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Mobile Automated External Defibrillator Response System during Road Races

Authors:

Abstract

In Japan, an automated external defibrillator (AED) response system for runners included paramedics on bicycles who carried AEDs, on-foot teams, and a central dispatch system. During 251 races, 28 of 30 runners who had a cardiac arrest were successfully resuscitated.
Cor responde nce
The new england journal of medicine
n engl j med 379;5 nejm.org August 2, 2018
Cor responde nce
Mobile Automated External Defibrillator Response System
during Road Races
To the Editor: The number of marathon races
and other road races has rapidly increased in
Japan,
1
as have the number of sudden cardiac
arrests during these races.
2
We developed a rapid
mobile automated external defibrillator (AED)
system to provide early cardiopulmonary resus-
citation (CPR) and AED intervention for runners
who have cardiac arrest during road races.
3,4
The system consists of mobile teams (pairs of
paramedics who ride bicycles and carr y AEDs
and emergency medical kits) and on-foot teams
(pairs of paramedic trainees who carry AEDs and
can provide basic life support). The system also
includes medical communications dispatchers,
staff at a first-aid station, and physician volun-
teers who run the race and are available by a
global positioning system–enabled telephone to
assist if needed. Details of the system and the
method of data collection are provided in the
Supplementary Appendix, available with the full
text of this letter at NEJM.org.
Between January 1, 2005, and March 7, 2017,
we used the system to support 1,965,265 runners
in 251 road races of a distance of 10.0 to 42.2 km,
and during that period we responded to 30 runners
with cardiac arrest (Table 1). There was 1 cardiac
arrest per 65,509 runners (1.53 cardiac arrests per
100,000 runners). Regardless of the length of the
race, a total of 21 of the cardiac arrests (70%)
occurred in the last quarter of the distance run or
near the finish line of the race. Gasping was noted
in 26 of the runners with cardiac arrest (87%).
Two runners had unwitnessed cardiac arrest.
The initial rhythm was pulseless electrical activ-
ity in one runner and asystole in the other, and
neither of the two runners was successfully re-
suscitated.
In the 28 runners with witnessed cardiac arrest,
the median interval bet ween collapse and the
initiation of basic CPR was 0.8 minutes (inter-
quartile range, 0.5 to 1.0) and the median inter-
val between collapse and delivery of the first
AED shock was 2.2 minutes (interquartile range,
1.6 to 4.4). Shocks were delivered to 23 runners
who had ventricular f ibrillation, and another 5 run-
ners (4 with pulseless electrical activity and 1 with
ventricular fibrillation) recovered with basic CPR
only. The median interval between collapse and
the return of spontaneous circulation was 5.5 min-
utes (interquartile range, 3.2 to 7.0); all these
runners had return of spontaneous circulation
in the f ield, and all had a favorable neurologic
outcome (Cerebral Performance Categor y of 1 or 2,
on a scale from 1 [good cerebral performance]
to 5 [death or brain death]) at 1 month and 1 year.
The median length of hospitalization was 5 days
(interquartile range, 3 to 8 days).
Tomoya Kinoshi, M.S.Sc.
Shota Tanaka, B.S.
Ryo Sagisaka, Ph.D.
Takahiro Hara, Ph.D.
Toru Shirakawa, M.E.M.
Etsuko Sone, M.E.M.
Hiroyuki Takahashi, Ph.D.
Masaru Sakurai, M.D., Ph.D.
Akira Maki, M.D., Ph.D.
this week’s letters
488 Mobile Automated External Def ibrillator
Response System during Road Races
490 Catheter Ablation for Atrial Fibrillation with
Heart Failure
493 Genetics of Diffuse Large B-Cell Lymphoma
494 Diagnostic Use of Base Excess in Acid–Base
Disorders
The New England Journal of Medicine
Downloaded from nejm.org on August 7, 2018. For personal use only. No other uses without permission.
Copyright © 2018 Massachusetts Medical Society. All rights reserved.
