Heart Attack Treatmentsamuelsdesign.yolasite.com/resources/Research.pdf · 2011. 7. 15. · Early...

A l e x S a m u e l s H e a r t A t t a c k T r e a t m e n t 2 0 1 0

Assessment of Heart Attack Treatment by First Responders, 2010

Heart Attack Treatment

According to the World Health Organisation Cardiovascular disease is the number one killer in the world today.

In this report early life support delivered by first responders to heart attack victims have been evaluated with a view to improving survival rates.

Alex Samuels


Acknowledgements

This report has been compiled with the help of the following people who were interviewed:

Claire Brisbourne. Safety Training Agency Qualifications Development Administrator for Life Saving and

First Aid

Steve Bland. Cornwall Council Cultural Services Health and Safety and First Aid Lead officer

Carol Davey. First Aid Trainer Assessor


Contents

1. Executive summary 4

2. Introduction 5

3. Research Methodology 6

4. Significant Findings 7

4.1 Top 5 Global Causes of Death 7

5. Surviving a heart attack 8

6. Heart attack treatment: Cardiopulmonary Resuscitation (CPR) 8

6.1. Effective CPR Steps 9

6.2. Common Problems in CPR 9

7. Heart attack treatment: Defibrillation 10

7.1. How does it work? 10

7.2. Defibrillator/AED History 10

8. AED Products 11

8.1. The Zoll AED Plus 11

8.2. The Schiller FRED Easyport 11

8.3. The Cardiac Science Powerheart AED G3 11

8.4. The Philips HeartStart OnSite Defibrillator 12

9. Manufacturing Process 14

i. Batteries 14

ii. Casing 14

iii. Electronics circuit board and assembly 15

iv. Electrodes 15

v. Final assembly and testing 15

10. Conclusion 16

11. References 17

12. Appendices 18


1. Executive summary

By the year 2030 the World Health Organisation (WHO) estimates that up to 23.6 million people will die

annually of cardiovascular related diseases.

This report presents the evaluation results of national and international statistics around the causes of global

death. The research has also highlighted high levels of concern amongst senior medical professionals

relating to poor and inadequate early response techniques.

The following questions were considered during the compilation of this report:

1. How many people on a global basis suffer from cardiovascular disease?

2. How many people suffering from cardiovascular disease die from related incidents associated with

this disease such as heart attacks?

3. How efficient is the current life saving intervention process that includes Cardiopulmonary

Resuscitation and the use of Automated External Defibrillators?

4. Are there shortcomings, and therefore areas that can be improved on, which might help reduce

overall death rates?

To summarize, it was found that the early stages of life intervention, often delivered by laypeople with little or

no training was the key area where improvements could be made.

As a result of this finding, time will be spent looking at this area in more detail, but early indications show that

the most common errors committed during CPR need be eradicated.


2. Introduction

The main objective of this report is to determine how the survival rates of a major cardiac incident could be

improved by scrutinising first aid delivery by trained and untrained people.

National and international statistics on the most common causes of death in developed and developing

countries have been examined. This data was supplied by various health organisations and governing

bodies responsible for health care.

Strong evidence was supplied by professionals involved in the implementation of current resuscitation

guidelines and first aid training. This evidence was sourced through discussion and interviews. The

consistent conclusion given was that early life support, commonly called CPR is critical to a successful

recovery, yet this is the area where the most consistent mistakes are made.

It is proposed to examine this process with a view to reducing the common errors and mistakes made by

trained and untrained people.


3. Research Methodology

Careful consideration was given to the sources of research especially as much of the data needed was of a

technical nature.

In addition, national and international statistics on medical information was acquired from various health

organisations, federations and agencies. These sources proved invaluable in supplying well evidenced and

reliable statistical facts.

It was decided that direct discussion with a number of selected professionals involved in first aid delivery and

development would provide additional information about first aid delivery.

