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Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
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Clinical Paper
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Epidemiological characteristics of sudden cardiac arrest in schools夽
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Tatsuya Nishiuchi a,∗ , Yasuaki Hayashino b , Taku Iwami c , Tetsuhisa Kitamura d , Chika Nishiyama e , Kentaro Kajino f , Masahiko Nitta g , Yasuyuki Hayashi h , Atsushi Hiraide a , the Utstein Osaka Project Investigators a
Department of Acute Medicine, Kinki University Faculty of Medicine, 377-2 Ohno-higashi, Osaka-Sayama, Osaka 589-8511, Japan Department of Endocrinology, Tenri Hospital, 200 Mishimacho, Tenri, Nara 632-8552, Japan Department of Preventive Services, Kyoto University School of Public Health, Yoshidahonmachi, Sakyo-ku, Kyoto 606-8317, Japan d Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan e Department of Pharmacoepidemiology, Kyoto University Graduate School of Medicine and Public Health, Yoshida Konoe-cho, Sakyo-ku, Kyoto 606-8315, Japan f Health Policy Bureau, Guidance of Medical Service Division, Ministry of Health, Labour and Welfare Government of Japan, 1-2-2 Kasumigaseki, Chiyoda-ku, Tokyo 100-8916, Japan g Departments of Emergency Medicine and Pediatrics, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka 569-0801, Japan h Senri Critical Care Medical Center, Osaka Saiseikai Senri Hospital, 1-1-6 Tsukumodai, Suita, Osaka 565-0862, Japan b c
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a b s t r a c t
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Article history: Received 9 January 2014 Received in revised form 5 April 2014 Accepted 28 April 2014
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Keywords: Cardiac arrest Schools Prevention Public access defibrillation Epidemiology
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1. Introduction
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Aims: The present study aimed to clarify the incidence and outcomes of sudden cardiac arrests in schools and the clinically relevant characteristics of individuals who experienced sudden cardiac arrests. Methods and results: We obtained data on sudden cardiac arrests that occurred in schools between January 1, 2005 and December 31, 2009 from the database of the Utstein Osaka Project, a populationbased observational study on out-of-hospital cardiac arrests in Osaka, Japan. The data were analyzed to show the epidemiological features of sudden cardiac arrests in schools in conjunction with prehospital documentation. In total, 44 cases were registered as sudden cardiac arrests in schools during the study period. Of these, 34 cases had nontraumatic cardiac arrests. Twenty-one cases (62%) had pre-existing cardiac diseases and/or collapsed during physical exercise. Twenty-three cases (68%) presented with ventricular fibrillation or pulseless ventricular tachycardia, with cases of survival 1 month after cardiac arrest and those having favourable neurological outcome (Cerebral Performance Category 1 or 2) being 12 (52%) and 10 (43%), respectively. The incidence of sudden cardiac arrests in students was 0.23 per 100,000 persons per year, ranging from 0.08 in junior high school to 0.64 in high school. The incidence of sudden cardiac arrests in school faculty and staff was 0.51 per 100,000 persons per year, a rate approximately 2 times of that observed in the students. Conclusions: Although sudden cardiac arrests in schools is rare, they majorly occurred in individuals with cardiac diseases and/or during physical exercise and presented as ventricular fibrillation or pulseless ventricular tachycardia observed initially as cardiac arrhythmia. © 2014 Published by Elsevier Ireland Ltd.
Sudden cardiac arrest (SCA) in schools is a rare event. When a tragic event occurs in these places that are expected to be absolutely safe, it can cause emotional distress to family members, students,
夽 A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2014.04.027. ∗ Corresponding author. E-mail address: [email protected] (T. Nishiuchi).
faculty members, and community members. To prevent sudden cardiac death of students, faculty, staff, or visitors, deployment of automated external defibrillators (AED) in Japanese schools has been strongly advocated since the implementation of the nationwide public access defibrillation program in 2004. The Ministry of Education, Culture, Sports, Science and Technology of Japan reported that by 2012, AED have been placed in 98% public and private schools at all three levels, elementary, junior high, and high schools.1 However, despite this wide spread use of AED in Japan, epidemiological data on SCA in schools are limited. We therefore examined SCA epidemiological characteristics in schools using the
http://dx.doi.org/10.1016/j.resuscitation.2014.04.027 0300-9572/© 2014 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Nishiuchi T, et al. Epidemiological characteristics of sudden cardiac arrest in schools. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.04.027
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Utstein-style registry database. The present study aimed to clarify SCA incidence and outcomes and the clinically relevant characteristics of individuals who experienced SCA in schools.
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2. Methods
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2.1. Study design, setting, and data sources
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resuscitation (CPR) by bystanders, first monitored rhythm confirmed by EMS personnel or AEDs used by bystanders if available, and CA cause (cardiac or noncardiac origin). Time factors were evaluated as the time intervals from the ambulance call to (1) arrival at patients side, (2) electrical shock if administered, and (3) hospital arrival. 2.3. Outcome measures
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This was a population-based, observational study conducted in the Osaka Prefecture (area, 1898 km2 ; population, 8.8 million), Japan. This prefecture had approximately 19% individuals aged ≤19 years. The study protocol was approved by the institutional review board of Osaka City University. In 1998, the Committee of the Utstein Osaka Project launched a population-based observational study of out-of-hospital cardiac arrest (OHCA) with the cooperation of medical institutions, fire departments, the Osaka Medical Association, and other relevant organizations in Osaka. The committee was authorized by the Osaka Prefectural Government in 2005, and the project has been conducted as a public service of the prefectural government since then. The inclusion criteria for the Utstein Osaka Project Registry are OHCA cases resuscitated and transported by emergency medical services (EMS) personnel. OHCA data variables were determined by the committee according to the Utstein Recommendations.2,3 In cooperation with the physician in charge of the patients, EMS personnel completed the data form. More detailed information on patient characteristics and prehospital emergency care was gathered from prehospital documentation (EMS run sheet). 2.2. Subjects and variables measured All SCA that occurred in school premises between January 1, 2005 and December 31, 2009 were included in the analysis. The term “school” included the following public and private educational institutions defined by the School Education Act in Japan: elementary schools, junior high schools, high schools, specialneeds schools, 2-year junior colleges, specialized training colleges, and universities. School premises are defined as school buildings, grounds, gymnasiums, swimming pools, and all other facilities belonging to the school organizations. Compulsory education in Japan starts at the age of 6 and lasts for 9 years: 6 years of elementary school and 3 years of junior high school. In 2009, 97% of junior high graduates advanced to high school in Osaka. Special needs schools and schools for students with learning or physical disabilities accommodate children aged 6–18 years. We obtained information on the number of schools, students, and school staff from the website of the Osaka Prefectural Government.4 By May, 2009, there were 1974 schools in Osaka with 1,214,594 students and 123,138 educational or clerical staff (Table 1). The following data were extracted from the Utstein Osaka Project database and relevant EMS run sheets: date, time, and location of CA, age, gender, pre-existing cardiac disease, physical activity at CA onset, bystander witness status, cardiopulmonary
No. of students
No. of faculty and staff
Elementary school Junior high school High school Special needs school University
1042 532 272 40 88
498,933 247,972 219,674 7,269 240,746
33,617 19,784 22,566 4,946 42,225
Total
1974
1,214,594
123,138
97 98 99 100 101
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The average annual incidence of CA was calculated as the number of cases divided by the number of schools, with the population stratified by the educational institution category. Survival 1 month after CA was defined as survival more than 1 month after collapse or discharged alive within 1 month. Neurological status was evaluated by the Cerebral Performance Category (CPC) scale.3 A CPC score of 1 or 2 was defined as a good neurological outcome. 2.4. Data analysis
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Statistical analysis was performed using STATA/SE 9.0 for Windows (STATA, College Station, TX, USA). Continuous data were expressed as the median and interquartile range. Categorical data were expressed as frequencies and percentages. We calculated the 95% confidence intervals for incidence using the Wilson method.
