American Journal of Emergency Medicine 32 (2014) 1408–1412

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

Review

Defibrillation in rural areas

Mathias Ströhle, MD a,⁎, Peter Paal, MD, DESA, EDIC a, b, Giacomo Strapazzon, MD b, c,
Giovanni Avancini, MD c, Emily Procter c, Hermann Brugger, MD b, c
a
Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria
b
International Commission for Mountain Emergency Medicine, ICAR MEDCOM
c
EURAC Institute of Mountain Emergency Medicine, Viale Druso 1, I-39100 Bozen/Bolzano, Italy

a r t i c l e i n f o a b s t r a c t

Article history: Aim of the study: Automated external defibrillation (AED) and public access defibrillation (PAD) have become
Received 16 December 2013 cornerstones in the chain of survival in modern cardiopulmonary resuscitation. Most studies of AED and
Received in revised form 18 July 2014 PAD have been performed in urban areas, and evidence is scarce for sparsely populated rural areas. The aim of
Accepted 19 August 2014 this review was to review the literature and discuss treatment strategies for out-of-hospital cardiac arrest in
rural areas.
Methods: A Medline search was performed with the keywords automated external defibrillation (617 hits), public
access defibrillation (256), and automated external defibrillator public (542). Of these 1415 abstracts and additional
articles found by manually searching references, 92 articles were included in this nonsystematic review.
Results: Early defibrillation is crucial for survival with good neurological outcome after cardiac arrest. Rapid
defibrillation can be a challenge in sparsely populated and remote areas, where the incidence of cardiac arrest is low
and rescuer response times can be long. The few studies performed in rural areas showed that the introduction of
AED programs based on a 2-tier emergency medical system, consisting of Basic Life Support and Advanced Life
Support teams, resulted in a decrease in collapse-to-defibrillation times and better survival of patients with out-of-
hospital cardiac arrest.
Conclusions: In rural areas, introducing AED programs and a 2-tier emergency medical system may increase survival
of out-of-hospital cardiac arrest patients. More studies on AED and PAD in rural areas are required.
© 2014 Elsevier Inc. All rights reserved.

1. Introduction or Oregon, USA, with 15 inhabitants km − 2. It is unclear how to equip

In North America, the incidence of out-of-hospital cardiac arrest
(OHCA) is approximately 50 to 55 per 100 000 inhabitants per year
[1,2]. Sudden cardiac arrest is caused by myocardial infarction in
more than 60% of cases, with ventricular fibrillation (VF) in 50% to
80% of collapsed patients [3,4]. In urban areas with rapid bystander
cardiopulmonary resuscitation (CPR) and public access defibrilla-
tion (PAD), survival rates from cardiac arrest have improved
substantially [5]. Most studies on automated external defibrillation
(AED) and PAD have been performed in urban areas (eg, Maastricht,
Netherlands, with a population density of 1975 inhabitants km − 2;
Goteborg, Sweden, with 2562 inhabitants km − 2; and Copenhagen,
Denmark, with 5985 inhabitants km − 2) [6–8]. Data are scarce in less
densely populated rural and mountain areas such as the European
Alps, with a population density of about 20 to 240 inhabitants km − 2,
rural areas with AEDs and PAD. The aim of this review was to review
the literature and discuss evidence regarding treatment strategies
for OHCA-VF in rural areas.
2. Material and methods
A literature search of the Medline database was performed using
the keywords automated external defibrillation (617 hits), public access
defibrillation (256), and automated external defibrillator public (542)
for articles published on or before July 18, 2014. A manual search of
the references was performed to find additional articles. In total, 92
articles related to AED and PAD in rural areas were included in this
nonsystematic review.
3. Results and discussion

⁎ Corresponding author. Department of Anesthesiology and Critical Care Medicine,
Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria. Tel.: +43 512
504 80496; fax: +43 512 504 22450.
E-mail addresses: mathias.stroehle@uki.at (M. Ströhle), peter.paal@uki.at (P. Paal),
giacomo.strapazzon@eurac.edu (G. Strapazzon), giovanni.avancini@gmail.com
(G. Avancini), emily.procter@eurac.edu (E. Procter), hermann.brugger@eurac.edu
(H. Brugger).
3.1. Collapse-to-defibrillation time is decisive for survival and
neurological outcome
Time from OHCA-VF to defibrillation is crucial for survival and
neurological outcome. The defibrillation success and survival rate of
OHCA-VF patients not receiving CPR rapidly decline in the first 5 to 10

http://dx.doi.org/10.1016/j.ajem.2014.08.046
0735-6757/© 2014 Elsevier Inc. All rights reserved.
 M. Ströhle et al. / American Journal of Emergency Medicine 32 (2014) 1408–1412 1409