Statistics and medical data were sourced from the following:

• World Heart Federation - State of the heart. Cardiovascular disease report 2010

• World Health Organisation – Avoiding heart attacks and strokes don’t be a victim yourself

• European Journal of Cardiovascular Medicine

Technical performance data were sourced from:

• Philips – Helping you save more lives

• Philips – Products and services maximizing defibrillator performance

• Philips – For the ordinary person in the extraordinary moment

• Philips – The link between early defibrillation and quality

• Philips – The HearStart OnSite Defibrillator

• Zoll – The first and only full-rescue AED

• Zoll – When they need CPR you need Zoll

• Zoll – Accessories and training products

• Zoll – AED Plus technical application notes

• Cardiac Science – The Powerheart AED G3 Plus

• Cardiac Science – The Powerheart family of products

• Schiller – FRED easyport AED

• NHS – Schiller FRED easyport

Competency and quality of first aid administration from:

• Safety Training Agency – New resuscitation guidelines 2010 notes for trainers

• Resuscitation Council (UK) – Resuscitation guidelines 2010

• Public Sector – health and safety first aid leads

• First Aid trainers


Cardiovascular Diseases

Infectious and Parasitic Diseases Ischemic Heart Diseases

Malignant Neoplasms (Cancers) Cerebrovascular disease (Stroke)

4. Significant Findings

According to the European Journal of Cardiovascular Medicine (EJCM) ‘it is estimated that 50% of all cardiovascular deaths are out-of-hospital sudden cardiac arrest (SCA) (heart attack)’. ‘Although the average victim is 65-years-old, approximately 10% of SCA events occur among people less than 40 years of age.’ Capucci (2010) (to view the full Journal visit appendix A)

The following represents significant information relating to global causes of death. A key factor here is the high percentage of deaths from cardiovascular diseases (29.34%) and Ischemic Heart Diseases (12.64%) (To view this and other related graphs/tables see appendix B)

4.1 Top 5 Global Causes of Death

According to the World Health Organization (WHO), the largest killer though out the world is cardiovascular disease, and more and more people die from it each year.

It has been calculated WHO that ‘17.5 millions of people died from cardiovascular diseases, which represents approximately 30% of total recorded deaths in the world.’ Capucci (2010)

Research completed by the American Heart Association (AHA) shows that ‘81 million Americans in the United States have one or more forms of cardiovascular disease. In 2006 151,000 killed by CVD were under the age of 65. Also more than 17 million Americans alive

today have a history of heart attack, angina pectoris or both.’ AHA (2010)

According to AHA statistics, coronary heart disease kills 300,000 people every year before getting to hospital and cardiac arrest is responsible for the deaths of 900 Americans each day.

A key estimate by the WHO indicates that ‘by 2030 the number of annual deaths caused by CVD will be almost 23.6 million’ WHO (2009)

The statistical research shown above concludes that cardiovascular diseases are the biggest killer in the world today. The biggest causes of death from cardiovascular diseases are heart attacks.


5. Surviving a heart attack

The chances of surviving a heart attack depend on a number of key factors. A victims survival chances depend on how early first aid support is administered. How soon this support is given and how competent this support is.

Early life support is commonly called Cardiopulmonary Resuscitation (CPR). According to the European Journal of Cardiovascular Medicine survival rates as high as 90% could be achieved if well administered CPR and Automated External Defibrillator (AED) support is delivered within the first minute of a cardiac arrest.

Sudden cardiac arrest inevitably will occur away from a hospital and according to EJCM 95% will die usually because life saving support is delivered too late, incorrectly or not at all. A victim’s chance of surviving a cardiac arrest according to the AHA will diminish by 7 to 10 percent as every minute passes until defibrillation is administered. The AHA also state that up to 48 to 74 percent survival rates can be achieved if CPR is immediately given and an AED shock applied within 3 to 5 minutes. (For additional information on surviving a heart attack view appendix C)

6. Heart attack treatment: Cardiopulmonary Resuscitation (CPR)

According to consultation with professionals involved in first aid training and the development of resuscitation guidelines, death can be prevented if a victim receives CPR treatment within minutes of a heart attack.

According to Steve Bland, Cornwall Council Cultural Services Health and Safety and First Aid Lead officer ‘permanent brain damage can occur within 4 to 6 minutes due to lack of oxygen and it essential to provide good quality CPR to prevent this happening’. Bland (2011)

Carol Davey, First Aid Trainer Assessor ‘without CPR the rate of a victim’s survival reduces by 10% every minute’. Davey (2011)

CPR mainly involves giving chest compressions to a victim who has suffered a cardiac arrest (the heart has stopped or is in ventricular fibrillation). This process involves the responder applying fast rhythmical compressions to the chest at 100 to 120 compressions per minute to a depth of 5 to 6 centimetres. This process helps to deliver oxygenated blood to the heart and the brain.

Artificial respiration is also delivered by administering rescue breath which entails the

responder exhaling into the victim’s airway to help maintain blood oxygen levels. Current best practice indicates that when CPR is delivered by untrained responders, high quality chest compressions are more preferable than delivering artificial respiration. This is because delivering artificial respiration often interrupts quality chest compression delivery.