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3. Results
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3.1. SCA incidence and outcomes in schools
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During the study period, 44 cases were registered as SCA in schools (Fig. 1). Of these, 34 were nontraumatic CA, with cases of survival 1 month after CA and those with good neurological outcome being 14 (41%) and 11 (32%), respectively. Twenty-three cases (68%) presented with ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) (i.e., shockable rhythm). The outcomes of these 23 cases were more favourable than those presenting with nonshockable rhythm (i.e., pulseless electrical activity and asystole), with survival 1 month after SCA being 52% vs. 18% and good neurological outcome, 43% vs. 9%, respectively. Traumatic SCA included one case of homicide (stabbing murder), three cases of suicide (two falls from height and one carbon monoxide poisoning), and six accidents (two falls from height, two drowning in swimming pools, one commotio cordis while playing
Cardiac arrest in Osaka n = 33,901 Cardiac arrest at schools n = 44
Traumatic cardiac arrest n = 10
Non traumatic cardiac arrest n = 34
VF/VT n = 23
Non VF/VT n = 11
Survival at one month n = 3 (30%)
Survival at one month n = 12 (52%)
Survival at one month n = 2 (18%)
CPC 1 or 2 n = 3 (30%)
CPC 1 or 2 n = 10 (43%)
CPC 1 or 2 n = 1 (9%)
Table 1 Number of schools, students, and school staff in the Osaka Prefecture. No. of schools
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Fig. 1. Utstein reporting template for sudden cardiac arrest in schools in Osaka between January 2005 and December 2009. VF/VT: ventricular fibrillation or pulseless ventricular tachycardia. CPC: cerebral performance category.
Please cite this article in press as: Nishiuchi T, et al. Epidemiological characteristics of sudden cardiac arrest in schools. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.04.027
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Table 2 Annual incidences of nontraumatic sudden cardiac arrest stratified by category of educational institutions.
Total Elementary school Junior high school High school University
No. of SCA among students
No. of SCA among school faculty, staff, or visitors
No. of schools
14
20
1934
3.52 (2.52–4.89)
4 1 7 2
10 3 7 0
1042 532 272 88
2.69 (1.60–4.49) 1.50 (0.59–3.83) 10.29 (6.18–16.91) 4.55 (1.25–15.83)
Incidence per 1000 schools per year (95% confidence interval)
SCA, sudden cardiac arrest. Table 3 Annual incidences of nontraumatic sudden cardiac arrest stratified by category of educational institutions among students and school faculty and staff. Students
No. of students or faculty/staff No. of school No. of SCA Incidence per 100,000 persons per year 95% CI Incidence per 1000 schools per year 95% CI
School faculty and staff
Elementary school
Junior high school
498,933 1,042 4 0.16 0.06–0.41 0.77 0.30–2.00
247,972 532 1 0.08 0.01–0.46 0.38 0.07–2.13
High school 219,674 272 7 0.64 0.31–1.32 5.15 2.5–10.6
University 240,746 88 2 0.17 0.05–0.61 4.55 1.25–16.4
Total 1,207,325 1,934 14 0.23 0.14–0.39 1.56 0.94–2.56
118,192 1,934 3 0.51 0.17–1.49 0.31 0.11–0.91
SCA, sudden cardiac arrest; CI, confidence interval.
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baseball, and one after being thrown to the ground while playing Japanese-style sumo wrestling). The two drowning cases and one case of commotio cordis survived with good neurological outcomes. The overall incidence of nontraumatic SCA in schools was 3.52 per 1000 schools per year, varying from 1.50 per 1000 schools per year in junior high schools to 10.29 per 1000 schools per year in high schools (Table 2). SCA annual incidence in high school was 2.3–6.9 times higher than that in other schools. Table 3 shows the annual incidence of nontraumatic SCA per school among students and school faculty and staff. SCA incidence in students was 0.23 per 100,000 persons per year, ranging from 0.08 per 100,000 persons per year in junior high schools to 0.64 per 100,000 persons per year in high schools. In comparison, CA incidence in school faculties and staff was 0.51 per 100,000 persons per year, approximately 2 times the rate observed in students. No nontraumatic CA event occurred in the special needs schools during the study period.
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3.2. SCA characteristics in schools
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Table 4 shows the characteristics of nontraumatic SCA in this study between students (student group) and school staff, faculty, and visitors (nonstudent group). Of the 34 cases of nontraumatic SCA in schools, 30 (88%) resulted from a cardiac cause, while the remaining four cases included two with subarachnoid haemorrhage, one thoracic aortic rupture, and one unspecified noncardiac cause. Shockable rhythm was the cardiac rhythm observed most commonly; 10 cases (71%) and 13 cases (65%) in the student and nonstudent groups, respectively. AED pads were applied by bystanders in 10 cases (29%), and electrical shock was administered by bystanders in five cases (15%). Three of the remaining five cases were confirmed as shockable rhythm by EMS and received electrical shock by EMS at the scene. All SCA in students occurred on weekdays, while 60% of SCAs in nonstudents occurred on weekends. Fifty percent of the nonstudent group survived 1 month after CA, with seven (35%) surviving with a good neurological outcome. Although survival 1 month after CA was lower for the student group than for the nonstudent group, all four survivors (29%) were discharged with a good neurological outcome.
Table 4 Characteristics of nontraumatic sudden cardiac arrest in schools.
Age, median (IQR), y Male, no. (%) Presumed cardiac origin, no. (%) Witnessed CA, no. (%) Bystander CPR, no. (%) VF/pulseless VT, no. (%) AED pad application, no. (%) Electrical shock by bystanders, no. (%) SCA on weekdays, no. (%) Pre-existing cardiac disease, no. (%) Physical exercise prior to CA, no. (%) Cardiac disease + physical exercise, no. (%) Time interval from ambulance call to, median (IQR), minutes Arrival at patients side Electrical shock by EMS Hospital arrival One-month survival, no. (%) CPC 1 or 2, no. (%)
Students n = 14
Nonstudents n = 20
17 (11–18) 9 (64) 12 (86) 13 (100) 14 (100) 10 (71) 8 (57) 4 (29) 14 (100) 8 (57) 8 (57) 6 (43)
61 (50–71) 14 (70) 18 (90) 15 (75) 13 (65) 13 (65) 2 (10) 1 (5) 8 (40) 8 (40) 6 (30) 3 (15)
8 (6,10) 10 (9, 11) 24 (21, 33) 4 (29) 4 (29)
5 (4, 6) 7 (5, 9) 20 (19,25) 10 (50) 7 (35)
SCA, sudden cardiac arrest; CPR, cardiopulmonary resuscitation; VF, ventricular fibrillation; VT, ventricular tachycardia; EMS, emergency medical services; IQR, interquartile range; CPC, cerebral performance category; AED, automated external defibrillator.
