be cyanotic and apneic. Various ventricular dysrhythmias, including ventricu~rfibrillation, required four separate 400 watt-second dilet current shocks, intubation, intracardiac epinephrine nd numerous intravenous med~catmns before G.S. s wtal 'tgns stabilized. A n initial left bundle branch block gave ~ay to normal intraventricular conduction over a period Ifseveral days. Anoxic encephalopathy was present for 24 lurs and thereafter improved rapidly. 1
"
"
''
'
'
"
Although one m o n t h l a t e r G.S. bore no d e t e c t a b l e eurologic or c a r d i o v a s c u l a r sequelae, he felt compelled pursue a new vocation. His application for W o r k m e n ' s ~0mpensation was denied. The referee stated: "This was 0t in his line of work . . . if he'd h a d a gun [instead of a ~fibrillator] he s u r e l y would have killed himself." This t r u e case vividly i l l u s t r a t e s t h a t blind f i b r i l l a t i o n ta be as g r e a t a m i s a d v e n t u r e as can blind d e f i b r i l l a t i o n e an a d v e n t u r e . Thus, w h e n the shocker-shockee relai0nship is reversed, c h a n g e s in perspective can be anticipated (as G.S. d e m o n s t r a t e d by r a p i d l y g e t t i n g out of the business). Unfortunately, the r e a l i t i e s of this point have not been tPpropriately e m p h a s i z e d in t h i s issue's article, B l i n d lefibrillation Outside the Hospital (p 512). Its advocacy of ~h01esale p l a c e m e n t of a p o t e n t lifesaving tool, w i t h an
• PJuly 1976
equal c a p a c i t y for lethality, in t h e h a n d s of m i n i m a l l y t r a i n e d i n d i v i d u a l s (who indeed do not function under " u n n e c e s s a r y l i m i t a t i o n s " as the a u t h o r s h a v e suggested) is in direct opposition to r e c o m m e n d a t i o n s of the American College of Cardiology's B e t h e s d a Conference2 T h a t report's section d e a l i n g with p a r a m e d i c a l a s s i s t a n t s emphasized t h a t a " n o n p h y s i c i a n who u n d e r t a k e s the duties or p r e r o g a t i v e s of a p h y s i c i a n is p r a c t i c i n g m e d i c i n e w i t h o u t a license," t h a t w h e n t h e p h y s i c i a n delegates duties, "supervision a n d direction m u s t be intense when he is u s i n g u n s k i l l e d persons," t h a t "if the function is an i m p o r t a n t or life-saving one, it r e q u i r e s m o r e supervision," a n d t h a t w h e n n o n p h y s i c i a n s t a f f is used t h e y m u s t ~have been carefully selected a n d qualified" and "have h a d special education, experience, a n d training." This conference f u r t h e r gave t h e explicit opinion t h a t p r o g r a m s t h a t use n o n p h y s i c i a n s to provide elite cardiac care be "judged a desirable m e a n s of s e r v i n g the public by e x p e r t s who are qualified by experience a n d education to m a k e such a d e t e r m i n a t i o n a n d who have a reasonable basis upon which to base such conclusions." Etsell and S m o c k ' s f a i l u r e to p r o v i d e a n y h a r d d a t a or h o m e g e n e r a t e d s u b s t a n t i a t i o n w h a t e v e r r e p r e s e n t s a signific a n t d e p a r t u r e from this requisite. U n q u e s t i o n a b l y , a p h y s i c i a n or group of p h y s i c i a n s m u s t a s s u m e r e s p o n s i b i l i t y for w h a t e v e r acts are performed by field p e r s o n n e l in o r d e r to g u a r a n t e e t h e i r c o m m u n i t y the professional direction, c o m m i t m e n t and conscience n e c e s s a r y to a s s u r e a service of o p t i m a l quali t y a n d p r o p r i e t y . T h i s c a n n o t be done b y p r o v i d i n g s t a n d i n g orders t h a t a r e d e l i b e r a t e l y designed to avoid t r a i n i n g , nor by e q u i p p i n g rescuers w i t h only a fraction of t h e skills necessary to do the complete job. In t h e delivery of field care both the p h y s i c i a n