The view by professionals involved in the delivery of first aid and CPR training is that there are higher chances of CPR being attempted if the untrained responder is told to perform chest compression CPR only.

It is significant at this stage to note the subtle change in the Resuscitation Council (UK) CPR guidelines on when to give Chest Compressions Only.

‘The 2005 Guidelines said to give compressions only CPR ‘if you are unwilling or unable to give rescue breaths…’ Brisbourne (2010) ‘In the new 2010 guidelines this has changed to ‘if you are not trained to, or are unwilling to give rescue breaths…’ Brisbroune (2010) (To view the full brochure on resuscitation guidelines view appendix D)


6.1. Effective CPR steps Overall, the information gathered suggests that CPR delivery can have a significant impact on cardiac arrest survival rates. It is preferred that CPR is delivered by trained responders as statistics show that success rates are greater. The current 2011 guidelines regarding CPR training can be broken down into the 4 following steps

• Step 1 - Call Emergency services

• Step 2 - Check for breathing, Tilt head & lift chin

• Step 3 - Give 2 rescue breaths

• Step 4 – Chest compressions - firmly push down in the centre of the chest 5-6 cm 30 times at a rate of 100 – 120 a minute.

• Repeat process until you physically can’t do any more, or you are relieved.

Whilst CPR training is considered best practice under health and safety guidelines, the reality is that CPR skills and knowledge reduces rapidly. Even the trained can make mistakes, according to the Resuscitation Council (UK) ‘after about 6 months of CPR training, 90% of the training has been forgotten.’ Nolan (2010)

6.2. Common problems in CPR

According to Carol Davey, First Aid Trainer Assessor, there are common and similar mistakes made by individuals that have received CPR training. These problems have been highlighted during First aid training updates where individuals are being reassessed on their knowledge and CPR delivery.

The most common mistakes made were:

• Incorrect hand location on chest which could result in punctured lungs and ineffective chest compressions

• Incorrect compression rate, either too slow or too fast

• Incorrect chest compression technique that could result in early fatigue or ineffective results

• Compression depth not delivered to the correct depth

• Incorrect compressions to breaths ratio • Wasting time due to uncertainty on what to

do

In conclusion, the experts agree that if the common mistakes made during the early stages of CPR could be eradicated, the survival rates of cardiac arrest could be significantly improved.

Figure 1 – CPR Compressions by Purple Plus, 2007


7. Heart attack treatment: Defibrillation

Whilst correct CPR is essential to a victim’s survival, it is only part of the process. The facts are that without early defibrillation the survival rates are extremely poor. In essence, the sooner a defibrillator is used, the greater the chance of survival.

Another factor to consider is that heart attacks occur mostly away from a hospital environment where defibrillators are widely available. This has led to the development of Automated External Defibrillator (AED). The AED can be used by untrained people and has become a standard piece of equipment located in public places.

According to Claire Brisbourne, STA Qualifications Development Administrator, ‘An AED should be viewed as a standard piece of first aid equipment and remains the single biggest factor in survival rates of sudden cardiac arrest.’ Brisbourne (2010)

7.1. How it works

A Defibrillator is designed to stop and restart a heart that is in fibrillation state. Two pads with electrodes are placed on the bare chest of the casualty and either the machine or operator administers an electric shock which travels through the body tissue into the heart. The electric shock will stop the heart and therefore stops the heart fibrillating allowing the heart to resume a regular rhythm heart beat. (For additional information regarding the use of AED’s refer to appendix E)

7.2. Defibrillator/AED history

The first defibrillation was tested on a dog in 1899. The first human to receive defibrillation was in 1947 by Claude Beck. Until the 1950’s defibrillation was only used on an open chest cavity

In 1956 Dr. Paul Zoll was the first man to successfully use external defibrillation to regulate heart rhythm in a patient. In the early 1960’s Prof. Frank Pantridge introduced the first out of hospital portable defibrillator. It was first successfully used in 1969.

The first traditional AED as we recognise which could do things like pacing the heart did not hit the scene until 1980. Trails for the device were in Brighton and it weighed 28 pounds.

In the early 1990’s, training for the AED for first responders began in the US and UK. The modern AED is designed for use by any person, medically trained or not.

Figure 2 – Electrode placement by Anon, 2006

Figure 3 – Paul Zoll defibrillator by AED Grant, 2010


8. AED Products

There are a variety of different AED products available on the market today. The following AED’s were analysed with each units individual characteristics measured and compared. The final AED in this section, the Phillips OnSite was selected for greater scrutiny and evaluation as this unit is one of the most common AED’s on sale today.