Ten (71%) and 11 (55%) cases in the student and nonstudent groups, respectively, had pre-existing cardiac diseases and/or collapsed during sports activities (Table 5). The pre-existing cardiac diseases included ischaemic heart disease (n = 4), dilated or hypertrophic cardiomyopathy (n = 4), arrhythmia (n = 4) including one Wolff–Parkinson–White syndrome and one long QT syndrome, congenital heart disease (n = 2), and unspecified cardiac disease (n = 2). The physical activities presumably related to SCA included running (n = 4), basketball (n = 3), football (n = 2), and swimming, tennis, indiaca, softball, and gateball (n = 1 each). 4. Discussion To the best of our knowledge, there have only been a small number of studies that comprehensively investigated CA in schools;5,6
Please cite this article in press as: Nishiuchi T, et al. Epidemiological characteristics of sudden cardiac arrest in schools. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.04.027
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Table 5 Details of pre-existing cardiac disease and physical activities prior to collapse with sudden cardiac arrest of cardiac origin. Age/sex
Students 8/M 8/F 11/M 11/F 13/M 16/F 17/M 17/F 18/F 18/M 18/M 20/M Nonstudents 23/M 45/F 45/M 50/M 50/M 54/F 58/M 58/M 61/M 61/M 62/M 65/M 70/M 71/F 75/F 75/F 76/M 76/M
Pre-existing cardiac disease
Activities prior to CA
Initial ECG rhythm
AED pad application/electrical shock by bystanders
Survival 1 month after CA
DCM ASD Long QT syndrome TOF Unspecified cardiac disease HCM Arrhythmia (not specified)
During physical education class, running During physical education class, swimming During physical education class, running During physical education class, basketball Unknown
VF/VT VF/VT PEA VF/VT VF/VT
−/− +/+ −/− −/− −/−
Survived Survived Dead Dead Dead
During physical education class, running During physical education class, running
Asystole VF/VT
−/− +/−
Survived Dead
During a recess, no physical activity In class, no physical activity During physical education class, basketball During physical education class, basketball In class, no physical activity
PEA VF/VT VF/VT VF/VT VF/VT
−/− +/+ +/− +/− +/+
Dead Survived Dead Dead Dead
While teaching in a gym, no physical activity During an examination, no physical activity While playing indiaca While playing soccer While playing soccer Walking While cleaning in the hall Unknown In a faculty room, no physical activity In class, no physical activity While playing softball
VF/VT VF/VT VF/VT VF/VT VF/VT VF/VT VF/VT PEA VF/VT PEA VF/VT
−/− −/− −/− −/− −/− −/− −/− −/− −/− −/− −/−
Survived Survived Survived Dead Dead Survived Dead Dead Survived Dead Dead
While playing tennis After cleaning task A spectator in an event, no physical activity A spectator in an event, no physical activity While playing gateball Unknown A spectator in an event, no physical activity
VF/VT VF/VT PEA PEA VF/VT Asystole VF/VT
−/− +/+ −/− +/− −/− −/− −/−
Survived Survived Survived Dead Survived Dead Survived
DCM
WPW syndrome
IHD
DCM IHD
Arrhythmia (not specified)
IHD Unspecified IHD
ECG, electrocardiogram; AED, automated external defibrillator; M, male; F, female, DCM, dilated cardiomyopathy; ASD, atrial septal defect; TOF, tetralogy of Fallot; HCM, hypertrophic cardiomyopathy; WPW syndrome, Wolff–Parkinson–White syndrome; IHD, ischaemic heart disease; VF/VT, ventricular fibrillation or pulseless ventricular tachycardia; PEA, puleseless electrical activity; CA, cardiac arrest.
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therefore, data on incidence based on a population-based study are particularly scarce. A single retrospective cohort study in Seattle/King County reported SCA incidence in schools,5 which was comparable with that measured in Osaka (0.18 per 100,000 persons per year in Seattle and King County, and 0.23 per 100,000 persons per year in Osaka). This is equivalent to a calculated risk for SCA in 1 student per 430,000 per year in Seattle/King Country and 1 student per 550,000 per year in Osaka. Conversely, SCA incidence in school staff in the US was approximately 10 times higher than that observed by us, i.e., 4.51 per 100,000 persons per year in Seattle/King County and 0.43 per 100,000 persons per year in Osaka. Because a large proportion of CAs were presumed to be due to cardiac cause in both studies and that ischaemic heart disease is considered the main cause of adult SCA,7 the difference in the prevalence and mortality of ischaemic heart disease between the two countries may have contributed to this significant difference.8,9 Another reason may be the different uses of schools between the two areas. School facilities meant for community use gather more people and thus higher SCA occurrence is expected. Regardless of differences in sporting preference or athletic talent, many students not only enjoy sports as recreation but also participate in physical or sporting activities as part of the school curriculum. Corrado et al. estimated that the relative risk of sporting activity for SCA was 1.95 in adolescents and young adults aged 12–35 years in Italy.10 We showed a similar tendency in our study, with three-quarters of cardiogenic SCA during physical activities occurring in students with known cardiac abnormalities. Although
the large cohort study in Italy found no significant association between a specific type of sports and SCA,10 the majority of sporting activities presumably related to SCA events in our study were relatively intense, with the exception of gateball. There is evidence that swimming is associated with cardiac events in individuals with the long QT syndrome,11,12 making it difficult to differentiate between drowning and arrhythmia-induced CA. The cause of SCA that occur in swimming pools may therefore be misdiagnosed as drowning. Although two of the three SCA cases in our study were registered as drowning, no data were available as to whether their electrocardiograms showed features of the long QT syndrome. The present study showed that CAs majorly in both the student and nonstudent groups were of cardiac origin. It is possible that inherited functional or structural cardiac diseases and cardiac electrical disorders were the underlying causes of SCA observed in our student group, similar to that reported in previous studies.13–16 This possibility leads to the concept that screening for cardiac diseases would be a promising measure to prevent life-threatening events, particularly in the younger generation.17,18 For example, systematic preparticipation athletic screening in Italy was shown to successfully reduce the annual incidence of sudden cardiovascular death in athletes by 89% from 3.6 per 100,000 person-years to 0.4 per 100,000 person-years over a 26-year period. This reduction occurred mainly because athletes diagnosed with cardiomyopathies during screening were disqualified from athletic competitions.19 In Japan, nationwide screening for cardiac diseases was implemented in 1973 for first and seventh grade students,
Please cite this article in press as: Nishiuchi T, et al. Epidemiological characteristics of sudden cardiac arrest in schools. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.04.027
