Katarzyna Pogorzelczyk1, Daniel Ślęzak1, Przemysław Żuratyński1, Marlena Robakowska2, Anna Tyrańska-Fobke1,
Piotr Robakowski1, Piotr Holajn1
1 Chair and Clinic of Emergency Medicine, Medical Emergency Laboratory, Faculty of Health Sciences with the Division of Nursing and Institute
of Maritime and Tropical Medicine, Medical University of Gdańsk , Gdansk, Poland
2 Department of Public Health and Social Medicine, Faculty of Health Sciences with the Department of Nursing and Institute of Maritime
and Tropical Medicine, Medical University of Gdansk, Gdansk, Poland
The beginning of research and scientific studies on defibrillation, continued in later times by both scientists and clinicians from around the world, dates primarily in the 18th century and it is referred to as the beginning of defibrillation. The cardiologist Albert Hyman and the electrician engineer C. Henry Hyman are the first constructors of the defibrillator device. Their invention from 1932 defines the beginning of works on the AED automation. The 20th century was dedicated to further works on the development of defibrillation. Defibrillator devices are spreading with advances in technology, defibrillation methods and the advancement of engineering.
Historical references to positive effects of electricity on the living organism are dated back to the ancient times. An example of an unspecified connection between the electric discharge and the sudden improvement of human health is also contained in the Bible. The beginning of research and scientific studies on defibrillation, continued in later times by both scientists and clinicians from around the world, dates in the 18th century and it is referred to as the beginning of defibrillation.
Luigi Galvani, an Italian physician, a physiologist and physicist, commonly known as the father of electrophysiological research, in 1771 made a discovery, which to this day is used in the world of medicine. When passing the electric current through muscles of the previously prepared frog limbs, he noticed the existence of physiological-electrical phenomena in animal tissues. He published the results of his research on the twentieth anniversary of the discovery in “De Viribus Elictricitatis in Motu Musculari Commentarius” [1–3].
At the same time as Galvani’s studies, the Danish vet Abildgaard experimented with chickens and made the same discovery. The first discharge used in the animal model (a hen) led to death, while the second reanimated the animal and caused its escape. This led to discontinuation of the study .
A breakthrough in the progress of works on the influence of the electric current on living organisms took place in 1899 thanks to L. Prevost and F. Batelli. Scientists – physiologists, working at the University of Geneva, through numerous experiments proved (the study group consisted of dogs and cats) that the high-voltage current restored the correct sinus rhythm, while low-voltage current caused ventricular fibrillation [5, 6].
The researches were continued in the 20th century. For the first time, the research team, working at the University of Cleveland, carried out experiments confirming the earlier achievements of the scientific world [6, 7].
The year 1914, or more precisely, the work done by the British physiologist George R. Mines also confirmed the effect of electricity on the living organism. The main observation of the study was to prove the existence of the direct correlation between the use of discharge and the occurrence of ventricular fibrillation. It was carried out in an animal model – a rabbit .
The 20th century was also the time of first works aimed at using the observed and confirmed effects of the application of the electric current to the living organism. The cardiologist Albert Hyman of Beth Davis Hospital in New York, as well as the electrician engineer C. Henry Hyman, are considered to be the pioneers of construction works in this field. In 1932, they constructed the device called “Hyman Otor”. The technical assumption was extremely simple. The current transformer was connected to the wire ended with a steel needle. In the event of ventricular fibrillation, the needle was inserted through the first intercostal space into the right atrium, and then a strong impulse was triggered. The clinical effectiveness of the device was confirmed by testing it in several animal models and in one human model. Despite efforts of creators of “Hyman Otor”, this invention did not find support and positive opinions in the medical community. Despite this, the pioneering invention gave rise to the spread of the term “artificial pacemaker” [9–11].
Two years earlier in 1930 there was another, equally important, worth noting, breakthrough for science. William Bennett Kouwenhoven, an American engineer, developed a defibrillation method. According to the literature, even as a student, he made a preliminary technical outline of the device that would stimulate the heart’s action without opening the chest [12–16].
The key moment in the work on the defibrillator construction took place in 1947. For the first time, in a critical situation, a device was used in a human being. The use of the internal defibrillation method helped to save a human life. The operation was performed by an American cardiac surgeon and neurosurgeon Professor Claude Schaeffer Beck. During the surgical correction of the skeleton of the 14-year-old boy’s chest, sudden cardiac arrest occurred in the mechanism of ventricular fibrillation. The immediate 45-minute internal heart massage with the use of a defibrillator was applied. However, this was preceded by intravenous administration of procainamide. The defibrillator used at that time consisted mainly of two silver electrodes (size of a table spoon). The discharge led to the return of the sinus rhythm [6, 17, 18].
Despite the fame gained by Prof. Beck, his breakthrough use of a defibrillator in a life-threatening situation, and subsequent, in-depth research into the possibilities of a new device in the medical world, defibrillators were used only during open-heart surgeries until the 1950s [6, 19].