Table 1
Influence of emergency medical technician defibrillation programs within EMS on survival from OHCA

Studies (n = 1713) Design Survival to hospital P

discharge before and
after implementation of AED

Before After

Eisenberg et al, 1980 [38] (n = 154) Prospective, historical controls 4% 19% b.01
Stults et al, 1984 [39] (n = 95) Prospective controlled 3% 19% b.05
Olson et al, 1989 [40] (n = 566) Prospective controlled 4% 6% b.02
Sweeney et al, 1998 [41]⁎(n = 627) Prospective controlled, crossover 5% 5% .8
Gottschalk et al, 2002 [42]⁎(n = 103) Prospective controlled 32% 22% .29
Stotz et al, 2003 [43]⁎(n = 168) Retrospective 24% 14% .112

Studies on early defibrillation within the emergency medicine system. ED denotes early defibrillation.
⁎ Studies in areas where the response time of the ALS team before introduction of the AED program was a few minutes.

minutes after collapse [9]. Other studies also report a steep decline in
survival [10,11], which underlines that a response time shorter than 5
minutes has the biggest impact on positive outcome [11–17]. In a British
study, patients with OHCA-VF witnessed by a physician had a survival
rate of about 60% when the outpatient clinics where they collapsed were
equipped with AEDs [18]. The response time was also decisive for
survival: the hospital discharge rate was about 60% with a response time
of less than 4 minutes and about 18% with a response time of more than
4 minutes. Automated external defibrillation studies with long call-to-
defibrillation intervals (eg, N 10 minutes) have not demonstrated a
substantial increase in the overall survival rate [19].
Short response times after OHCA-VF are also essential for good
neurological outcome. In Amsterdam, survivors of OHCA-VF had less
neurological impairment and loss of autonomy when the collapse-to-CPR
and collapse-to-defibrillation times were shorter [20,21]. Another study
reported that life expectancy and quality of life were similar in patients
who had survived OHCA-VF compared to a matched population [22].
Whereas early studies suggested a benefit of CPR before
defibrillation [23–27], recent studies do not support these findings
[28–33]. Thus, current CPR guidelines do not recommend a specific
CPR interval before defibrillation but highlight the importance of
efficient and continuous chest compressions with as short as possible
hands-off time until successful defibrillation [25,34,35].
3.2. Early defibrillation programs in urban areas within emergency
medical services
Emergency medical services (EMSs) have different structures. A
single-tier EMS consists of an Advanced Life Support (ALS) team that
is called to an emergency; a 2-tier system consists of Basic Life Support
(BLS) and ALS teams that are dispatched according to medical
information and needs. Other systems have a nontransporting first
responder team whose members are BLS or ALS trained and a
transporting unit that is dispatched simultaneously. Two-tier systems
may be more cost-effective because less qualified personnel and less
equipment are needed to provide a good standard of care [36]. In a
review, survival from OHCA-VF ranged from 3% to 33% but was higher
with a 2-tier compared to a single-tier system [37]. The greatest
improvements in survival from OHCA-VF were reported in areas
where no preclinical defibrillation was available before these
programs were introduced [38–40]. However, the advantage of a 2-
tier system could not be replicated in areas where the response time
of an ALS team had been fast (within minutes) before the program
was introduced [41–43]. As a result, both the American Heart
Association and European Resuscitation Council recommend that
BLS teams should be equipped with AEDs [44]. Studies reporting
outcomes after early defibrillation in urban areas within an EMS are
listed in Table 1.
3.3. Early defibrillation programs in urban areas outside EMS
In some 2-tier systems, BLS AED is performed by BLS first
responders trained in the use of AEDs, for instance, fire brigade
members and police officers. These first responders perform contin-
uous CPR and apply AED until the arrival of an ALS team. A 2-tier
system outside the EMS can shorten call-to-defibrillation time; and it
may improve outcome if the call-to defibrillation time is reduced to a
few minutes, especially in areas where an ALS team is not rapidly
available [3,15,45–50]. Some studies did not report improved
outcomes because call-to defibrillation time could not be sufficiently
reduced (eg, b 10 minutes). Studies reporting outcomes after early
defibrillation in urban areas outside an EMS are listed in Table 2.
3.4. Public access defibrillation
Public access defibrillation is defined as the installation of AEDs in
public places (eg, airplanes, airports, casinos). Introduction of PAD in
densely populated or heavily frequented areas can increase preexisting

