Editor's Note: This Expert Analysis provides commentary on Kinoshi T, Tanaka S, Sagisaka R, et al. Mobile automated external defibrillator response system during road races. N Engl J Med 2018;379:488-9.

Study question: To evaluate the effectiveness of implementation of a rapid mobile cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) system to support runners who suffer a cardiac arrest during road races.¹

Methods: A prospective 12-year interventional cohort study evaluated the effectiveness of implementation of a rapid mobile AED system to provide cardiopulmonary resuscitation (CPR) for runners who suffered a cardiac arrest in road races in Japan between 2005 and 2017. The system consisted of mobile teams including pairs of paramedics on bicycles and pairs of paramedic trainees on-foot teams (carrying AEDs and emergency medical kits). The system also included medical communication dispatchers, staff at a first-aid station, and physician volunteers who run the race and were available by a GPS-enabled telephone to assist if needed. Team members were positioned along the course so that they could reach a victim rapidly and initiate CPR within 1 minute of collapse and apply an AED within 3 minutes of collapse. Team members also performed field triage and acute care for significant trauma, shock and heath stroke. The study analyzed resuscitation records and medical records for patients who suffered cardiac arrest during the implementation period for this system.

Results: A total of 1,965,265 runners participated in a total of 251 road races (10 to 42.2 km – 6.2 to 26.2 miles) between Jan 1, 2005 and March 7, 2017. The system supported 30 runners with cardiac arrest. There was one cardiac arrest per 65,509 runners (1.53 per 100, 000 runners). 21 of the cardiac arrests (70%) occurred in the last quarter of the race or near the finish line. Two runners had unwitnessed cardiac arrest. One runner had a pulseless electrical activity arrest and the other had an asystolic arrest. Neither of these two runners were successfully resuscitated. In the 28 runners with witnessed cardiac arrest, the median interval between collapse and the initiation of CPR was 0.8 minutes (interquartile range, 0.5 to 1.0) in the median interval between collapse in the delivery of the first AED shock was 2.2 minutes (interquartile range 1.6 to 4.4). The median interval between collapse and the return of spontaneous circulation was 5.5 minutes (interquartile range, 3.2 to 7.0); all of these runners had return of spontaneous circulation in the field, and all had favorable neurologic outcome (cerebral performance category of 1 or 2) at one month and one year. 19 cardiac arrests (63%) occurred in 30 (18.6 mile) to 42.2 km (26.2 mile) races, 7 cases (23%) in 21.1 km (half marathon) races, and four cases (13%) in 10 Km (6.2 mile) or less races. Regardless of the length of the race, 70% of the sudden cardiac arrest occurred within the last quarter of the course distance or near the finish line.

Conclusion: These results suggest an excellent neurologic outcome after implementing a rapid mobile AED response system during road races.

Perspective:
These findings suggest that a mobile AED response system (including paramedics on bikes and on-foot carrying AEDs, preidentified physician runners and volunteers) yields favorable neurological outcomes and survival rates for witnessed cardiac arrest during road races. The response time (CPR and AED shocks) was remarkably short and the survival rate was excellent. The sudden cardiac arrest survival rate to hospital discharge on the streets of most US urban areas is approximately 10-15%,² whereas the rate on the field of play and on marathon and half-marathon races ranges from 30-90%.^3-5

This paper also highlights the importance of knowing where most of these events occur during the race course. This information is crucial for event organizers, local EMS, law enforcement and other public safety personnel. A higher concentration of emergency response teams in the last quarter of road races should be considered.

Cardiac arrests during road races are relatively uncommon. Nonetheless, the growing popularity of road races and the number of runners with known or subclinical cardiovascular disease could increase the risk and frequency of cardiac arrest. The most likely first responder in an endurance race will be another runner or a spectator. Therefore, there is a growing impetus to offer hands-only CPR training for runners and spectators at the race weekend expositions.⁶ A well-prepared emergency action plan with strategic allocation of resources throughout the course will have better outcomes when such events do occur. The key component to a successful program involves regular rehearsal, and rapid access to CPR, AED (delivering a shock less than 5 min from the time of collapse) and rapid transportation to medical facilities.^7-8

References

1. Kinoshi T, Tanaka S, Sagisaka R, et al. Mobile automated external defibrillator response system during road races. N Engl J Med 2018;379:488-9.
2. Benjamin EJ, Virani SS, Callaway CW, et al. Heart disease and stroke statistics-2018 update: a report from the American Heart Association. Circulation 2018;137:e67-492.
3. Drezner JA, Rao AL, Heistand J, et al. Effectiveness of emergency response planning for sudden cardiac arrest in United States high schools with automated external defibrillators. Circulation 2009;120:518-25.
4. Kim JH, Malhotra R, Chiampas G, et al. Cardiac arrest during long-distance running races. N Engl J Med 2012;366:130-40.
5. Roberts WO, Roberts DM, Lunos S. Marathon related cardiac arrest risk differences in men and women. Br J Sports Med 2013;47:168-71.
6. Bhanji F, Donoghue AJ, Wolff MS, et al. Part 14: education: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2015;132:S561-73.
7. Hazinski MF, Markenson D, Meish 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.
8. ECC Committee, Subcomittees and Task Forces of the American Heart Association. 2005. American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, part 4: sdult basic life support. Circulation 2005;112.

Keywords: Sports, Athletes, First Aid, Cardiopulmonary Resuscitation, Reaction Time, Defibrillators, Heart Arrest, Death, Sudden, Cardiac

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