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while in 1995, an electrocardiogram was adopted as a required item for primary screening of first, seventh, and 10th grade students. A cohort study conducted in Kagoshima, Japan20 also demonstrated the effectiveness of athletic limitation, with eight of nine students categorized as high-risk subjects and placed under athletic limitation having no cardiac events during the follow-up period. The findings of our study combined with those of the Italian study indicate that identification of at-risk individuals by nationwide screening and appropriate limitation of physical activity could be an effective measure for reducing morbidity and mortality due to SCA. VF or pulseless VT accounted for the majority of the cardiac rhythms monitored immediately after collapse in both the student and nonstudent groups. However, compared with students, fewer individuals in the nonstudent group had AED pads applied before EMS arrival, regardless of the high rate of CPR administered by bystanders. There appears to be several reasons for this difference. In our study, school visitors accounted for the majority of nontraumatic SCA in nonstudents, and 60% of the SCA in nonstudents occurred on weekends, whereas all SCA occurred on weekdays in the students. The variable use of AED between groups was therefore assumed to be because of differences in the availability and accessibility of AED and trained personnel. For example, even if schools own AED, they may be placed inside school buildings or other places where visitors are not allowed to enter on weekends and also be difficult to locate or impossible to reach. Personnel trained in AED use may also not be present on weekends, or alternatively, AED may not have been available in some schools during the study period. Cognitive errors could be another reason for the difference because bystanders may fail to recognize seizure activity or agonal respirations as CA.6 This study highlighted the unique features of schools in terms of developing strategies to decrease morbidity and mortality due to SCA. A nationwide screening program of cardiac diseases in schools throughout Japan has the potential to identify individuals with cardiac diseases predisposing them to SCA. This program is required for primary prevention that would lead to appropriate medical treatments and avoidance of triggering factors, such as disqualification from competitive or intensive sports.21 Even if the primary prevention failed, early defibrillation with prompt and effective CPR, i.e., secondary prevention of sudden death has been shown to improve survival of individuals who experienced SCA in schools.5,6 A school-based AED program in the US resulted in a 64% survival to discharge rate for SCA that occurred on school grounds.22 Irrespective of the low SCA incidence, every school should be encouraged to introduce an emergency response plan for SCA, including (1) establishing an efficient communication system, (2) training of likely responders in CPR and AED use, (3) providing a coordinated and practiced response plan, and (4) ensuring access to early defibrillation.23,24 School administrators or others in charge of school health also need to focus on SCA that can occur in visitors after school or on weekends and to take effective measures so that immediate CPR is provided at any time using a deployed AED. There were several limitations to our study. All subjects analyzed were SCA cases transported by EMS personnel. Therefore, any patient who was not transported by ambulance could not be identified and was excluded. However, such cases were considered quite rare because it is highly unlikely for ambulances not to be called immediately after a collapse in public places such as schools. Detailed information on pre-existing cardiac diseases was obtained from EMS run sheets. Although EMS personnel were diligent in their attempts to record information on pre-existing cardiac diseases from the school faculty and/or family members, they may have not obtained this information in some cases. Moreover, histories obtained in hospitals were not available because the data were anonymously registered, and hence, no personal identification
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information was accessible. Therefore, cases with pre-existing cardiac diseases may have been missed and their numbers could have been underestimated. Although exercise intensity is associated with SCA onset,24 estimating the intensity and duration of physical activities from the EMS run sheets was difficult. Exercise capacity or threshold for triggering lethal arrhythmia can also vary from individual to individual. Therefore, how low intensity sports or physical activities such as gateball affect SCA onset remains unclear. AED placement and use for SCA is of interest as an indicator of successful emergency responses in schools.22 School names and addresses were anonymous in our database, and it was thus impossible to obtain data retrospectively. Furthermore, data on AED pad application by bystanders were obtained from EMS run sheets, although “whether common people delivered electrical shock to SCA victims” was a factor that needed to be recorded in our analyses. The number of AED pad applications could thus have been underestimated. In conclusion, while SCA incidence in schools is extremely low, several features were identified to provide invaluable clues for reducing morbidity and mortality due to SCA. Identifying individuals with cardiac diseases that potentially predispose them to CA and providing appropriate treatment for these people and advising them to refrain from strenuous exercise could reduce SCA prevalence in schools. The fact that shockable rhythm was the most common cardiac rhythm observed in both students and nonstudents emphasizes the relevance of the widespread deployment of AED in Japanese schools. A medical emergency response plan should be introduced in every school so that early and effective CPR can be provided by a deployed AED. Conflict of interest statement The authors declare that they have no conflict of interest. Funding sources This work was supported by Grants-in-Aid for Scientific Research (KAKENHI) of the Ministry of Education, Culture, Sports, Q2 Science and Technology, Japan (No. 24592743). Acknowledgments We are very grateful to all the members of the Utstein Osaka Project for their contribution to the organization of the study project. We would like to thank all the front-line emergency medical personnel and physicians who contributed significantly to our research by collecting data. We also offer our special thanks to the Osaka Medical Association and Osaka Prefectural Government for their continued dedication and support of our study. References 1. Ministry of Education C, Sports, Science and Technology. Report on Outcomes of Plan on the Promotion of School Safety (Japanese); 2013. 2. Cummins RO, Chamberlain DA, Abramson NS, et al. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein Style. A statement for health professionals from a task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council. Circulation 1991;84:960–75. 3. Jacobs I, Nadkarni V, Bahr J, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada,
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InterAmerican Heart Foundation, Resuscitation Councils of Southern Africa). Circulation 2004;110:3385–97. Government OP. Statistical Yearbook in Osaka. Lotfi K, White L, Rea T, et al. Cardiac arrest in schools. Circulation 2007;116:1374–9. Swor R, Grace H, McGovern H, Weiner M, Walton E. Cardiac arrests in schools: assessing use of automated external defibrillators (AED) on school campuses. Resuscitation 2013;84:426–9. Lippert FK, Raffay V, Georgiou M, Steen PA, Bossaert L. European Resuscitation Council Guidelines for Resuscitation 2010 Section 10. The ethics of resuscitation and end-of-life decisions. Resuscitation 2010;81:1445–51. Nishiuchi T, Hiraide A, Hayashi Y, et al. Incidence and survival rate of bystander-witnessed out-of-hospital cardiac arrest with cardiac etiology in Osaka, Japan: a population-based study according to the Utstein style. Resuscitation 2003;59:329–35. Iso H. Changes in coronary heart disease risk among Japanese. Circulation 2008;118:2725–9. Corrado D, Basso C, Rizzoli G, Schiavon M, Thiene G. Does sports activity enhance the risk of sudden death in adolescents and young adults? J Am Coll Cardiol 2003;42:1959–63. Moss AJ, Schwartz PJ, Crampton RS, et al. The long QT syndrome. Prospective longitudinal study of 328 families. Circulation 1991;84:1136–44. Johnson JN, Ackerman MJ. QTc: how long is too long? Br J Sports Med 2009;43:657–62. Anderson BR, Vetter VL. Return to play? Practical considerations for young athletes with cardiovascular disease. Br J Sports Med 2009;43:690–5. Liberthson RR. Sudden death from cardiac causes in children and young adults. N Engl J Med 1996;334:1039–44.