Table 2
Influence of AED programs outside the EMS on survival from OHCA

Studies (n = 7942) Design Responders Controls Survival to hospital P

discharge before
and after
implementation
of AED

Before After

van Alem et al, 2003 [3] (n = 469) Prospective controlled, randomized, crossover Police, firefighters EMS 15% 18% .33
Stiell et al, 1999 [15] (n = 6331) Prospective controlled, interventional Firefighters, EMT-D EMS 4% 5% .03
Myerburg et al, 2002 [45] (n = 420) Prospective controlled Police EMS 9% 17% .05
Kellermann et al, 1993 [46] (n = 431) Prospective controlled, crossover Firefighters EMS 10% 14% NS
White et al, 1996 [47] (n = 84) Retrospective Police, EMT-D EMS 43% 58% .2
Mosesso et al, 1998 [48] (n = 207) Prospective interventional, historical controls Police EMS 6% 14% .1

EMT-D denotes emergency medical technician with AED skills; NS, nonsignificant.
1410 M. Ströhle et al. / American Journal of Emergency Medicine 32 (2014) 1408–1412

Table 3
Public access defibrillation programs outside the EMS and survival from OHCA-VF

Studies (n = 16 580) PAD locations Responders Survival to hospital discharge

Folke et al, 2009 [8] (n = 1274) Copenhagen, Denmark Volunteers 13.9%

O’Rourke et al, 1997 [13] (n = 46) Qantas aircrafts Air crew members 26%
Valenzuela et al, 2000 [16] (n = 105) Casinos, USA Casino officers 53%
Caffrey et al, 2002 [51] (n = 26) Chicago airports, USA Volunteers 56%
MacDonald et al, 2002 [52] (n = 53) Boston Airport, USA Firefighters, EMS 21%
Page et al, 2000 [53] (n = 200) US airline Flight attendants 40%
Culley et al, 2004 [54] (n = 50) Seattle, King County, USA Volunteers 50%
Hallstrom et al, 2004 [56] (n = 235) USA Volunteers 23% vs 14% CPR only (P = .03)
Kitamura et al, 2010 [60] (n = 12631) Japan Volunteers, EMS 37.2% PAD (survival at 1 mo)
Wassertheil et al, 2000 [87] (n = 28) Stadium, ANZAC Parade, Australia Volunteers, EMS 71%
Capucci et al, 2002 [88] (n = 354) Piacenza, Italy Volunteers 44% vs 21% EMS (P = .046)
Davies et al, 2005 [89] (n = 172) UK airports, railway stations Volunteers 28%
Cappato et al, 2006 [90] (n = 1394) Brescia, Italy Volunteers, EMS 1.4% vs 4.4% after PAD (P = .04)
Hanefeld, 2010 [91] (n = 12) Bochum, Germany Volunteers 50%

