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

Children With Special Healthcare Needs

Children with special healthcare needs have chronic physical, developmental, behavioral, or emotional conditions and require health and related services of a type or amount not usually required by typically developing children.^14–16 These children may need emergency care for acute, life-threatening complications that are unique to their chronic conditions (such as severe asthma or obstruction of a tracheostomy airway), or they may develop progression of underlying respiratory failure or neurologic disease. However, approximately half of EMS responses to children with special healthcare needs are unrelated to the child’s special needs and include traditional causes of EMS calls such as injury.

When a child with special healthcare needs or any illness with life-threatening complications attends school, the school nurse should have access to specific medical information about the child’s baseline condition, the medical plan of care, the child’s current medications, and potential complications or signs of deterioration. The healthcare provider guiding the child’s care should provide information to school personnel about emergency actions.

A standardized form, the Emergency Information Form (EIF), was developed by the American Academy of Pediatrics and the American College of Emergency Physicians¹⁶ and is available on the Worldwide Web at http://www.pediatrics.org/cgi/content/full/104/4/e53. In most instances the school nurse is responsible for interpreting the EIF and developing an individual emergency care plan that is specific to the school environment.^17,18

The school should have specific instructions about whom to contact for emergencies and when such contact should be made.¹⁸ If the child has a tracheostomy, everyone responsible for the child’s care at school should be taught to assess airway patency, clear the airway, and provide CPR with the artificial airway. If the child has asthma, the school nurse and any teacher responsible for the child’s care should be able to recognize wheezing and signs of breathing difficulty and should know to follow the asthma action plan for the child.⁶

If the physician who cares for the child, the child’s parents, and the child (as appropriate) have made a decision to limit resuscitation efforts or withhold resuscitation attempts, the physician should write a Do-Not-Attempt-Resuscitation (DNAR) or “no-CPR” order specifically for use in the out-of-hospital (OOH) setting. The child’s primary caretaker, the school, and the EMS systems for the child’s home and school should have a copy of these orders.

Sudden Cardiac Arrest in Children and Adolescents

Sudden cardiac arrest is the sudden cessation of cardiac activity so that the victim becomes unresponsive with no normal breathing and no signs of circulation. Unless the victim receives immediate CPR and other treatment to restore normal cardiac activity, he or she will die. Although the precise incidence of sudden cardiac arrest in children is unknown, it is not a leading cause of death in children and young adults.

Response to sudden cardiac arrest is a major focus of this statement. Although sudden cardiac arrest is relatively uncommon in children and young adults, victims are more likely to survive sudden cardiac arrest than prehospital traumatic cardiac arrest if they receive prompt support and treatment.

When sudden cardiac arrest does occur in children and young adults, it may be precipitated by ventricular fibrillation (VF) or rapid ventricular tachycardia (pulseless VT). These abnormal heart rhythms in children are typically caused by inherited or congenital cardiac conditions or by acute medical problems that cause inflammation of the heart. Examples of conditions that may be familiar to school nurses, physicians, and parents include long Q-T syndrome, hypertrophic cardiomyopathy, abnormal development of the coronary arteries, aortic dissection, myocarditis, and congenital aortic stenosis.¹⁹ Many of these conditions will not be detected during routine screening for school physicals or sports activities,^20,21 so sudden cardiac arrest may be the first sign of these problems. Vigorous exercise appears to act as a trigger for lethal arrhythmias.²¹

Sudden cardiac arrest may also result from commotio cordis, a blow to the chest that causes VT or VF. Each year ∼5 to 10 cases of commotio cordis are reported nationwide for victims of all ages.^21–23

A statewide survey of sudden cardiac arrest in athletes in Minnesota conducted by Maron et al^24,25 was the basis for estimating the risk of sudden cardiac arrest in high school athletes, which is thought to be 0.5 to 1.0 per 100 000 high school athletes (or 1 per 200 000 to 1 per 100 000) per year.^21,25 This risk is ∼1/100 to 1/200 of the risk reported in the adult population 35 years of age and older.²⁶ In 1999 an estimated 5 000 000 athletes competed in varsity athletics in 34 486 public and private high schools throughout the United States. Extrapolation from the Maron Minnesota data predicted ∼25 to 50 episodes of sudden cardiac arrest nationwide among all high school athletes per year.