8.1. The Zoll AED Plus

The Zoll AED Plus is one of the leading AED’s on the market. With a RRP of £1,250, the products main distinctive feature is an integrated neck and head plate which forms part of the casing. The neck and head plate can removed from the AED during CPR to help maintain an open airway in the casualty.

The AED Plus has been designed for use in extreme conditions enabling this machine to be operated in wet or dusty conditions. An additional feature is the unique all in one CPR-D padz which eliminates errors when placing pads on a victim’s chest. (For additional information on the AED Plus view appendix F1, F2, and F3)

8.2. The Schiller FRED Easyport

The revolutionary FRED Easyport by Schiller certainly pushed the boundaries of technology. Designed to fit into the palm of one hand, this light weight AED comes with a strong recommendation from the NHS as a compact and extremely portable unit with a good technical performance. (To view the full NHS report see appendix G1)

With a RRP of £2,400 the Easyport is not cheap. Other disadvantages with the Easyport are the self test function which is only carried out when switched on and the battery capacity. (For additional information on the FRED Easyport view appendix G2).

8.3. The Cardiac Science Powerheart AED G3

The Powerheart AED G3 Plus by Cardiac Science has a built in automatic self-test safety system that checks the battery, pads, internal electronics, SHOCK/CONTINUE button and software on a daily basis. Additional checks are carried out every week on the partial energy charge and monthly tests are again the same as the daily checks with an additional check on the full energy charge cycle. With an RRP of £1,575 the Powerheart AED G3 AED is in close competition with the Zoll AED Plus. (For additional information on the Powerheart AED G3 Plus view appendix H1, and H2)

Figure 4 – Zoll AED Plus by Zoll, 2007

Figure 6 – Powerheart AED G3 by Cardiac Science, 2009

Figure 5 – FRED Easyport by Schiller, 2006


8.4. The Philips HeartStart OnSite

‘With over 350,000 automated external defibrillators installed, Philips is the leader in public access defibrillation’ Philips (2007)

The Philips HeartStart OnSite Defibrillator is recognised as one of the leading AED products available on the market today. It has been designed ‘for the ordinary person in the extraordinary moment’ Philips (2007) The OnSite claims to be the easiest to use and most reliable. Weighing in at just 3.3 lbs., the OnSite is light weight making it extremely portable, enabling it to be transported quickly and easily to the aid of a victim.

The long battery life of 5 years ensures the product is always ready for operation. To maintain safe working order the OnSite has an automatic self-test system installed. This self-test system checks the electrical components, subsystems and battery, whilst also checking that the shock pads are installed correctly and working. A flashing green ‘ready’ light confirms that all systems have been checked and are in working order.

The OnSite is extremely easy to use; the operator simply pulls the green handle to activate the defibrillator and a calming voice guides the user through each step. These steps are spoken at a pace which matches the operator’s actions. As the adhesive pads are removed to be placed on the patient’s chest as indicated by illustrations on the pads, the defibrillator recognised that this is happening and the voice commands are adjusted accordingly. This process is simple and no prior training is required.

If a shock is going to be administered, the defibrillator will direct the operator to press a flashing orange shock button. The defibrillator then sends ‘a dose of low-energy biphasic therapy, a highly-effective defibrillation waveform that is also gentle to the heart.’ Philips (2007) If the defibrillator determines that a shock is not required the defibrillator will instruct the operator to commence or continue with CPR. The OnSite will also remind the operator to call the emergency services. The emergency services can also access a full summary of the care administered through the built in verbal memory system.

Figure 7 – OnSite AED in use by Philips, 2007


The Onsite Defibrillator can be used on patients of any age, ranging from infants up to fully grown adults. The device is smart enough to know when the product is being used on an infant or child and changes the energy shock accordingly. The same applies with the CPR coaching. The instructor voice changes automatically, giving the correct instructions to carry out weather the patient is an adult, child or infant.

The Philips HeartStart OnSite Defibrillator retails at approximately £1000 per unit.

The OnSite was assessed for ease of operation by 90 untrained responders against 5 other AED product leaders. The 90 untrained responders were left to use the AEDs on manikins where they

were assessed on, the time to shock a victim, CPR execution, pad placement, and clarity of instructions. The results from these tests suggest that the OnSite defibrillator offered the best performance against the other AED’s.