15. Campbell RM, Berger S, Drezner J. Sudden cardiac arrest in children and young athletes: the importance of a detailed personal and family history in the preparticipation evaluation. Br J Sports Med 2009;43:336–41. 16. Pediatric sudden cardiac arrest. Pediatrics 2012;129:e1094–102. 17. Haneda N, Mori C, Nishio T, et al. Heart diseases discovered by mass screening in the schools of Shimane Prefecture over a period of 5 years. Jpn Circ J 1986;50:1325–9. 18. Tasaki H, Hamasaki Y, Ichimaru T. Mass screening for heart disease of school children in Saga city: 7-year follow up study. Jpn Circ J 1987;51:1415–20. 19. Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA 2006;296:1593–601. 20. Tanaka Y, Yoshinaga M, Anan R, et al. Usefulness and cost effectiveness of cardiovascular screening of young adolescents. Med Sci Sports Exerc 2006;38:2–6. 21. Corrado D, Drezner J, Basso C, Pelliccia A, Thiene G. Strategies for the prevention of sudden cardiac death during sports. Eur J Cardiovasc Prev Rehabil 2011;18:197–208. 22. Drezner JA, Rao AL, Heistand J, Bloomingdale MK, Harmon KG. Effectiveness of emergency response planning for sudden cardiac arrest in United States high schools with automated external defibrillators. Circulation 2009;120:518–25. 23. Hazinski MF, Markenson D, Neish S, et al. Response to cardiac arrest and selected life-threatening medical emergencies: the medical emergency response plan for schools: a statement for healthcare providers, policymakers, school administrators, and community leaders. Circulation 2004;109:278–91. 24. Drezner JA, Courson RW, Roberts WO, Mosesso VN, Link MS, Maron BJ. Inter-association task force recommendations on emergency preparedness and management of sudden cardiac arrest in high school and college athletic programs: a consensus statement. J Athl Train 2007;42:143–58.
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Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
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Clinical Paper
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Epidemiological characteristics of sudden cardiac arrest in schools夽
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Q1
Tatsuya Nishiuchi a,∗ , Yasuaki Hayashino b , Taku Iwami c , Tetsuhisa Kitamura d , Chika Nishiyama e , Kentaro Kajino f , Masahiko Nitta g , Yasuyuki Hayashi h , Atsushi Hiraide a , the Utstein Osaka Project Investigators a
Department of Acute Medicine, Kinki University Faculty of Medicine, 377-2 Ohno-higashi, Osaka-Sayama, Osaka 589-8511, Japan Department of Endocrinology, Tenri Hospital, 200 Mishimacho, Tenri, Nara 632-8552, Japan Department of Preventive Services, Kyoto University School of Public Health, Yoshidahonmachi, Sakyo-ku, Kyoto 606-8317, Japan d Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan e Department of Pharmacoepidemiology, Kyoto University Graduate School of Medicine and Public Health, Yoshida Konoe-cho, Sakyo-ku, Kyoto 606-8315, Japan f Health Policy Bureau, Guidance of Medical Service Division, Ministry of Health, Labour and Welfare Government of Japan, 1-2-2 Kasumigaseki, Chiyoda-ku, Tokyo 100-8916, Japan g Departments of Emergency Medicine and Pediatrics, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka 569-0801, Japan h Senri Critical Care Medical Center, Osaka Saiseikai Senri Hospital, 1-1-6 Tsukumodai, Suita, Osaka 565-0862, Japan b c
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a r t i c l e
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a b s t r a c t
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Article history: Received 9 January 2014 Received in revised form 5 April 2014 Accepted 28 April 2014
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Keywords: Cardiac arrest Schools Prevention Public access defibrillation Epidemiology
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1. Introduction
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Aims: The present study aimed to clarify the incidence and outcomes of sudden cardiac arrests in schools and the clinically relevant characteristics of individuals who experienced sudden cardiac arrests. Methods and results: We obtained data on sudden cardiac arrests that occurred in schools between January 1, 2005 and December 31, 2009 from the database of the Utstein Osaka Project, a populationbased observational study on out-of-hospital cardiac arrests in Osaka, Japan. The data were analyzed to show the epidemiological features of sudden cardiac arrests in schools in conjunction with prehospital documentation. In total, 44 cases were registered as sudden cardiac arrests in schools during the study period. Of these, 34 cases had nontraumatic cardiac arrests. Twenty-one cases (62%) had pre-existing cardiac diseases and/or collapsed during physical exercise. Twenty-three cases (68%) presented with ventricular fibrillation or pulseless ventricular tachycardia, with cases of survival 1 month after cardiac arrest and those having favourable neurological outcome (Cerebral Performance Category 1 or 2) being 12 (52%) and 10 (43%), respectively. The incidence of sudden cardiac arrests in students was 0.23 per 100,000 persons per year, ranging from 0.08 in junior high school to 0.64 in high school. The incidence of sudden cardiac arrests in school faculty and staff was 0.51 per 100,000 persons per year, a rate approximately 2 times of that observed in the students. Conclusions: Although sudden cardiac arrests in schools is rare, they majorly occurred in individuals with cardiac diseases and/or during physical exercise and presented as ventricular fibrillation or pulseless ventricular tachycardia observed initially as cardiac arrhythmia. © 2014 Published by Elsevier Ireland Ltd.
Sudden cardiac arrest (SCA) in schools is a rare event. When a tragic event occurs in these places that are expected to be absolutely safe, it can cause emotional distress to family members, students,
夽 A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2014.04.027. ∗ Corresponding author. E-mail address: [email protected] (T. Nishiuchi).
faculty members, and community members. To prevent sudden cardiac death of students, faculty, staff, or visitors, deployment of automated external defibrillators (AED) in Japanese schools has been strongly advocated since the implementation of the nationwide public access defibrillation program in 2004. The Ministry of Education, Culture, Sports, Science and Technology of Japan reported that by 2012, AED have been placed in 98% public and private schools at all three levels, elementary, junior high, and high schools.1 However, despite this wide spread use of AED in Japan, epidemiological data on SCA in schools are limited. We therefore examined SCA epidemiological characteristics in schools using the
http://dx.doi.org/10.1016/j.resuscitation.2014.04.027 0300-9572/© 2014 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Nishiuchi T, et al. Epidemiological characteristics of sudden cardiac arrest in schools. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.04.027
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Utstein-style registry database. The present study aimed to clarify SCA incidence and outcomes and the clinically relevant characteristics of individuals who experienced SCA in schools.