Cor re spondence
n engl j med 379;5 nejm.org August 2, 2018
Hiroshi Takyu, Ph.D.
Hideharu Tanaka, M.D., Ph.D.
Kokushikan University
Tokyo, Japan
maezumi@kokushikan.ac.jp
Disclosure forms provided by the authors are avail able wit h
the fu ll text of th is letter at NEJM.org.
1. Sasakawa Sport s Foundation. Spor ts li fe dat a. (htt ps:/ / ww w
.ssf .or .jp/ research/ sldata/ tabid/ 381/ Default .aspx). (I n Japa nese.)
2. Shirakawa T, Tanaka H, Kinoshi T, Tanaka S, Taky u H.
Analysis of sudden cardiac arrest cases during marathon races
in Japan. I nt J Clin Med 2017; 8: 472-80.
3. Maezumi T, Tana ka H, Hosokawa T, et al. Importa nce of
bicycle mobi le tea m (Mobile AED team) in citizen marathon.
Journa l of Clinical Spor ts Medicine 2009; 26: 329-34. (In Japanese.)
4. Tanaka H, Tokunaga T, Maezumi T, Hosokawa T. A develop-
ment of an ef fect ive emergency med ical support in the cit izens’
marat hon events. The An nual Reports of Healt h, Physical Edu-
cation and Sport Science 2008; 27: 115-22. (In Japanese.)
DOI: 10.1056/NEJMc1803218
Variable
All Runners with
Cardiac Arrest
(N = 30)
Runners with
Witnessed
Cardiac Arrest
(N = 28)
Runners with
Unwitnessed
Cardiac Arrest
(N = 2)
Distance of race — no. (%)
>21.1 to full marathon, 42.2 km 19 (63) 19 (68) 0
Half-marathon, 21.1 km 7 (23) 6 (21) 1 (50)
10.0 to <21.1 km 4 (13) 3 (11) 1 (50)
Demographic characteristics of runners
Median age (IQR) — yr 51 (35–59) 52 (36–59) 28 (27–29)
Male sex — no. (%) 27 (90) 25 (89) 2 (100)
Cardiac arrests
Median time from start of race to cardiac arrest (IQR) — min 159 (121–192) 161 (134–195) Unknown
Gasping — no. (%) 26 (87) 25 (89) 1 (50)
Median time from collapse to contact with rapid mobile AED system
team (IQR) — min
0.8 (0.5–1.1) 0.8 (0.5–1.0) Unknown
Median time from witnessed cardiac arrest to initiation of CPR (IQR)
— min
Unknown 0.8 (0.5–1.0) Unknown
Person who initially performed CPR — no. (%)
Rapid mobile AED system team member 23 (77) 21 (75) 2 (100)
Another runner 7 (23) 7 (25) 0
AED analysis
Defibrillation performed — shocks delivered/patients with ventricular
fibrillation (%)
23/24 (96) 23/24 (96) 0
Median time from collapse to delivery of AED shock (IQR) — sec 131 (99–263) 131 (99–263) Unknown
Documented ECG waveform according to initial AED data — no. (%)
Ventricular fibrillation 24 (80) 24 (86) 0
Pulseless electrical activity 5 (17) 4 (14) 1 (50)
Asystole 1 (3) 01 (50)
Outcome
Return of spontaneous circulation in field — no. (%) 28 (93) 28 (100) 0
CPC 1 or 2 — no. (%)†
At 1 mo 28 (93) 28 (100) 0
At 1 yr 28 (93) 28 (100) 0
Median hospital stay (IQR) — day 5 (3–8) 5 (3–8) Unknown
* AED denotes automated external defibrillator, ECG electrocardiographic, and IQR interquartile range.
The Cerebral Performance Category (CPC) is graded on a scale from 1 (good cerebral performance) to 5 (death or brain death).
Table 1. Characteristics of Races, Runners, and Sudden Cardiac Arrests.*
The New England Journal of Medicine
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Copyright © 2018 Massachusetts Medical Society. All rights reserved.