For example, the OnSite achieved the highest rating when it came to pad placement, scouring 100% accuracy. Whereas the Zoll AED Plus achieved a 50% fail rate where responders placed the pads on the outside of the clothes. The OnSite also created a 90% risk reduction when it came to responders performing CPR. In Conclusion, when used by untrained responders, the OnSite was the only defibrillator to successfully deliver a shock to the manikin every time. (To view these results further, and a more in depth look at the OnSite AED view appendix I1, I2, I3)

Figure 8 – HeartStart OnSite AED by Philips, 2007

Figure 9 – OnSite carry case by Philips, 2007

Figure 10 – OnSite pads cartridge by Philips, 2007


9. AED Manufacturing Process

Modern AED’s are usually manufactured in components parts by a variety of different suppliers. These different component parts are assembled by the manufacturer ready for distribution to the market place.

The different component parts and manufacturing process of an AED can be split into the following sections.

I. Batteries II. Casing III. Electronic circuit board and assembly IV. Electrodes V. Final assembly and testing

I. Batteries

The normal type of power unit used in AED’s is lithium batteries. Lithium batteries are made by connecting cells made of lithium metal. The lithium is compressed into a solid case in an oxygen free environment then sulphur dioxide is added.

At this stage the cell is sealed to ensure that moister cannot enter the cell and sulphur dioxide gas does not escape. The cells are then packed in a solid housing, fused and vented to help reduce pressure under extreme temperatures.

II. Casing

Injection moulding is used to from the outer casing which is a process where plastic pellets are pressurised into shape

The melted pellets pass through a rotating hydraulic screw which melts the plastic further allowing the material to be injected through a nozzle into the mould.

Two metal halves make up the shape of the mould. The hot plastic is maintained in the mould at pressure before cooling which allows the plastic to into the desired shape.

Injection Moulding Process

Figure 11 – Injection moulding process by Thompson, 2007


V. Final assembly and testing

The final product is delivered to a test bed station where all of the electronic systems including battery, connections and fail safe devices are tested before the product is packaged and shipped.

III. Electronics circuit board and assembly

All of the electronic control systems including electrical circuitry, resistors, semiconductor chips and capacitors are combined to form a complex circuit using a method called hybridization.

The appropriate components are then aligned with a printout on the circuit board and pinned into place. The components are then soldered into place, allowed to cool and connected and tested in the control box casing.

The circuit boards are attached under clean working conditions by hand. After this stage electrode adaptors and control buttons are fitted with fasteners and screws.

IV. Electrodes

The electrodes are made out of thin sheets of tin which forms the conducting pad of the electrode. The electrode is wired into the outer shell of the machine and the electronic pads using polymeric wrapped conducting wires

The thin layers of tin used in the pads are manufactured using a ‘continuous caster’ which compresses and forces hot liquid tin through rollers cooled by water. The final stage of producing the electrode involves the spraying of a thin coating of stannous chloride onto the sheet tin before cutting to the appropriate shape of the electrode pad.

Figure 13 – Pads for OnSite by Philips, 2007

Figure 12 – Printed Circuit Board Assembly by Shenzhen BQC Electronic, 2009


10. Conclusion

All the evidence collected shows that in the event of a heart attack, if an AED is administered within a

reasonable time and quality CPR has taken place, the outcome for the patient can often be a very positive

one.

The number of cardiac related incidents around the world has been shown to be a consistent problem

regardless of socio economic status. The forecasts by the major health organisations have also shown that

cardiac arrest heart attack problems are increasing year on year.

In addition, in depth consultation with professionals involved in developing CPR training protocols and

deliverers of first aid training courses has highlighted concerns over the delivery of CPR. As stated earlier,

the quality of early CPR prior to the application of an AED is critical in determining a positive outcome for a

patient. With this in mind, it has been concluded that further examination of the first steps of CPR, (where

the most common mistakes are made) would be most beneficial to improving survival rates.

This could develop into either (a) better and more efficient training procedures, or (b) the development of

mechanical or technical support systems, that could guide an individual delivering CPR until professional

help arrives and an AED can be administered.

At this stage, the development of a support system is viewed as more appropriate, which is supported by the

various professionals that have been consulted during the preparation of this report.