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2. Methods
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2.1. Study design, setting, and data sources
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resuscitation (CPR) by bystanders, first monitored rhythm confirmed by EMS personnel or AEDs used by bystanders if available, and CA cause (cardiac or noncardiac origin). Time factors were evaluated as the time intervals from the ambulance call to (1) arrival at patients side, (2) electrical shock if administered, and (3) hospital arrival. 2.3. Outcome measures
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This was a population-based, observational study conducted in the Osaka Prefecture (area, 1898 km2 ; population, 8.8 million), Japan. This prefecture had approximately 19% individuals aged ≤19 years. The study protocol was approved by the institutional review board of Osaka City University. In 1998, the Committee of the Utstein Osaka Project launched a population-based observational study of out-of-hospital cardiac arrest (OHCA) with the cooperation of medical institutions, fire departments, the Osaka Medical Association, and other relevant organizations in Osaka. The committee was authorized by the Osaka Prefectural Government in 2005, and the project has been conducted as a public service of the prefectural government since then. The inclusion criteria for the Utstein Osaka Project Registry are OHCA cases resuscitated and transported by emergency medical services (EMS) personnel. OHCA data variables were determined by the committee according to the Utstein Recommendations.2,3 In cooperation with the physician in charge of the patients, EMS personnel completed the data form. More detailed information on patient characteristics and prehospital emergency care was gathered from prehospital documentation (EMS run sheet). 2.2. Subjects and variables measured All SCA that occurred in school premises between January 1, 2005 and December 31, 2009 were included in the analysis. The term “school” included the following public and private educational institutions defined by the School Education Act in Japan: elementary schools, junior high schools, high schools, specialneeds schools, 2-year junior colleges, specialized training colleges, and universities. School premises are defined as school buildings, grounds, gymnasiums, swimming pools, and all other facilities belonging to the school organizations. Compulsory education in Japan starts at the age of 6 and lasts for 9 years: 6 years of elementary school and 3 years of junior high school. In 2009, 97% of junior high graduates advanced to high school in Osaka. Special needs schools and schools for students with learning or physical disabilities accommodate children aged 6–18 years. We obtained information on the number of schools, students, and school staff from the website of the Osaka Prefectural Government.4 By May, 2009, there were 1974 schools in Osaka with 1,214,594 students and 123,138 educational or clerical staff (Table 1). The following data were extracted from the Utstein Osaka Project database and relevant EMS run sheets: date, time, and location of CA, age, gender, pre-existing cardiac disease, physical activity at CA onset, bystander witness status, cardiopulmonary
No. of students
No. of faculty and staff
Elementary school Junior high school High school Special needs school University
1042 532 272 40 88
498,933 247,972 219,674 7,269 240,746
33,617 19,784 22,566 4,946 42,225
Total
1974
1,214,594
123,138
97 98 99 100 101
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The average annual incidence of CA was calculated as the number of cases divided by the number of schools, with the population stratified by the educational institution category. Survival 1 month after CA was defined as survival more than 1 month after collapse or discharged alive within 1 month. Neurological status was evaluated by the Cerebral Performance Category (CPC) scale.3 A CPC score of 1 or 2 was defined as a good neurological outcome. 2.4. Data analysis
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Statistical analysis was performed using STATA/SE 9.0 for Windows (STATA, College Station, TX, USA). Continuous data were expressed as the median and interquartile range. Categorical data were expressed as frequencies and percentages. We calculated the 95% confidence intervals for incidence using the Wilson method.
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3. Results
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3.1. SCA incidence and outcomes in schools
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During the study period, 44 cases were registered as SCA in schools (Fig. 1). Of these, 34 were nontraumatic CA, with cases of survival 1 month after CA and those with good neurological outcome being 14 (41%) and 11 (32%), respectively. Twenty-three cases (68%) presented with ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) (i.e., shockable rhythm). The outcomes of these 23 cases were more favourable than those presenting with nonshockable rhythm (i.e., pulseless electrical activity and asystole), with survival 1 month after SCA being 52% vs. 18% and good neurological outcome, 43% vs. 9%, respectively. Traumatic SCA included one case of homicide (stabbing murder), three cases of suicide (two falls from height and one carbon monoxide poisoning), and six accidents (two falls from height, two drowning in swimming pools, one commotio cordis while playing
Cardiac arrest in Osaka n = 33,901 Cardiac arrest at schools n = 44
Traumatic cardiac arrest n = 10
Non traumatic cardiac arrest n = 34
VF/VT n = 23
Non VF/VT n = 11
Survival at one month n = 3 (30%)
Survival at one month n = 12 (52%)
Survival at one month n = 2 (18%)
CPC 1 or 2 n = 3 (30%)
CPC 1 or 2 n = 10 (43%)
CPC 1 or 2 n = 1 (9%)
Table 1 Number of schools, students, and school staff in the Osaka Prefecture. No. of schools
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Fig. 1. Utstein reporting template for sudden cardiac arrest in schools in Osaka between January 2005 and December 2009. VF/VT: ventricular fibrillation or pulseless ventricular tachycardia. CPC: cerebral performance category.
Please cite this article in press as: Nishiuchi T, et al. Epidemiological characteristics of sudden cardiac arrest in schools. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.04.027
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Table 2 Annual incidences of nontraumatic sudden cardiac arrest stratified by category of educational institutions.
Total Elementary school Junior high school High school University
No. of SCA among students
No. of SCA among school faculty, staff, or visitors
No. of schools
14
20
1934
3.52 (2.52–4.89)
4 1 7 2
10 3 7 0
1042 532 272 88
2.69 (1.60–4.49) 1.50 (0.59–3.83) 10.29 (6.18–16.91) 4.55 (1.25–15.83)
Incidence per 1000 schools per year (95% confidence interval)
SCA, sudden cardiac arrest. Table 3 Annual incidences of nontraumatic sudden cardiac arrest stratified by category of educational institutions among students and school faculty and staff. Students
No. of students or faculty/staff No. of school No. of SCA Incidence per 100,000 persons per year 95% CI Incidence per 1000 schools per year 95% CI
School faculty and staff
Elementary school
Junior high school
498,933 1,042 4 0.16 0.06–0.41 0.77 0.30–2.00
247,972 532 1 0.08 0.01–0.46 0.38 0.07–2.13
High school 219,674 272 7 0.64 0.31–1.32 5.15 2.5–10.6
University 240,746 88 2 0.17 0.05–0.61 4.55 1.25–16.4
Total 1,207,325 1,934 14 0.23 0.14–0.39 1.56 0.94–2.56
118,192 1,934 3 0.51 0.17–1.49 0.31 0.11–0.91
SCA, sudden cardiac arrest; CI, confidence interval.
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baseball, and one after being thrown to the ground while playing Japanese-style sumo wrestling). The two drowning cases and one case of commotio cordis survived with good neurological outcomes. The overall incidence of nontraumatic SCA in schools was 3.52 per 1000 schools per year, varying from 1.50 per 1000 schools per year in junior high schools to 10.29 per 1000 schools per year in high schools (Table 2). SCA annual incidence in high school was 2.3–6.9 times higher than that in other schools. Table 3 shows the annual incidence of nontraumatic SCA per school among students and school faculty and staff. SCA incidence in students was 0.23 per 100,000 persons per year, ranging from 0.08 per 100,000 persons per year in junior high schools to 0.64 per 100,000 persons per year in high schools. In comparison, CA incidence in school faculties and staff was 0.51 per 100,000 persons per year, approximately 2 times the rate observed in students. No nontraumatic CA event occurred in the special needs schools during the study period.
