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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
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.