... Mass-gathering events were suspended or scaled down worldwide in 2020 due to the spread of coronavirus disease 2019 (COVID- 19), but now that the COVID-19 pandemic has subsided, such events are being held as usual. As described above, marathon running is extremely beneficial for physical fitness. ...
... A previous study reported that the incidence rate of CA was 0.54 per 100,000 runners (17). Tokyo marathon had a slightly higher rate of 0.65 per 100,000 runners than other marathon races (19). To increase the survival rate of patients with CA during marathon races, the early initiation of CPR and defibrillation with AED is important (19). ...
... Tokyo marathon had a slightly higher rate of 0.65 per 100,000 runners than other marathon races (19). To increase the survival rate of patients with CA during marathon races, the early initiation of CPR and defibrillation with AED is important (19). In the Yokohama Marathon, 3 of 13,500 runners were confirmed to have experienced CA during the marathon race at a rate of 2.2 per 100,000. ...
Preprint
Background: Although the number of individuals who enjoy sports every day is increasing owing to growing health consciousness, marathons pose health risks and can cause various types of health damage, including cardiac arrest. Furthermore, it is important to establish a system for predicting dangers and providing medical care in advance, including securing routes for transporting individuals in need of medical care during mass gathering events. Objective: This study aimed to investigate cases requiring medical care that occurred since the introduction of the full marathon at the Yokohama Citizen Marathon in 2015 and to examine the medical care system and its safety in relation to efforts to build a safer medical system for large scale marathon races. Methods: We retrospectively examined the incidence of health disorders and cardiac arrest during the Yokohama marathon race using the medical records provided by our committee from 2015 to 2024. Additionally, we retrospectively examined the changes in the medical support system. Results: The total number of participants in the full marathon was 134,946 (total number of runners, 147,861), while the number of medical staff was 4,669 (total number of runners, 3.1%). There were 136 cases of emergency transport (0.1%), of which 27 required hospitalization (0.02%), and 3 cases of cardiac arrest during the competition (0.002%). All patients were quickly resuscitated on-site with cardiopulmonary resuscitation, and no deaths occurred. The patient presentation ratio (PPR), which represents the number of injuries and sickness per 1,000 runners, was 14.76 (range, from 11.1 to 17.7), and the transport-to-hospital ratio (TTHR), which represents the number of emergency transports per 1,000 runners, was 0.96 (range, from 0.4 to 2.1). Discussion: Although the number of emergency transports increased and decreased owing to changes in the timing of the event and changes in temperature, it was possible to provide faster and more appropriate medical care to those in need of medical assistance. Analyzing these results annually and reviewing countermeasures to improve the medical support manual will lead to safer marathons. Such efforts will directly lead to a reduction in the number of emergency transports. In fact, the PPR was significantly lower in the current study than that in previous studies, while the TTHR was lower or similar to that in a previous study. Conclusion: The Yokohama marathon is one of the largest marathons in Japan, and this study identified some participants requiring care on course every year. Analysis of annual injury data has enabled better prediction and response to injuries, leading to safer marathon events. Most medical complaints were minor illness caused by dehydration or musculoskeletal in nature; however, there were life threatening conditions such as CA that highlight the need for detailed planning, multi-disciplined coordination, and communication to ensure a safe and secure event. More detailed analysis of past race data under various environmental conditions is essential for running a safer large scale citizen marathon, and the establishment of All Yokohama medical support system that includes local medical institutions, volunteer staff, fire departments, police, and medical staff contributes to running a safer citizen marathon.
... According to a report from Japan, there were 1.53 OHCAs per 100,000 runners in citizen marathons between 2005 and 2017. 121 Children are particularly susceptible to commotio cordis because of their softer chest wall; in Japan, 34 of 44 cases of commotio cordis between 1997 and 2013 occurred during sports, with baseball being the most common cause. 122 ...
... In citizen marathons between 2005 and 2017, all 30 individuals experiencing an OHCA received bystander CPR, with 23 receiving AED shocks. 121 The median times to CPR initiation and AED shock were 0.8 min and 131 s, respectively. Of these 30 individuals experiencing an OHCA, 28 (93%) achieved ROSC at the scene and were reintegrated into the community. ...