11. References

Books/ Reports

• Nolan, Jerry (2010) 2010 Resuscitation Guidelines. London: Resuscitation Council

Brochures

• Birsbourne, Clair (2010 New Resuscitation Guidelines 2010 Notes for Trainers. Safety Training Agency

• Philips (2007) For The Ordinary Person In The Extraordinary Moment. Netherlands

Interviews

• Bland, S. (2011) Interview on CPR & Defibrillation Importance. Conducted by Samuels, A on 07/01/2011 at Cornwall Council Offices, Bodmin

• Davey, C. (2011) Interview on CPR & First Aid Issues. Conducted by Samuels, A on 07/01/2011 at Cornwall Council Offices, Bodmin

Journals

• Capucci, A. Aschieri, D. Pelizzoni, V. (2010) Sudden Cardiac Death and Defibrillation. European Journal of Cardiovascular Medicine, Vol I Issue II, pp. 49

Websites

• American Heart Association (2010) Cardiovascular Disease Statistics http://www.americanheart.org/presenter.jhtml?identifier=4478 [viewed 05/12/2010]

• World Health Organization (2009) Cardiovascular Diseases (CVDs) Fact Sheet N˚ 371 http://www.who.int/mediacentre/factsheets/fs317/en/index.html [viewed 03/12/2010]

Images

• Purple Plus. (2007) CPR Compressions [Rendering] http://kingmagic.wordpress.com/2007/01/05/the-chain-of-survivalit-works/ [Viewed 15/12/10]

Figure 1

•

Anon. (2006) Electrode placement [Rendering] Figure 2

http://www.madehow.com/Volume-7/External-Defibrillator.html [Viewed 22/12/10]

• AED grant (2010) Paul Zoll defibrillator [Scan of photograph]

Figure 3

http://www.aedgrant.com/aed-history.htm [viewed 09/12/2010]

• Zoll (2007) Zoll AED Plus [Photograph] Figure 4

http://www.thetrainingco.co.uk/#/aed/4531701111 [Viewed 15/01/11]

• Schiller (2006) FRED Easyport [Photograph] Figure 5

http://www.schiller.ch/upload/2.500416_0910_EN_FRED easyport _ manual_LQ.pdf [viewed 16/01/11]

• Cardiac Science (2009) Powerheart AED G3 [Photograph]

Figure 6

http://sklep.paramed-group.pl/?58,defibrylator-aed-g3-pro-firmy-cardiac-science-z-bateria-stala [viewed 15/01/11]

• Philips (2007) OnSite AED in use [Photograph] Philips – ‘Helping you save lives’ Brochure

Figure 7

•

Philips (2007) HeartStart OnSite AED [Photograph] ‘Philips – Helping you save lives’ Brochure

Figure 8

•

Philips (2007) OnSite Carry Case [Photograph] ‘Philips – Philips HeartStart OnSite Defibrillator supplies and accessories’ Brochure

Figure 9

•

Philips (2007) OnSite Pads Cartridge [Photograph] ‘Philips – Philips HeartStart OnSite Defibrillator supplies and accessories’ Brochure

Figure 10

•

Thompson (2007) Injection Moulding Process [Rendering] – ‘Manufacturing Processes for design professionals’ Book

Figure 11

•

Shenzhen BQC Electronic (2009) Printed Circuit Board Assembly [Photograph]

Figure 12

http://www.bridgat.com/sell_pcba_printed_circuit_board_assembly-o88582.html [Viewed 10/01/11]

• Philips (2007) pads for the OnSite [Photograph] http://defibrillators.us/defibrillators/philips/heartstart-fr2/ [Viewed 09/12/10]

Figure 13


12. Appendix

A European Journal of Cardiovascular Medicine – Sudden Cardiac Death and Defibrillation: The Solution Around The Corner. Vol I Issue II

B World Health Organization – Fact Sheet: The Top Ten Causes of Death

C American Heart Association – Heart Attack/Sudden Cardiac Death

D Safety Training Agency – New Resuscitation Guidelines 2010 Notes For Trainers

E Resuscitation Council (UK) – The Use of Automated External Defibrillators

F Zoll

F1 Zoll – AED Plus: The First and Only Full-Rescue AED

F2 Zoll – Automated External Defibrillators: When they need CPR you need Zoll

F3 Zoll – AED Plus: Technical Application Note

G Schiller

G1 NHS – Evaluation Report 06048: Defibrillator, Schiller FRED easyport

G2 Schiller – FRED easyport & FRED easyport manual: The World’s First Pocket Defibrillator

H Cardiac Science

H1 Cardiac Science – The Powerheart AED G3 Plus

H2 Cardiac Science – The Powerheart family of products

I Phillips

I1 Phillips – For the ordinary person in the extraordinary moment

I2 Phillips – Helping you save more lives

I3 Phillips – The HeartStart OnSite Defibrillator: Unsurpassed Ease of Use for Better Rescue Success

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