and the rescuer are t o t a l l y d e p e n d e n t one upon the other. The p h y s i c i a n ext e n d s h i s e y e s , h a n d s , a n d j u d g m e n t s to t h e v i c t i m t h r o u g h the rescuer while t h a t rescuer relies upon the p h y s i c i a n not only to p r o p e r l y p r e p a r e h i m to c a r r y out the charge b u t moreover to accept u l t i m a t e responsibility. This i n t e r a c t i o n is w o r k a b l e only if t h e r e is a m u t u a l confidence founded in t h e u t m o s t of skill a t t a i n m e n t and discipline. Shortcuts simply a r e not t e n a b l e to the EMTs, the p h y s i c i a n s or t h e victims, who respectively have t h e i r prides, licenses a n d lives on the line. Beyond these conceptual considerations, o t h e r reasons m i l i t a t e a g a i n s t b l i n d defibrillation by basic EMTs. A r e p e r t o i r e of advanced skills is n e c e s s a r y not only to effect a n d maintain successful defibrillation but,most imp o r t a n t l y , to prevent v e n t r i c u l a r fibrillation in the first place. Of t h e half-dozen critical d y s r h y t h m i a s encount e r e d in the field, only v e n t r i c u l a r t a c h y c a r d i a and/or fib r i l l a t i o n r e q u i r e countershock. Of those t r e a t e d in the first hour by the t e a m s of A d g e y and P a n t r i d g e , 15 over h a l f h a d b r a d y a r r h y t h m i a s or v e n t r i c u l a r ectopics, w h e r e a s only 3% h a d v e n t r i c u l a r t a c h y c a r d i a and 10% h a d v e n t r i c u l a r fibrillation. W h e n e x t e n d i n g t h e i r total p a t i e n t - d y s r h y t h m i a - i n c i d e n c e s t a t i s t i c s over four hours, t h e y found t h a t v e n t r i c u l a r t a c h y c a r d i a increased tenfold a n d v e n t r i c u l a r fibrillation doubled. These d a t a demons t r a t e t h a t in t h e first hour only 13% of serious dysr h y t h m i a s m i g h t be a p p r o p r i a t e l y t r e a t e d by blind deftbrillation, a l t h o u g h if the r e s c u e r does n o t possess a full r a n g e of skills, his o p p o r t u n i t y to e v e n t u a l l y apply a de-
Volume 5 Number 7 Page 543
Filtering Emergency Blood Transfusions I N THIS ISStrE OF JACEP (p 510) Drs. Olcott and Lim report their study of the effect on fresh platelets of ultrapore filters which are used to remove microaggregates from stored blood. They found t h a t these filters remove 20% to 40% of the platelets present in freshly drawn blood. They conclude that the use of such filters is probably deleterious when transfusing m a n y units of fresh blood to actively bleeding t r a u m a victims. Can these findings be translated into appropriate policy at the time of an emergency transfusion? It would be helpful to know the answer to the question, "When does one use the filter?" These facts are unquestioned: Ultrapore filters remove aggregates of platelets and white blood cells that form in stored bank blood. Such aggregates lodge as microemboli in lung capillaries causing pulmonary hypertension, the so-called '~shock-lung" phenomenon. This is ameliorated by filtering the particles from stored blood at the time of transfusion. Platelet adhesiveness is increased and platelet-leukocyte aggregates form, in vivo, in response to hypotension. Further, platelets store serotonin. W h e n their serotonin is released, it increases platelet adhesiveness. To complicate the picture a bit more, platelet aggregation enhances release of platelet serotonin. Though armed with such information, issues involving platelet function remain muddy. It is not clear w h a t is the impact of transfusing fresh platelets to patients in surgical shock on the f o r m a t i o n and embolization of endogenous platelet-leukocyte aggregates. While e x a m i n i n g complex laboratory matters, it is easy to lose~sight of the administrative problems t h a t affect medical decisions in important ways.