... Of these 30 individuals experiencing an OHCA, 28 (93%) achieved ROSC at the scene and were reintegrated into the community. 121 This suggests that the 3 requirements for saving lives, namely the OHCA being witnessed, having a bystander nearby, and having an AED available, can be satisfied by preparing for SCA at sports events, where it is easy to meet these 3 requirements. 124 This scenario is important as a model for SCA countermeasures. ...
... Severe complications include systemic and pulmonary hypertension, cardiomyopathies congestive heart failure, coronary artery disease, cardiac arrhythmias, stroke, venous thromboembolism and increased risk for SCD [55]. It is also associated with gastroesophageal reflux which improves significantly with CPAP, however the mechanism linking the two has remained unknown [56]. Notably, CPAP reduces diaphragm workload and maintains airway patency from muscle collapse. ...
... Looking at Figure . Similarly, reflux occurs in OSA as mentioned above (and improves with CPAP) [56]. It could be caused by intermittent esophageal clamping and release from diaphragm spasms combined with negative intrathoracic pressures generated by breathing against the inactivated diaphragm. ...
Preprint
Full-text available
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... However, this approach is likely only feasible during organized sessions and may be best operationalized in formal team or club environments. Although this model has not been evaluated directly, similar frameworks, such as the mobile AED response teams used in Japanese long-distance road races, 22,23 have yielded high survival rates and favourable neurologic outcomes. Encouraging nearby athletes and exercisers to assist in responding to SCA events may enable prompt resuscitation interventions to occur prior to the arrival of professional responders, optimizing survival outcomes. ...
... Electrocutions [23,24,194] Mechanical asphyxiation (e.g., restraint cardiac arrest, crush syndrome) [67,68] Heat stroke/hyperthermia (e.g., vehicular, marathon runner arrests) [73,154,[195][196][197] Chemical asphyxiants, inhalational injuries [69,198] Cold water immersion and near-drownings [70] Barotrauma [199] Other Malnourishment [45] ...
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This version is the one formally published in "Diagnostics" medical journal on Oct. 18, 2024... ABSTRACT: The diaphragm is the primary muscle of respiration. Here, we disclose a fascinating patient’s perspective that led, by clinical reasoning alone, to a novel mechanism of spontaneous respiratory arrests termed diaphragm cramp-contracture (DCC). Although the 7-year-old boy survived its paroxysmal nocturnal “bearhug pain apnea” episodes, essentially by breathing out to breathe in, DCC could cause sudden unexpected deaths in children, especially infants. Diaphragm fatigue is central to the DCC hypothesis in SIDS. Most, if not all, SIDS risk factors contribute to it, such as male sex, young infancy, rebreathing, nicotine, overheating and viral infections. A workload surge by a roll to prone position or REM-sleep inactivation of airway dilator or respiratory accessory muscles can trigger pathological diaphragm excitation (e.g., spasms, flutter, cramp). Electromyography studies in preterm infants already show that diaphragm fatigue and temporary failure by transient spasms suddenly induce apneas, hypopneas and forced expirations, all leading to hypoxemic episodes. By extension, prolonged spasm as a diaphragm cramp would induce sustained apnea with severe hypoxemia and cardiac arrest if not quickly aborted. This would cause a sudden, rapid, silent death consistent with SIDS. Moreover, a unique airway obstruction could develop where the hypercontracted diaphragm resists terminal inspiratory efforts by the accessory muscles. It would disappear postmortem. SIDS autopsy evidence consistent with DCC includes disrupted myofibers and contraction band necrosis as well as signs of agonal breathing from obstruction. Screening for diaphragm injury from hypoxemia, hyperthermia, viral myositis and excitation include serum CK-MM and skeletal troponin-I. Active excitation could be visualized on ultrasound or fluoroscopy and monitored by respiratory inductive plethysmography or electromyography.