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3.2. SCA characteristics in schools
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Table 4 shows the characteristics of nontraumatic SCA in this study between students (student group) and school staff, faculty, and visitors (nonstudent group). Of the 34 cases of nontraumatic SCA in schools, 30 (88%) resulted from a cardiac cause, while the remaining four cases included two with subarachnoid haemorrhage, one thoracic aortic rupture, and one unspecified noncardiac cause. Shockable rhythm was the cardiac rhythm observed most commonly; 10 cases (71%) and 13 cases (65%) in the student and nonstudent groups, respectively. AED pads were applied by bystanders in 10 cases (29%), and electrical shock was administered by bystanders in five cases (15%). Three of the remaining five cases were confirmed as shockable rhythm by EMS and received electrical shock by EMS at the scene. All SCA in students occurred on weekdays, while 60% of SCAs in nonstudents occurred on weekends. Fifty percent of the nonstudent group survived 1 month after CA, with seven (35%) surviving with a good neurological outcome. Although survival 1 month after CA was lower for the student group than for the nonstudent group, all four survivors (29%) were discharged with a good neurological outcome.
Table 4 Characteristics of nontraumatic sudden cardiac arrest in schools.
Age, median (IQR), y Male, no. (%) Presumed cardiac origin, no. (%) Witnessed CA, no. (%) Bystander CPR, no. (%) VF/pulseless VT, no. (%) AED pad application, no. (%) Electrical shock by bystanders, no. (%) SCA on weekdays, no. (%) Pre-existing cardiac disease, no. (%) Physical exercise prior to CA, no. (%) Cardiac disease + physical exercise, no. (%) Time interval from ambulance call to, median (IQR), minutes Arrival at patients side Electrical shock by EMS Hospital arrival One-month survival, no. (%) CPC 1 or 2, no. (%)
Students n = 14
Nonstudents n = 20
17 (11–18) 9 (64) 12 (86) 13 (100) 14 (100) 10 (71) 8 (57) 4 (29) 14 (100) 8 (57) 8 (57) 6 (43)
61 (50–71) 14 (70) 18 (90) 15 (75) 13 (65) 13 (65) 2 (10) 1 (5) 8 (40) 8 (40) 6 (30) 3 (15)
8 (6,10) 10 (9, 11) 24 (21, 33) 4 (29) 4 (29)
5 (4, 6) 7 (5, 9) 20 (19,25) 10 (50) 7 (35)
SCA, sudden cardiac arrest; CPR, cardiopulmonary resuscitation; VF, ventricular fibrillation; VT, ventricular tachycardia; EMS, emergency medical services; IQR, interquartile range; CPC, cerebral performance category; AED, automated external defibrillator.
Ten (71%) and 11 (55%) cases in the student and nonstudent groups, respectively, had pre-existing cardiac diseases and/or collapsed during sports activities (Table 5). The pre-existing cardiac diseases included ischaemic heart disease (n = 4), dilated or hypertrophic cardiomyopathy (n = 4), arrhythmia (n = 4) including one Wolff–Parkinson–White syndrome and one long QT syndrome, congenital heart disease (n = 2), and unspecified cardiac disease (n = 2). The physical activities presumably related to SCA included running (n = 4), basketball (n = 3), football (n = 2), and swimming, tennis, indiaca, softball, and gateball (n = 1 each). 4. Discussion To the best of our knowledge, there have only been a small number of studies that comprehensively investigated CA in schools;5,6
Please cite this article in press as: Nishiuchi T, et al. Epidemiological characteristics of sudden cardiac arrest in schools. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.04.027
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Table 5 Details of pre-existing cardiac disease and physical activities prior to collapse with sudden cardiac arrest of cardiac origin. Age/sex
Students 8/M 8/F 11/M 11/F 13/M 16/F 17/M 17/F 18/F 18/M 18/M 20/M Nonstudents 23/M 45/F 45/M 50/M 50/M 54/F 58/M 58/M 61/M 61/M 62/M 65/M 70/M 71/F 75/F 75/F 76/M 76/M
Pre-existing cardiac disease
Activities prior to CA
Initial ECG rhythm
AED pad application/electrical shock by bystanders
Survival 1 month after CA
DCM ASD Long QT syndrome TOF Unspecified cardiac disease HCM Arrhythmia (not specified)
During physical education class, running During physical education class, swimming During physical education class, running During physical education class, basketball Unknown
VF/VT VF/VT PEA VF/VT VF/VT
−/− +/+ −/− −/− −/−
Survived Survived Dead Dead Dead
During physical education class, running During physical education class, running
Asystole VF/VT
−/− +/−
Survived Dead
During a recess, no physical activity In class, no physical activity During physical education class, basketball During physical education class, basketball In class, no physical activity
PEA VF/VT VF/VT VF/VT VF/VT
−/− +/+ +/− +/− +/+
Dead Survived Dead Dead Dead
While teaching in a gym, no physical activity During an examination, no physical activity While playing indiaca While playing soccer While playing soccer Walking While cleaning in the hall Unknown In a faculty room, no physical activity In class, no physical activity While playing softball
VF/VT VF/VT VF/VT VF/VT VF/VT VF/VT VF/VT PEA VF/VT PEA VF/VT
−/− −/− −/− −/− −/− −/− −/− −/− −/− −/− −/−
Survived Survived Survived Dead Dead Survived Dead Dead Survived Dead Dead
While playing tennis After cleaning task A spectator in an event, no physical activity A spectator in an event, no physical activity While playing gateball Unknown A spectator in an event, no physical activity
VF/VT VF/VT PEA PEA VF/VT Asystole VF/VT
−/− +/+ −/− +/− −/− −/− −/−
Survived Survived Survived Dead Survived Dead Survived
DCM
WPW syndrome
IHD
DCM IHD
Arrhythmia (not specified)
IHD Unspecified IHD
ECG, electrocardiogram; AED, automated external defibrillator; M, male; F, female, DCM, dilated cardiomyopathy; ASD, atrial septal defect; TOF, tetralogy of Fallot; HCM, hypertrophic cardiomyopathy; WPW syndrome, Wolff–Parkinson–White syndrome; IHD, ischaemic heart disease; VF/VT, ventricular fibrillation or pulseless ventricular tachycardia; PEA, puleseless electrical activity; CA, cardiac arrest.