Page 542 Volume 5 Number 7
The bleeding p a t i e n t is so c o m m o n an emergency visitor t h a t one can rarely recall a day of bloodless pa. tient care. Paradoxically, the replacement of shed blood in the hospital e m e r g e n c y d e p a r t m e n t is uncommon, even in busy t r a u m a centers. Emergency receiving units t h a t treat victims of major hemorrhage generally initiate volume replacement with electrolyte solutions and colloid materials. The laboratory studies necessary to safely de. liver type specific blood take time. Patients requiring immediate surgical intervention to arrest hemorrhage are often rushed to the operating room while receiving infusions of volume expanders rather t h a n blood. Very few hospitals have a frequent demand for fresh blood and few have the capability to collect, store and test it prop. erly. In Orange County, Califoynia, with a population ap. p r o a c h i n g two million people, there are 38 hospital emergency departments, not one of which has total blood banking services. Fresh blood,~nonetheless, is generally available, though not without a small delay. Almost all institutions have blood storage units and some rotate preserved units with the Red Cross Blood Bank and other hospitals to maximize availability of limited supplies. Since platelet function is not preserved in cold storage, these procedures do not a u g m e n t supplies of truly fresh blood. In dire emergency, other sources are at hand. Emer. gency departments frequently m a i n t a i n a file containing the blood type of hospital personnel. Such lists m a y als0 i n c l u d e t h e blood t y p e s of a m b u l a n c e personnel, firefighters, police officers and paramedics who can be called upon to donate blood in response to unusual de. mand. Blood obtained by this means, t h o u g h fresh, is subject to the delay of collection, cross matching, and testing for hepatitis-associated antigen. Hepatitis testing t a k e s a b o u t six hours. If m a t c h i n g s t u d i e s are abbreviated, hepatitis screening deferred and donor exam. ination omitted, the recipient incurs various transfusi0n risks minimized by the comprehensive blood banking system. In m o s t e m e r g e n c y d e p a r t m e n t s t h e r e will be shortcomings in the system of supply, distribution, stor. age and preservation of blood. These shortcomings must be weighed against the problems created by attempting to obtain fresh blood from donors on short notice. Autotransfusion devices provide access to what may be the freshest blood of all, the patient's own shed blood. This blood must be filtered and would not obviate the need to obtain platelets from b a n k sources. It may be very difficult to predict initially the extent of future blood demands of the patient. Collins ~ has recently reviewed the numerous problems t h a t arise with massive transfusion. In addition to platelet problems, micro' aggregates, mismatch and transmission of disease, the list includes altered hemoglobin affinity for oxygen, coagulation abnormalities, acid-base imbalance, citrate toxicity, hypothermia, impaired red cell deformability, elevated potassium and a score of others. In facilities with comprehensive blood banking services offering very fresh blood on short notice, plateletpheresis
July 1976 , . , ~ P
ch~ique§ p e r m i t large q u a n t i t i e s of fresh p l a t e l e t s to be ~pplied for infusion. Thus, carefully screened b a n k blood 0uld be t r a n s f u s e d t h r o u g h a f i l t e r a n d p l a t e l e t s pC,~lPi e d v by a s e p a r a t e u n f i l t e r e d infusion.
ft0
~he i s s u e of t r a n s f u s i n g fresh as opposed to s t o r e d l00d, where the l a t t e r m a y be supplied as the s u m of ashed r e d cells, frozen p l a s m a and fresh platelets, reains unresolved. U n t i l it is, it will be well to keep filrs readily at h a n d in the e m e r g e n c y d e p a r t m e n t . Stanley R. Gold, MD, J A C E P Editorial Board l. Collins JA: Problems associated with the massive transfusion Ifstored blood. Surgery 75:274-295, 1974.