... According to the AED siting results of the LSCP model, it can be found that the overall distribution of new AEDs is more uniform, which can effectively cope with the uneven spatial distribution of AEDs. The number of new AED devices is also higher in areas with high population density and more high-rise buildings (Wuchang District, Some studies have shown that the effective coverage of mobile AED sites is about three times that of fixed AEDs (Hajari et al., 2020;Kinoshi et al., 2018), so with limited resources, using public transportation or drones to carry a relatively small number of mobile AED devices can largely reduce human and material resource overhead and simultaneously better meet the need for emergency care (Bhatt et al., 2018;Ślęzak et al., 2021). Comparing the siting results in this work, it can also be found that AEDs based on the LSCP model have a high service capacity in both central and distant urban areas, but require a high number of AEDs. ...
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The effective deployment of medical emergency equipment, such as automated external defibrillator (AED), is essential to myocardial infarction (MI) patients. However, there are shortcomings in current studies that simultaneously consider the risk of MI and the availability of medical resources when siting the AEDs. In this study, an AED site recommendation framework was proposed to address the lack of consideration for both the MI risk and medical resources when siting the AEDs. It conducts the AED sitting under different scenarios considering the spatial distribution of MI risk and healthcare accessibility in Chinese cities. First, an automated machine learning framework data is proposed to estimate the MI risk at the community scale based on multi-source spatio-temporal. Second, the accessibility of medical resources was calculated by an improved Gaussian two-step moving search algorithm. Finally, the AED siting in multiple scenarios is conducted based on the coverage model. The performance of the AED siting model was evaluated at Wuhan city. The results show that MI risk is impacted by both socioeconomic and cultural characteristics (municipal utilities, streetscape environment, educational and commercial facilities). There is a strong spatial heterogeneity in the distribution of both MI risk and medical resources in Wuhan, and an unreasonable match between the two was detected in some regions. Medical resources need to be strengthened in some high-risk areas, such as rural areas and tourist attractions. In addition, 1015 AED candidate sites were identified by the location set covering problem model, with a 15-min accessibility rate of 96.5%. Given the limited resources, mobile AEDs which have about 15-min service range can be deployed based on the maximum covering location problem model to meet the demand in central urban areas efficiently. This study can contribute to more rational selection of AED sites and the prevention of myocardial infarction among residents, particularly when supported by policies that promote balanced regional development of pre-hospital medical emergency networks.
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Sudden cardiac arrest (SCA) is the leading cause of sudden death in athletes during high-level, organised sport. Patient-related and event-related factors provide an opportunity for rapid intervention and the potential for high survival rates. The aim of this consensus was to develop a best-practice guideline for dedicated field-of-play medical teams responding to SCA during an organised sporting event. A task-and-finish group from Resuscitation Council UK identified a stakeholder group of relevant experts and cardiac arrest survivors in March and April 2022. Together, they developed a best-practice guideline using the best available evidence. A public consultation period further refined the guideline before it was finalised in December 2023. Any sudden collapse, without rapid recovery during sporting activity, should be considered an SCA until proven otherwise. Field-of-play medical teams should be empowered to access the collapsed athlete as soon as possible and perform initial essential interventions in situ. This includes a suggested minimum of three cycles of cardiopulmonary resuscitation and defibrillation in persistent shockable rhythms while other aspects of advanced life support are initiated. There should be careful organisation and practice of the medical response, including plans to transport athletes to dedicated facilities for definitive medical care. This best-practice guideline complements, rather than supersedes, existing resuscitation guidelines. It provides a clear approach to how to best treat an athlete with SCA and how to organise the medical response so treatments are delivered effectively and optimise outcomes.
Importance of bicycle mobile team (Mobile AED team) in citizen marathon.
  • T Maezumi
  • H Tanaka
  • T Hosokawa
  • Maezumi T
A development of an effective emergency medical support in the citizens’ marathon events.
  • H Tanaka
  • T Tokunaga
  • T Maezumi
  • T Hosokawa
  • Tanaka H