The National Center for Catastrophic Sports Injury Research (NCCSIR) tracks voluntary reports of serious injuries and deaths that occur during training or competition in male and female high school and college sports.²⁷ The NCCSIR reports deaths attributable to an injury (direct injury death) and those not attributable to an injury (indirect nontraumatic death). In 2000 the NCCSIR reported 15 deaths of high school athletes nationwide: 12 deaths were caused by sudden cardiac arrest (indirect nontraumatic death), 2 deaths resulted from direct injury with commotio cordis(blow to the chest), and 1 death resulted from a brain injury.²⁸ The 14 reported cardiac deaths among 5 000 000 high school athletes is lower than the 25 to 50 fatalities predicted by the Maron Minnesota data and yields an incidence of 0.28 cardiac deaths per 100 000 high school athletes or 1 death per 357 000 high school athletes.

Over a 10-year period from July 1983 to June 1993, the NCCSIR reported 126 nontraumatic sports deaths in high school athletes and 34 deaths in college athletes, or an average of 16 reported deaths per year nationwide.²⁹ Most of these deaths were caused by cardiovascular conditions, especially hypertrophic cardiomyopathy and congenital anomalous coronary arteries. Estimated death rates in male athletes were 5-fold higher than those in female athletes (0.747 vs 0.133 per 100 000 athletes per year; P < .0001) and 2-fold higher in male college athletes than in male high school athletes (1.45 vs 0.66 per 100 000 athletes per year; P < .0001).²⁹

The NCCSIR database includes only voluntary reports of deaths or injuries at athletic activities sanctioned and sponsored by high schools and colleges. It does not include deaths or injuries that occur during routine class hours, physical education classes, or pickup sporting activities. Despite these limitations, the NCCSIR represents the best on-going source of data on high school athletic injuries and death.

There is little information about sudden cardiac arrest among high school students who do not compete in athletics or about sudden cardiac arrest among elementary students. Although sudden cardiac arrest has been reported in nonathletic adolescents during sedentary activities, the risk of sudden cardiac arrest appears to be lower in high school students who do not play competitive sports than in athletes.^21,24,30 When the limited data from EMS systems are examined,³¹ the risk of sudden cardiac arrest in elementary school-age children appears to be much lower than that reported in high school-age students who are not athletes and substantially lower than that reported in high school athletes.

Because the Maron and NCCSIR registries provide the most concrete data available, the risk of sudden cardiac death (SCA) of 0.5 to 1.0 per 100 000 (or 1 per 200 000 to 1 per 100 000) children and young adults is used for calculations in this statement. This figure will likely overestimate the incidence of SCA, particularly in elementary school children and adolescents who do not participate in athletics.²¹

As in an adult, if a child develops sudden cardiac arrest caused by VF or pulseless (rapid) VT, immediate bystander CPR and early defibrillation are needed. AEDs are computerized defibrillators designed for use by lay rescuers to treat sudden cardiac arrest. The AED provides voice and visual prompts to guide the rescuer. When attached with adhesive pads to an unresponsive victim in cardiac arrest, the AED analyzes the victim’s heart rhythm and determines if a shock is needed, charges to an appropriate shock dose, and prompts the rescuer to deliver a shock. The AED delivers a shock only if VF or rapid VT is present.

The US Food and Drug Administration has now cleared several AEDs for use in children younger than 8 years of age. Two of these devices have been shown to accurately identify VF and rapid VT in young children and are also accurate in identifying pediatric rhythms that do not require defibrillation.^32,33 When used with a designated pediatric pad-cable system, these AEDs deliver an energy dose that is smaller than that delivered with adult pads. The AHA² and the National Association of EMS Physicians⁴ state that AEDs may be used with CPR for treatment of prehospital cardiac arrest (victims who are unresponsive, with no breathing and no signs of circulation) in children 1 to 8 years of age. The AHA continues to recommend the use of CPR with AEDs for treatment of cardiac arrest in children 8 years of age and older and in adults.³⁴

Noncardiac Life-Threatening Emergencies in Adults

In developing the 2000 international guidelines for CPR and emergency cardiovascular care, the AHA and the International Liaison Committee on Resuscitation (ILCOR) identified the leading causes of death in persons 25 to 64 years of age. The 10 leading causes of death are malignancy, heart disease, unintentional injury, suicide, stroke, diabetes, liver disease, human immunodeficiency virus (HIV), respiratory disease (bronchitis, emphysema, and asthma), and homicide. The leading causes of work-related fatalities are transportation incidents (41%), assaults and violence (20%), contacts with objects and equipment including poisons (16%), environmental exposure (12%), falls (10%), and fires and explosions (3%).^10,11

Adult workplace emergencies are likely to be representative of life-threatening emergencies among adults who work in schools. Rescuers responding to these emergencies must recognize the condition, notify the EMS system when appropriate, and provide basic first aid until EMS providers arrive. First aid rescuers must know the general principles for all emergencies such as how to ensure scene safety and how to assess responsiveness, how to use personal protective equipment when in contact with blood or other body fluids, when and how to phone the EMS system, and when it is acceptable to move a victim. In addition, as noted above, first aid rescuers must be able to control bleeding, recognize and treat shock, immobilize the spine, warm the victim of hypothermia, cool the victim of heatstroke, detect and treat hypoglycemia, support the airway, and provide CPR and use an AED when needed.