~lind Defibrillation by Basic EMTs IWENTY-TWO YEAR OLD G.S. pointed with pride to his edentials - an A d v a n c e d R e d Cross First A i d Card, a .auffeur s hcense, ecent completion o f an E m e r g e n c y edical Technician ( E M T ) curriculum and m a n y Saturty night viewings o f Emergency! He had six months o f xperience with a private ambulance company that stood , at professional football games. Their vehicle was outfit'with a new monitor-defibrillator because the N F L reires this in case a doctor needs it on the field, a consid~tion apparently resulting from the Detroit Lions' Chuck ughes' death in 1971. The vendor o f the apparatus had ~pplied some operating instructions and a manual. '
"
r
While the ambulance was being processed through a arwash in preparation for its appearance in that S u n lays game, G.S. was in some manner investigating the lefibrillator w h e n it d i s c h a r g e d . Upon h e a r i n g two thumps (the m a c h i n e on G.S. a n d then G.S. on the loot), the driver p r o m p t l y turned on the red light and sign, extricated the ambulance from the washatorium a n d Fpedto a nearby hospital where, two minutes later, G.S. ~asnoted to be cyanotic and apneic. Various ventricular dysrhythmias, including ventricu~rfibrillation, required four separate 400 watt-second dilet current shocks, intubation, intracardiac epinephrine nd numerous intravenous med~catmns before G.S. s wtal 'tgns stabilized. A n initial left bundle branch block gave ~ay to normal intraventricular conduction over a period Ifseveral days. Anoxic encephalopathy was present for 24 lurs and thereafter improved rapidly. 1
"
"
''
'
'
"
Although one m o n t h l a t e r G.S. bore no d e t e c t a b l e eurologic or c a r d i o v a s c u l a r sequelae, he felt compelled pursue a new vocation. His application for W o r k m e n ' s ~0mpensation was denied. The referee stated: "This was 0t in his line of work . . . if he'd h a d a gun [instead of a ~fibrillator] he s u r e l y would have killed himself." This t r u e case vividly i l l u s t r a t e s t h a t blind f i b r i l l a t i o n ta be as g r e a t a m i s a d v e n t u r e as can blind d e f i b r i l l a t i o n e an a d v e n t u r e . Thus, w h e n the shocker-shockee relai0nship is reversed, c h a n g e s in perspective can be anticipated (as G.S. d e m o n s t r a t e d by r a p i d l y g e t t i n g out of the business). Unfortunately, the r e a l i t i e s of this point have not been tPpropriately e m p h a s i z e d in t h i s issue's article, B l i n d lefibrillation Outside the Hospital (p 512). Its advocacy of ~h01esale p l a c e m e n t of a p o t e n t lifesaving tool, w i t h an
• PJuly 1976
equal c a p a c i t y for lethality, in t h e h a n d s of m i n i m a l l y t r a i n e d i n d i v i d u a l s (who indeed do not function under " u n n e c e s s a r y l i m i t a t i o n s " as the a u t h o r s h a v e suggested) is in direct opposition to r e c o m m e n d a t i o n s of the American College of Cardiology's B e t h e s d a Conference2 T h a t report's section d e a l i n g with p a r a m e d i c a l a s s i s t a n t s emphasized t h a t a " n o n p h y s i c i a n who u n d e r t a k e s the duties or p r e r o g a t i v e s of a p h y s i c i a n is p r a c t i c i n g m e d i c i n e w i t h o u t a license," t h a t w h e n t h e p h y s i c i a n delegates duties, "supervision a n d direction m u s t be intense when he is u s i n g u n s k i l l e d persons," t h a t "if the function is an i m p o r t a n t or life-saving one, it r e q u i r e s m o r e supervision," a n d t h a t w h e n n o n p h y s i c i a n s t a f f is used t h e y m u