In 1955 William Kouwenhoven made another step towards spreading the use of the defibrillator [20, 21]. However, a year later, in 1956, the cardiologist Paul Maurice Zoll, when assisting the injured person (without opening his chest), already used a stronger aggregate (up to 750 V and variable current) [6, 22, 23]. At the same time, in the area of present Kyrgyzstan, Dr. Eskin and Dr. Klimow performed percutaneous external defibrillation. The applied voltage was higher than previously mentioned [6, 24].
Dr. Bernard Lown, an American cardiologist, in 1959 conducted numerous studies to improve the use of the electric current in the treatment of cardiac arrhythmias. His work focused mainly on using a monophasic damped sinusoidal waveform (MDS) with a voltage of up to 1000V and energy of 100–200 J in a defibrillator .
The Lown’s team conducted in 1962 the research study which led to the creation of a defibrillation protocol. It assumed the use of high energy up to 360 J. The necessity to introduce such regulations was dictated by the device using high peak current (50–80 A), which in turn was related to post-defibrillation cardiomyocytes injury .
The year 1965 is considered the year of introduction of the mobile defibrillator to the ambulance depot. Its use in the course of transporting a sick person in the ambulance took place less than a year later. The portable defibrillator prototype weighed 70 kg and was powered by a car battery. Technological progress, accompanying the development of defibrillators in 1968, allowed to construct a device weighing 3 kg. The year 1971 is the date of performing the first defibrillation in the world by a paramedic without the presence of a doctor [26, 27].
The end of the 20th century was primarily the time of research and numerous works on the construction of automatic external defibrillators (AED). Joshua L. Koelker and Jordan M. Blondino were persons responsible for the introduction of the first, and at the same time pioneering AED devices. Their work contributed to saving the victim’s life just after the incident, in the place where the heart stopped. This event contributed to the dissemination and development of defibrillation automation .
The end of the 20th century was associated primarily with a diametrical increase in the number of researches on AED devices and, hence, defibrillation itself. The American Heart Association (AHA), in 1991, introduced the so-called “survival chain” . Originally, it was a list of several basic resuscitation activities leading to increased survival among people who experienced sudden cardiac arrest.
The last years of the 20th century were the time when the main goal of research projects was to minimize myocardial damage as a consequence of using the defibrillator. For this purpose, a biphasic truncated exponential (BTE) impulse was used [6,30]. Additional recommended protocols used among BTE defibrillators were:
• low-energy defibrillation protocol in the sequence of 150-150-150 J,
• high-energy defibrillation protocol of 200-200-360 J .
The biphasic impulse mentioned above was also used in implantable cardioverter defibrillators (ICD).
With the increasing strength and significance of defibrillation in the medical care process of people with cardiac arrest, the AED was becoming a more common phenomenon in non-hospital settings due to the worldwide program of the widespread access to defibrillation .
The year 2000 was a year of breakthrough in the work on improving external devices. At that time, Zoll Company introduced a rectilinear biphasic (RLB) waveform that was specially developed for AED. This action contributed to a significant minimization of negative consequences of the use of AED – skin burns and, above all, it reduced the occurrence of post-defibrillation heart damage. Both AHA and ILCOR gave positive feedback on the new solution. This also contributed to the introduction of this invention in the resuscitation protocol in guidelines from 2000 .
Access to the defibrillator, in principle, in case of sudden cardiac arrest in out-of-hospital setting, should be as quick as possible. According to the current CPR guidelines established in 2010, the AED should be located in a place where the risk of sudden cardiac arrest occurs at least once every 2 years . In the case of those with high risk of ventricular arrhythmias, the medical community recommends surgical implantation of a cardioverter-defibrillator. This method is currently referred to as the only proved method of prolonging the patient’s life.
Automatic defibrillator devices offered on the medical market are devices using intracardiac electrodes. Apart from the issue of providing health care at the scene of sudden cardiac arrest, AED also cooperate with control units. Modern defibrillators aimed at non-hospital use are complete therapeutic systems. In addition to the basic function – the use of defibrillation in the injured person, they enable stimulation as well as monitoring of the patient’s situation and the state of health .
The standard AED equipment includes: an analyzing and defibrillating module (with attached battery or accumulator), two identical, separate electrodes or one analyzing-defibrillating electrode, connecting cables as well as additional components, including an instruction for use, gloves, razors or masks for ventilation [34-36].
Currently, there are over a dozen different manufacturers of external defibrillators on the market. They offer constructionally similar devices. The differences between them result primarily from innovativeness supported by competition. The lack of uniformity of devices is therefore the main reason for the occurrence of difficulties during training processes, as well as the subsequent use of the equipment in everyday life. An effective and more common access to defibrillation therefore has to be harmonized. In addition to technical issues, the aspect worth paying attention to is the definition of uniform standards related to the external appearance of the AED .
AED IN POLAND
The technological development of AED contributed to the increase of its recognition and universality, improving also undoubtedly the survival rates after sudden cardiac arrest not only in Poland, but also abroad. It is particularly noticeable in countries of Western Europe, North America or Asia (Japan).