Sudden Cardiac Arrest in Adults

Sudden cardiac arrest is a leading cause of death for adults ≥35 to 40 years of age and is the most common cause of death for those >45 years of age. In the United States each year sudden cardiac arrest occurs with an estimated frequency of ∼1 per 1000 persons ≥35 years of age per year.^34–37 These statistics can be used to estimate the risk of adult sudden cardiac arrest for any location based on the number of adults aged 35 and older typically present at that location and the number of hours they are present at that location per year (see Appendix A). Note that the risk of sudden cardiac arrest in adults is ∼100 to 200 times the estimated risk in children and adolescents and those under 35.^21,24–26

VF and, much less frequently, pulseless VT are the most common abnormal heart rhythms that cause sudden cardiac arrest in adults, although they are not the only rhythms that cause cardiac arrest.³¹ VF and pulseless VT are treated with a defibrillator that delivers a shock to the heart. This shock briefly “stuns” the heart, eliminating the abnormal rhythm and allowing the heart’s normal rhythm to resume.

Victims of sudden cardiac arrest due to VF/VT can survive if bystanders and EMS providers act quickly. Bystanders must be able to recognize cardiac arrest, phone the EMS system, perform CPR, and use the AED. The AHA has depicted these rescue steps of early recognition, early access to the EMS system, early CPR, and early defibrillation as links in the Adult Chain of Survival³⁸:

1. Early recognition of the emergency and early activation of the EMS system

2. Early CPR

3. Early defibrillation

4. Early advanced life support

Studies have shown that immediate bystander CPR and defibrillation within minutes provide the best survival from sudden VF cardiac arrest in adults. Survival rates of 50% to 74% have been reported when adult victims of VF sudden cardiac arrest collapse in front of witnesses and receive immediate bystander CPR plus defibrillation within 3 to 5 minutes of collapse. These adult survival rates have been documented in settings such as airports,³⁹ commercial airlines,^40,41 casinos,⁴² and communities with police who are trained and equipped to respond to sudden cardiac arrest.^43–46

Plan Development

The school nurse and school or team physicians and athletic trainers should be involved in development of the medical emergency response plan. The plan should specify their participation in the emergency response and in documentation, evaluation, and postevent support of students, teachers, and staff.

The school should coordinate the plan with the local EMS agency and integrate it with the local EMS system. School administrators should invite input from both the emergency medical dispatch system and the EMS system that provides responding units to the school. The local EMS agency should be encouraged to conduct an on-site “preincident” visit to identify problems such as restrictive passages through the school parking lot or buildings or any areas that are inaccessible to a crew in an ambulance.

Written notification protocols should list the appropriate contact people and their contact telephone numbers and should specify when parents, school district personnel, and the EMS system should be contacted. Forms should be available to document the details of an emergency event. A complete EIF should be available for reference during emergencies involving children with special healthcare needs.

The school should give a copy of the final emergency response plan to the local EMS system and local EMS dispatcher. This plan should include the location and type of emergency equipment. The school should notify the local fire/emergency rescue agency if any faculty, staff, or students at the school are dependent on mechanical ventilation or other electrical equipment so that the agency is prepared to provide support in the event of a power failure or other emergency. National crisis plans now require schools to keep detailed floor plans and maps of the school property for use in emergencies. Much of this information can be entered into computer-aided dispatch (CAD) systems at the 911 dispatch center and linked to the school’s address and telephone numbers. Entering this information will permit 911 dispatchers to have immediate access to this information during the emergency call.