s t ~have been carefully selected a n d qualified" and "have h a d special education, experience, a n d training." This conference f u r t h e r gave t h e explicit opinion t h a t p r o g r a m s t h a t use n o n p h y s i c i a n s to provide elite cardiac care be "judged a desirable m e a n s of s e r v i n g the public by e x p e r t s who are qualified by experience a n d education to m a k e such a d e t e r m i n a t i o n a n d who have a reasonable basis upon which to base such conclusions." Etsell and S m o c k ' s f a i l u r e to p r o v i d e a n y h a r d d a t a or h o m e g e n e r a t e d s u b s t a n t i a t i o n w h a t e v e r r e p r e s e n t s a signific a n t d e p a r t u r e from this requisite. U n q u e s t i o n a b l y , a p h y s i c i a n or group of p h y s i c i a n s m u s t a s s u m e r e s p o n s i b i l i t y for w h a t e v e r acts are performed by field p e r s o n n e l in o r d e r to g u a r a n t e e t h e i r c o m m u n i t y the professional direction, c o m m i t m e n t and conscience n e c e s s a r y to a s s u r e a service of o p t i m a l quali t y a n d p r o p r i e t y . T h i s c a n n o t be done b y p r o v i d i n g s t a n d i n g orders t h a t a r e d e l i b e r a t e l y designed to avoid t r a i n i n g , nor by e q u i p p i n g rescuers w i t h only a fraction of t h e skills necessary to do the complete job. In t h e delivery of field care both the p h y s i c i a n and the rescuer are t o t a l l y d e p e n d e n t one upon the other. The p h y s i c i a n ext e n d s h i s e y e s , h a n d s , a n d j u d g m e n t s to t h e v i c t i m t h r o u g h the rescuer while t h a t rescuer relies upon the p h y s i c i a n not only to p r o p e r l y p r e p a r e h i m to c a r r y out the charge b u t moreover to accept u l t i m a t e responsibility. This i n t e r a c t i o n is w o r k a b l e only if t h e r e is a m u t u a l confidence founded in t h e u t m o s t of skill a t t a i n m e n t and discipline. Shortcuts simply a r e not t e n a b l e to the EMTs, the p h y s i c i a n s or t h e victims, who respectively have t h e i r prides, licenses a n d lives on the line. Beyond these conceptual considerations, o t h e r reasons m i l i t a t e a g a i n s t b l i n d defibrillation by basic EMTs. A r e p e r t o i r e of advanced skills is n e c e s s a r y not only to effect a n d maintain successful defibrillation but,most imp o r t a n t l y , to prevent v e n t r i c u l a r fibrillation in the first place. Of t h e half-dozen critical d y s r h y t h m i a s encount e r e d in the field, only v e n t r i c u l a r t a c h y c a r d i a and/or fib r i l l a t i o n r e q u i r e countershock. Of those t r e a t e d in the first hour by the t e a m s of A d g e y and P a n t r i d g e , 15 over h a l f h a d b r a d y a r r h y t h m i a s or v e n t r i c u l a r ectopics, w h e r e a s only 3% h a d v e n t r i c u l a r t a c h y c a r d i a and 10% h a d v e n t r i c u l a r fibrillation. W h e n e x t e n d i n g t h e i r total p a t i e n t - d y s r h y t h m i a - i n c i d e n c e s t a t i s t i c s over four hours, t h e y found t h a t v e n t r i c u l a r t a c h y c a r d i a increased tenfold a n d v e n t r i c u l a r fibrillation doubled. These d a t a demons t r a t e t h a t in t h e first hour only 13% of serious dysr h y t h m i a s m i g h t be a p p r o p r i a t e l y t r e a t e d by blind deftbrillation, a l t h o u g h if the r e s c u e r does n o t possess a full r a n g e of skills, his o p p o r t u n i t y to e v e n t u a l l y apply a de-
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