The very installation and location of the apparatus in public space, however, will not contribute to 100% of the use of capabilities of automatic defibrillators. Education, social campaigns, and thus increasing the level of awareness about the benefits of using these devices in the event of sudden cardiac arrest in non-hospital settings, is an inherent element of efforts to further increase the use of AEDs and each time it is an integral element of subsequent installations of urban space [38, 39]. The goal is to consolidate the knowledge on the subject and increase the awareness of AED among citizens [40, 41].
Nowadays, no form of legal regulations is applied to the necessity of installing this apparatus in the public space. Nevertheless, in 2000 the national work on the Universal Defibrillation Access Program (PAD project) was started, similarly to other European countries .
In order to achieve best results associated with the investment in non-hospital defibrillators, as already mentioned, one should also focus on educational campaigns and promotion aids in the field of first aid using the AED. The PAD project covers a range of accompanying activities. It includes, above all, dissemination in the society the knowledge on the AED and the consequences of its use in the event of a threat to life and health [44, 45].
The first Polish project implemented within this framework was the introduction in 2003 the pilot version of the Orlen First Aid Program. It assumed conducting the course of the first premedical aid, which was joined by 130 employees of the concern. The second stage contributed to the installation of the apparatus and the continuation of staff training. The initiative covered 9 service stations located on roads with the highest traffic in Poland .
Currently, the policy promoting the use of AED is carried out primarily within the activities of local self-government units (LGUs). Every year, within the municipal activities carried out under the Citizen Budget, ideas are submitted about the purchase and installation of new defibrillators in the LGU/city. An example would be Gdańsk and the edition from 2018 during which an idea was announced that would include the purchase of further ten AEDs.
In addition, for several years, the largest companies – those operating in the field of railway transport, both country and regional, are involved in the process of defibrillator installations in the newest trainsets and on the most popular routes, thus caring for the safety of their passengers. An example can be PKP Intercity. The company, since 2016, has placed defibrillators AED Plus (semi-automatic apparatus) in each of the Express Intercity Premium depots. The cost of the investment – the purchase of 20 AEDs with the necessary equipment amounted to over PLN 117 000 .
One of the leading activities currently implemented within the PAD project has been the creation of the RatujzSercem.pl website in 2009  as well as the creation of the Life Rescue Foundation in 2014 . The website aims to create a map with confirmed locations of the installed AED within Poland. The second form of action mentioned above – the foundation, is, like RatujzSercem.pl, one of the main national propagators of placing further AEDs in the non-hospital space, as well as using them in the event of a life and health threat to the person in whom sudden cardiac arrest occurred. This foundation, apart from the implementation of basic tasks within the PAD project, is the national entity responsible for the only, so far operating in Poland, application informing about access to the nearest AED as well as giving technical advice during the premedical help with the use of AED. Staying Alive, because this is how the application is called, similar to the RatujzSercem.pl website uses a map with localized and verified on its surface AED. However, unlike the website, the application uses the current GPS position, while showing the closest AED point. Additional advantages are the possibility of using Staying Alive also outside the country (access to the application is international, operates all over the world), as well as short-term features included in its functions, reminders of the principles of the first aid and guidelines for providing such assistance displayed in the right order, in a graphical form that makes it easier to pick them up. This application is free, available for phones with both Android and iOS systems . What is also worth adding, Staying Alive was created thanks to Prophone in cooperation with the Polish Resuscitation Council .
Since the introduction of PAD project in Poland, despite the widespread opinion about its initial stage of development after almost 18 years of commencement of works – the numerous investments of AED installations in the public space are becoming noticeable. Having results of activities and projects at the time, not so much next AED locations within the country, but additional promotional and educational activities, and based on foreign reports, Polish society is becoming more aware and knowledgeable about the positive consequences of using AED in the event of sudden cardiac arrest in out-of-hospital settings. Piśmiennictwo
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Conflict of interest
All authors state that there is no conflict of interest.
Chair and Clinic of Emergency Medicine,
Medical Emergency Laboratory,
Faculty of Health Sciences with the Division of Nursing
and Institute of Maritime and Tropical Medicine,
Medical University of Gdańsk,
Fig. 1. Easily accessible AED enables to perform CPR and deliver a defibrillation shock more quickly and improves survival chances. A simple, step-by-step process with clear, adaptive voice instructions empowers even the most inexperienced responders.
Ryc. 1. Łatwo dostępny defibrylator AED skraca czas podjęcia czynności ratunkowych oraz zwiększa szanse na przeżycie. Dzięki niezwykle prostej obsłudze i jasnym, dostosowującym się komunikatom głosowym pomocy udzielić może każdy, nawet nieprzeszkolona osoba.
Fig. 2. AED (Automated External Defibrillator) – Philips Heartstart FRx.
Ryc. 2. Urządzenie AED (Automatyczny Defibrylator Zewnętrzny) Philips Heartstart FRx.