AED's in Schools?

By: Dr. Stuart Berger

Introduction
This article is based on Dr. Stuart Berger's presentation to the chapter presidents of the National Association of School Nurses on June 29, 2000. Dr. Berger is the medical director of the pediatric heart transplant program and the Heart Center at Children's Hospital of Wisconsin. He is also the medical director of Project ADAM™, section chief of pediatric cardiology in the department of pediatrics, and associate professor of pediatrics at Medical College of Wisconsin in Milwaukee. The presentation was sponsored by School Health Corporation, Medtronic Physio-Control, and Good-Lite.

Adam Lemel was an outstanding athlete. At 17, he was a star basketball player and one of the best high school tennis players in Wisconsin. While playing basketball at a neighboring Milwaukee high school in January 1999, he collapsed during a time-out.

Tragically, Adam was dying on the basketball court, and not until the paramedics arrived, was CPR begun. By that time, it was too late. Adam died. His autopsy revealed a rare condition known as arrhythmogenic right ventricular dysplasia (ARVD).

One month later, Wilmot High School student Mark Barranco, 18, also experienced sudden cardiac death (SCD) while playing basketball. His autopsy revealed an anomalous left coronary artery.

The following November, a Milwaukee Technical High School football player died of SCD while playing basketball with friends. And, in April 2000, two more Milwaukee-area deaths were attributed to SCD: a Marquette University senior and a visiting 12-year-old baseball player from Illinois. On autopsy, all three had hypertrophic cardiomyopathy.

These events in Milwaukee occurred in just over a year's time. Seventy miles away, a 14-year-old Manitowac student, Craig Handl, collapsed while playing basketball at recess. This time, the cardiac arrest did not end in tragedy.

Within three minutes, the emergency team arrived on the scene and began CPR. Within five minutes of Craig's collapse, the paramedics used an automated external defibrillator (AED) to "jump-start" his heart. They then defibrillated Craig's heart four more times. Craig not only survived, but he also made a full recovery. The medical team determined that his SCD was caused by long QT syndrome (LQTS). Since LQTS is a hereditary condition, Craig's family members were evaluated. His brother and father were also found to have LQTS. In order to prevent their premature deaths, internal defibrillators were implanted in all three family members.

These cases make three points. First, although more common in adults, SCD can occur at any age-even in apparently healthy children and adolescents. Second, early intervention in SCD is essential. As was true in Craig's case, a combination of CPR and the use of AEDs can save lives. Third, some individuals who are at risk for SCD, like Craig's brother and father, can be identified to prevent their premature deaths.

What is SCD?
SCD occurs when there is a total cessation of the heartbeat, often as a result of ventricular fibrillation. Ventricular fibrillation can result from lack of oxygen (ischemia) to the heart muscle or from a primary electrical disorder (arrhythmia). In either case, ventricular fibrillation leads to an ineffective quivering of the heart. Death quickly ensues if the heart's electrical impulses are not converted to an effective, blood-pumping rhythm.

This "defibrillation" can be achieved with a machine called a defibrillator. A defibrillator administers an electrical shock that often "jump-starts" the heart into a normal rhythm.

Survival depends on how quickly the defibrillator is used. Research demonstrates there is only an 8-10 minute window of opportunity for a successful rescue-and the greatest chance for survival occurs within the first three minutes. For each minute that passes without defibrillation, survival decreases seven to 10 percent.

Who's at Risk?
SCD claims about 225,000 adults annually, according to the American Heart Association. Moreover, 5,000-7,000 children and another 5,000-7,000 infants die of SCD each year. In the Chicago-Milwaukee area, there have been eight episodes of SCD in children or adolescents over the past 18 months, which is greater than anyone would expect based on commonly accepted statistics. (Seven of these eight died.) Researchers estimate that one in every 200,000 to 300,000 children will have an episode of SCD.

Typically, SCD in adults is caused by atherosclerotic coronary artery disease. This is not the case in children. In children and adolescents, SCD has many different origins, most of which are undetected congenital conditions.