Plan Practice and Evaluation

Each school should practice and evaluate the response plan with participation of the school nurse, school or team physicians, athletic trainers, and the local EMS system. This plan should target a collapse-to-EMS call time of ≤1 minute, provision of first aid and CPR when appropriate, and a collapse-to-first shock time of <3 minutes for sudden cardiac arrest if an AED program is on site.³⁴

Designated rescuers should participate in unannounced practice drills on a regular basis (eg, at the beginning of every school year and repeated during the school year) to promote an efficient, organized, and timely response to life-threatening medical emergencies anywhere on the schoolgrounds. These practice drills should include real-time participation by students, staff, and faculty who feign emergency conditions or participate as members of the response or communication team. The drill should use manikins to simulate victims in cardiac arrest. The AHA has created scenario cards that may be used for these practice drills. Scenario cards are available in the AHA instructor materials.⁴⁸ Scenarios are also included in the ARC First Aid/CPR/AED program instructor materials.

During each practice drill an observer should record the following:

1. Critical time intervals: time from development of the emergency to 911 call; time from development of the emergency to administration of first aid; time from collapse to bystander initiation of CPR (if indicated); time from collapse in cardiac arrest to delivery of first shock (if an AED program is in place); and time to arrival of EMS personnel at the victim’s side

2. Availability and function of emergency equipment at the school

After each drill, review performance of each component of the plan and revise the school emergency response plan as needed to improve performance and efficiency.

When a life-threatening medical emergency does occur at the school, administrators should hold a postevent meeting of all involved personnel. This meeting should be scheduled within a few days of the emergency and should provide the opportunity for a frank discussion of what worked, what didn’t work, and how to improve the response plan. This will enable revision of the response plan to better serve the next emergency.

Postincident counseling should be available to staff and students whenever a fatal or near-fatal event occurs at the school. Most school districts have designated counseling staff to handle such needs. The school supervisor should identify resource personnel before an emergency arises and should have contact numbers for use in the event of an emergency. The local children’s hospital, medical center, community mental health agency, or local EMS agency may be able to provide names of experts.

Training in First Aid and Universal Precautions

All school nurses, physicians, athletic trainers, and several faculty and staff should be trained and equipped to provide first aid because immediate first aid can prevent a life-threatening problem from becoming a fatal one. Potential rescuers must be able to recognize and provide initial treatment for breathing emergencies such as choking, severe asthma or severe allergic reaction; injury emergencies such as burns, shock, head or spinal cord injury, or bleeding; neurologic emergencies such as seizures and stroke; temperature-related emergencies such as heatstroke and hypothermia; and poisoning. Certified athletic trainers are educated to care for student athletes with sports-related injuries and emergencies.⁵ Coaches should be trained to provide CPR (with an AED if indicated) and first aid for common and life-threatening sports-related emergencies.⁴⁹

Every school should comply with precautions to minimize the risk of blood-borne pathogens. In some states public schools must comply with the Occupational Safety and Health Administration (OSHA) standards regarding blood-borne pathogens.

Several courses have been developed in recent years to provide training in first aid, including precautions to minimize risk of blood-borne pathogens. The AHA and ARC have developed first aid courses to teach these essential assessment, knowledge, and first aid skills to workplace rescuers.⁵⁰ The University of Connecticut College of Continuing Studies developed the School Nurse Emergency Medical Services for Children (SNEMS-C) Program.⁵¹ The National Standards for Athletic Coaches provide information needed by coaches to deal with sports-related injuries.⁴⁹ Visual aids such as first aid posters can be displayed in conspicuous places to remind faculty, staff, and students of critical first aid and CPR skills. Immediate bystander CPR for adults with SCA can double survival.

Training in CPR

CPR training is important for several reasons. First, rapid bystander CPR, particularly provision of rescue breathing, may prevent breathing problems and other emergencies from progressing to cardiac arrest. Second, CPR has been shown to improve the chance of survival in adults and children with cardiac arrest. In one recent study of children who required CPR in the OOH setting, ∼1 child was resuscitated by bystander CPR alone for every 7 children who required CPR by EMS personnel.^52,53

Because bystander CPR is so critical in improving survival from sudden cardiac arrest, the AHA recommends that all high school students be trained in CPR. To facilitate this training, the AHA and ARC have developed school CPR courses with course materials tailored for teaching children in a classroom setting.⁵⁴ The Maternal and Child Health Bureau has also developed a course to teach CPR in schools.⁵⁵ Such training should increase the likelihood of immediate initiation of bystander CPR for victims of sudden cardiac arrest and should contribute to improved survival rates. CPR training may also have less quantifiable benefits. For example, CPR training implies an underlying commitment to fellow citizens and may encourage and model a willingness to provide assistance to victims of medical emergencies.