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therefore, data on incidence based on a population-based study are particularly scarce. A single retrospective cohort study in Seattle/King County reported SCA incidence in schools,5 which was comparable with that measured in Osaka (0.18 per 100,000 persons per year in Seattle and King County, and 0.23 per 100,000 persons per year in Osaka). This is equivalent to a calculated risk for SCA in 1 student per 430,000 per year in Seattle/King Country and 1 student per 550,000 per year in Osaka. Conversely, SCA incidence in school staff in the US was approximately 10 times higher than that observed by us, i.e., 4.51 per 100,000 persons per year in Seattle/King County and 0.43 per 100,000 persons per year in Osaka. Because a large proportion of CAs were presumed to be due to cardiac cause in both studies and that ischaemic heart disease is considered the main cause of adult SCA,7 the difference in the prevalence and mortality of ischaemic heart disease between the two countries may have contributed to this significant difference.8,9 Another reason may be the different uses of schools between the two areas. School facilities meant for community use gather more people and thus higher SCA occurrence is expected. Regardless of differences in sporting preference or athletic talent, many students not only enjoy sports as recreation but also participate in physical or sporting activities as part of the school curriculum. Corrado et al. estimated that the relative risk of sporting activity for SCA was 1.95 in adolescents and young adults aged 12–35 years in Italy.10 We showed a similar tendency in our study, with three-quarters of cardiogenic SCA during physical activities occurring in students with known cardiac abnormalities. Although
the large cohort study in Italy found no significant association between a specific type of sports and SCA,10 the majority of sporting activities presumably related to SCA events in our study were relatively intense, with the exception of gateball. There is evidence that swimming is associated with cardiac events in individuals with the long QT syndrome,11,12 making it difficult to differentiate between drowning and arrhythmia-induced CA. The cause of SCA that occur in swimming pools may therefore be misdiagnosed as drowning. Although two of the three SCA cases in our study were registered as drowning, no data were available as to whether their electrocardiograms showed features of the long QT syndrome. The present study showed that CAs majorly in both the student and nonstudent groups were of cardiac origin. It is possible that inherited functional or structural cardiac diseases and cardiac electrical disorders were the underlying causes of SCA observed in our student group, similar to that reported in previous studies.13–16 This possibility leads to the concept that screening for cardiac diseases would be a promising measure to prevent life-threatening events, particularly in the younger generation.17,18 For example, systematic preparticipation athletic screening in Italy was shown to successfully reduce the annual incidence of sudden cardiovascular death in athletes by 89% from 3.6 per 100,000 person-years to 0.4 per 100,000 person-years over a 26-year period. This reduction occurred mainly because athletes diagnosed with cardiomyopathies during screening were disqualified from athletic competitions.19 In Japan, nationwide screening for cardiac diseases was implemented in 1973 for first and seventh grade students,
Please cite this article in press as: Nishiuchi T, et al. Epidemiological characteristics of sudden cardiac arrest in schools. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.04.027
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while in 1995, an electrocardiogram was adopted as a required item for primary screening of first, seventh, and 10th grade students. A cohort study conducted in Kagoshima, Japan20 also demonstrated the effectiveness of athletic limitation, with eight of nine students categorized as high-risk subjects and placed under athletic limitation having no cardiac events during the follow-up period. The findings of our study combined with those of the Italian study indicate that identification of at-risk individuals by nationwide screening and appropriate limitation of physical activity could be an effective measure for reducing morbidity and mortality due to SCA. VF or pulseless VT accounted for the majority of the cardiac rhythms monitored immediately after collapse in both the student and nonstudent groups. However, compared with students, fewer individuals in the nonstudent group had AED pads applied before EMS arrival, regardless of the high rate of CPR administered by bystanders. There appears to be several reasons for this difference. In our study, school visitors accounted for the majority of nontraumatic SCA in nonstudents, and 60% of the SCA in nonstudents occurred on weekends, whereas all SCA occurred on weekdays in the students. The variable use of AED between groups was therefore assumed to be because of differences in the availability and accessibility of AED and trained personnel. For example, even if schools own AED, they may be placed inside school buildings or other places where visitors are not allowed to enter on weekends and also be difficult to locate or impossible to reach. Personnel trained in AED use may also not be present on weekends, or alternatively, AED may not have been available in some schools during the study period. Cognitive errors could be another reason for the difference because bystanders may fail to recognize seizure activity or agonal respirations as CA.6 This study highlighted the unique features of schools in terms of developing strategies to decrease morbidity and mortality due to SCA. A nationwide screening program of cardiac diseases in schools throughout Japan has the potential to identify individuals with cardiac diseases predisposing them to SCA. This program is required for primary prevention that would lead to appropriate medical treatments and avoidance of triggering factors, such as disqualification from competitive or intensive sports.21 Even if the primary prevention failed, early defibrillation with prompt and effective CPR, i.e., secondary prevention of sudden death has been shown to improve survival of individuals who experienced SCA in schools.5,6 A school-based AED program in the US resulted in a 64% survival to discharge rate for SCA that occurred on school grounds.22 Irrespective of the low SCA incidence, every school should be encouraged to introduce an emergency response plan for SCA, including (1) establishing an efficient communication system, (2) training of likely responders in CPR and AED use, (3) providing a coordinated and practiced response plan, and (4) ensuring access to early defibrillation.23,24 School administrators or others in charge of school health also need to focus on SCA that can occur in visitors after school or on weekends and to take effective measures so that immediate CPR is provided at any time using a deployed AED. There were several limitations to our study. All subjects analyzed were SCA cases transported by EMS personnel. Therefore, any patient who was not transported by ambulance could not be identified and was excluded. However, such cases were considered quite rare because it is highly unlikely for ambulances not to be called immediately after a collapse in public places such as schools. Detailed information on pre-existing cardiac diseases was obtained from EMS run sheets. Although EMS personnel were diligent in their attempts to record information on pre-existing cardiac diseases from the school faculty and/or family members, they may have not obtained this information in some cases. Moreover, histories obtained in hospitals were not available because the data were anonymously registered, and hence, no personal identification
5
information was accessible. Therefore, cases with pre-existing cardiac diseases may have been missed and their numbers could have been underestimated. Although exercise intensity is associated with SCA onset,24 estimating the intensity and duration of physical activities from the EMS run sheets was difficult. Exercise capacity or threshold for triggering lethal arrhythmia can also vary from individual to individual. Therefore, how low intensity sports or physical activities such as gateball affect SCA onset remains unclear. AED placement and use for SCA is of interest as an indicator of successful emergency responses in schools.22 School names and addresses were anonymous in our database, and it was thus impossible to obtain data retrospectively. Furthermore, data on AED pad application by bystanders were obtained from EMS run sheets, although “whether common people delivered electrical shock to SCA victims” was a factor that needed to be recorded in our analyses. The number of AED pad applications could thus have been underestimated. In conclusion, while SCA incidence in schools is extremely low, several features were identified to provide invaluable clues for reducing morbidity and mortality due to SCA. Identifying individuals with cardiac diseases that potentially predispose them to CA and providing appropriate treatment for these people and advising them to refrain from strenuous exercise could reduce SCA prevalence in schools. The fact that shockable rhythm was the most common cardiac rhythm observed in both students and nonstudents emphasizes the relevance of the widespread deployment of AED in Japanese schools. A medical emergency response plan should be introduced in every school so that early and effective CPR can be provided by a deployed AED. Conflict of interest statement The authors declare that they have no conflict of interest. Funding sources This work was supported by Grants-in-Aid for Scientific Research (KAKENHI) of the Ministry of Education, Culture, Sports, Q2 Science and Technology, Japan (No. 24592743). Acknowledgments We are very grateful to all the members of the Utstein Osaka Project for their contribution to the organization of the study project. We would like to thank all the front-line emergency medical personnel and physicians who contributed significantly to our research by collecting data. We also offer our special thanks to the Osaka Medical Association and Osaka Prefectural Government for their continued dedication and support of our study. References 1. Ministry of Education C, Sports, Science and Technology. Report on Outcomes of Plan on the Promotion of School Safety (Japanese); 2013. 2. Cummins RO, Chamberlain DA, Abramson NS, et al. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein Style. A statement for health professionals from a task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council. Circulation 1991;84:960–75. 3. Jacobs I, Nadkarni V, Bahr J, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada,
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