Causes of Sudden Cardiac Death in Children and Adolescents
	Hypertrophic cardiomyopathy
	Congenital coronary artery anomalies
	ARVD and/or dilated cardiomyopathy
	Long QT syndrome
	Marfan syndrome
	Commotio cordis
	Cocaine or other stimulant abuse

Many children and teens at risk for SCD do not experience symptoms. The first sign or symptom is the SCD itself.

Nevertheless, some at-risk students can be identified. A review of the medical and family history, a comprehensive physical examination and a symptom review can be helpful in distinguishing which students should be referred for further evaluation. These should include students who report the following symptoms:

	Chest pain with exertion
	Dizziness or fainting after vigorous exercise
	Palpitations
	Shortness of breath

Echocardiography (ultrasound) and directed electrocardiography (ECG) can identify some high-risk students. Even so, there is no test or combination of tests that will identify every student at risk for SCD-even if those tests are performed on every high school athlete.

	To bring CPR training and public access defibrillation into schools
	To educate communities about preventing sudden cardiac death
	To save lives

Today, Project ADAM™ has successfully introduced AEDs into several Wisconsin schools. School nurses have played an integral role in these cases. (See sidebar.) It is their hope that sudden cardiac death will be a topic that students simply study in health class-not an event they witness in their schools.

Making A Difference: The Gift of an AED Program
By: Karen Smith, R.N.

Karen Smith is Coordinator of Nursing Services and Special Activities at Pewaukee School District, Pewaukee, Wisconsin.

There are times in life when you realize you can really make a difference in students' lives. When Registered Nurse Pam Marlin, Health Room Aide Fran Holloway, and I decided to pursue the dream of an AED program in our school district, we knew this was one of those times. Our administrators, teachers, and community members were very supportive, and the kids were absolutely fascinated with the technology.

The first step we took was to lay the groundwork. We found the ideas in Public Access Defibrillation in Schools: Project ADAM™ guided us through this process.

We shared these Project ADAM™ materials and newspaper articles on AEDs with our administrators and insurance carrier. Next, we invited Pediatric Cardiologist Stuart Berger, M.D., to speak to our administrative team, insurance carrier, athletic department personnel, and health teachers.

After Dr. Berger's in-service, Pam, Fran, and I went for AED instructor training. About the same time, we heard that the local Masons were looking for a philanthropy project, so Pam, Intensive Care Physician Rainer Gedeit, M.D., and I headed for the Masonic Lodge to present an in-service. Within a few months, the Masons gave us a check for $4,000.

At the same time, we developed crisis plans with our local emergency medical system. How would we handle a rescue in the day, evening, or weekend? How would we transfer the defibrillator to the hospital with the patient? (The AED holds crucial information about the SCD event, such as rhythm strips, numbers of shocks and corresponding joules.)

Because we believe education is key, we set up a booth at our annual blood drive. We presented in-services to all staff members at our four schools, distinguishing between cardiac arrest and myocardial infarction and demonstrating how a defibrillator works. With the help of juniors and seniors in our health volunteer program, we educated our 600 high school students about cardiac arrest and AEDs. As a result of these educational efforts, we received some unexpected benefits: the National Honor Society purchased the AED case, drama students donated half their play proceeds to our project fund, and parents and grandparents called to offer their financial support. We also spoke to our parent teacher organization and the Booster Club; both groups made significant contributions.

Along with education, we provided AED training for key personnel, including custodians, coaches, teachers, and our health room staff.

Finally, we enhanced the health curriculum. We added CPR and AED demonstration to the tenth-grade this year. Next year, we'll add AED training and certification in tenth grade. In the eleventh and twelfth grade, we'll re-certify students. The education continues through the summer when we'll open AED training to high school students whom we missed (because we started with the tenth grade) and to community and staff members.

What a tremendous gift and opportunity we have as school nurses: to be able to educate an entire community, reduce the risk of sudden cardiac death, and send children out into the world who know how to save lives.

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