Equipment

Equipment is an important part of any medical emergency response plan, beginning with a first aid kit and CPR barrier devices and may include an AED. First aid and CPR-AED equipment should be carefully selected on the basis of the types of emergencies likely to develop at the school. For example, if football, gymnastics, or diving events take place on campus, a backboard with restraints should be available to immobilize an athlete with suspected spine injury.

Epinephrine can be life saving for victims with anaphylaxis (severe allergic reaction) such as that resulting from a bee sting, a severe food allergy, or latex allergy. Some states and EMS systems encourage the use of epinephrine auto-injectors for emergency treatment of severe allergic reactions. If state and EMS regulations allow, these auto-injectors can be included in the school’s emergency equipment, and staff should be trained in their use. A physician’s prescription is required to purchase auto-injectors. To check state regulations concerning epinephrine auto-injectors, contact the AHA at 1-888-277-5463.

A physician may determine that other medications such as bronchodilators (medicines that open narrowed airways) administered by metered-dose inhalers with spacers, oxygen, and glucose or glucagon (a rapid-acting hormone for treatment of severe low blood sugar) should be kept at the school for at-risk students or staff. In this case the student’s family or a member of the school staff is responsible for providing the medication. A school nurse must be regularly available to give medications or delegate administration of medications if allowed by local law and school district policy.

School personnel first aid training includes recognition of low blood sugar (hypoglycemia) and administration of a source of rapid-acting sugar. The parent of the diabetic child is responsible for providing the school with such foods as fruit juice, packets of sugar, or a (nondiet) soft drink to be administered by trained staff if the child shows signs of hypoglycemia.

Any equipment is useless unless it is readily accessible in an emergency and rescuers are appropriately trained to use it. First aid and resuscitation equipment should be placed in a central, highly visible, and accessible location near a telephone, and all school faculty, staff, and students should know where the equipment is stored. If the school is large, it may be necessary to keep duplicate equipment in several areas. Because injuries are most likely to occur during athletic activities, the athletic facilities should be considered high-priority areas for placement of equipment such as the first aid kit and spine backboards.

General emergency equipment should not be placed in a locked office or cabinet because this might delay emergency care. Unfortunately accessibility will provide opportunities for theft or vandalism of equipment. This problem has been solved in many schools and public places such as airports by the use of mounted cabinets with audible alarms that sound when the cabinet door is opened. These cabinets cost ∼$250 to $500.

If medications such as epinephrine auto-injectors, bronchodilators, and glucagon are included in the school medical emergency response plan or a child’s emergency care plan, these items should be kept in a location that is readily available to trained rescuers and the school nurse but not accessible by students and the general public. If a student has a healthcare problem that may require the use of emergency medications, the school nurse must develop a plan to make the medication available to the child when needed.

EMS and 911 centers must know in advance where emergency equipment is kept on school property. This can prevent failure to use available equipment (such as an AED) because responders are unaware of the existence or location of the equipment. If the 911 center knows where emergency equipment is located on the schoolgrounds, the dispatcher can tell the rescuer where to find the equipment, and instruct rescuers in the use of the equipment before the arrival of EMS personnel.

Calculating Risk in a School

Person-hours are calculated by multiplying the number of persons gathered in one place by the number of hours they will spend at the same site in a given year. On the basis of limited epidemiologic data, the incidence of sudden cardiac arrest in high school athletes has been estimated at 0.5 to 1.0 sudden cardiac arrest per 100 000 athletes per year, and that figure has been extrapolated to apply to the young population under 35 years of age per year. That translates to 0.5 to 1.0 possible episode of sudden cardiac arrest per 876 million young person-hours (100 000 young persons × 24 h/d × 365 d/y = 876 million young person-hours), compared with 1 sudden cardiac arrest per 8.76 million adult person-hours based on adult risk.

To provide a rough estimate of the risk of a child’s sudden cardiac arrest in a school, calculate the number of hours that students spend in a given school per year, including all sports events and conferences. In a school of 4000 students who attend school 10 hours per day, 5 days per week, 40 weeks per year, the result is 8 million young person-hours at that school per year (4000 young persons × 10 h/d × 5 d/wk × 40 wks/y = 8 million young person-hours per year). If no other students or adults gather at that school, 1 sudden cardiac arrest is predicted in a child or adolescent attending that school every 100 to 200 years. This calculation is likely to overestimate the number of cardiac arrests per year because it is based on risk in high school athletes; risk will likely be lower in nonathletes and elementary school children. Note that the number of hours that adults spend at the school should also be calculated to consider the risk of an adult sudden cardiac arrest (see Calculation Formulas).