survival rates to hospital discharge by up to 50% [54]. The achieved
survival rates can be as high as 55% [13,16,51–53]. In a large PAD study,
bystanders were trained in either CPR or CPR with defibrillation;
survival was 14% in the CPR group and 23% in the CPR with defibrillation
group (P = .03) [55,56].
It has been suggested that automated external defibrillators should
be positioned in any area where an ALS team cannot arrive in less than 5
minutes and where at least 1 OHCA-VF is expected to occur over a period
of 5 years [55,57]. Suitable locations for AED include airports, factories,
nursing homes, marinas, schools, shopping malls, sport arenas, and train
stations [55,57,58]. Automated external defibrillators have also been
recommended for places where more than 250 persons older than 50
years gather [59]. In Japan, a national PAD program decreased mean
collapse-to-defibrillation time from 3.7 to 2.2 minutes (P b .001),
increased the number of defibrillations administered by laypersons,
and increased the number of patients surviving with minimal neurologic
impairment from 2.4 to 8.9 per 10 million inhabitants (P = .01) [60]. As a
result of these retrospective studies, some authors proposed locations
deemed suitable for installing an AED [7,61–65] and stated that cost-
effectiveness should be assessed before starting a PAD program [66,67]
and first responders should be regularly trained. Studies on PAD are
listed in Table 3.
3.5. Early defibrillation in rural and mountain areas
The chance of surviving OHCA-VF is higher in dense urban areas
than in rural areas [68]. The 2000 European Resuscitation Council
guidelines state that early defibrillation should be standard for EMS
“except in sparsely populated and remote settings, where the
frequency of cardiac arrest is low and rescuer response times are
excessively long” [69]. However, some studies have found data
opposing this advice (Table 4); on San Juan Island, USA, survival of
OHCA-VF was 43% with a 2-tier system, which is comparable to
similar studies in urban areas [70]. In Ketchikan, AK, USA, survival
increased from 15% to 38% (P = .03) using AEDs [71]. In 2 further
studies performed in rural US communities with BLS- and AED-
trained paramedics, survival increased from about 3% to 18% [39,72].
In Galicia, Spain, the survival rate from VF was 12%; but overall
survival from OHCA was only 2.3% due to the low incidence of
shockable rhythms upon arrival of an EMS team. In this setting, time
of activation and response of the EMS were slow (15-minute median
collapse-to-crew arrival time), negatively affecting the incidence of VF
and survival [19]. In a Swedish retrospective analysis of more than 14
000 cardiac arrests, OHCA survival in rural areas was not significantly
different from survival in urban areas (4.8% vs 5.5%). The conclusion
was to place AEDs closer to patients of small communities, allowing
fire brigades and other first responders to shorten the time to
defibrillation [73]. Similarly, the Italian government issued a regula-
tion that obliges organizers of sporting events to have AEDs and
trained personnel available on site [74].
Mountain regions have strong seasonal fluctuations in population
with resulting fluctuations in the incidence of OHCA-VF. In small
communities, the response time of a BLS or ALS team to OHCA-VF is
usually more than 5 minutes. The Medical Commission of Mountain
Emergency Medicine suggests that AEDs should primarily be installed in
ski areas in the winter and in mountain huts near cable cars or popular
hiking trails The location is determined by the sport type, risk factors of
the general participant, and environmental conditions [75,76]. In some
remote American and European mountainous regions, first responders
(eg, mountain rescuers, fire brigade members, ski lift officers) have been
trained in BLS and AED to reduce call-to-defibrillation time. A survey
reported that AEDs have been widely implemented by mountain rescue

Table 4
Influence of AED programs on survival from OHCA in rural areas

Studies (n = 1121) Design Location Responders Controls Survival to hospital P

discharge before and after
introduction of AED
programs

Before After

Colquhoun, 2002 [18] (n = 259) Retrospective GP office; Cardiff, UK GP with AED GP 12.5% 63% NR
unwitnessed witnessed
by GP by GP
Stults et al, 1984 [39] (n = 95) Prospective, controlled Rural communities; Iowa, USA EMT-D EMT 3% 19% b.05
Killien et al, 1996 [70] (n = 78) Retrospective Island community; San Juan Island, USA EMT-D/paramedic EMT NA 43% NR
Kriegsman et al, 1998 [71] (n = 71) Retrospective Rural community; Alaska, USA EMT/paramedic EMT 9% 20% NR
Vukov et al, 1988 [72] (n = 63) Prospective, controlled, Rural communities; Minnesota, USA EMT-D EMT 4% 17% NR
crossover
Colquhoun, 2006 [92] (n = 555) Retrospective GP office; Cardiff, UK GP with AED GP NA 27% NR

GP denotes general practitioner; NA, not applicable; NR, not reported.

 M. Ströhle et al. / American Journal of Emergency Medicine 32 (2014) 1408–1412
services worldwide [77], and some mountain rescue backpacks are now
equipped with AEDs [78].
The literature on AED use in mountain and remote areas is limited,
and only few case reports of patients with favorable outcomes have
been published [79,80]. In these settings, the probability to rescue a
hypothermic patient in OHCA is high; and the chance of survival at
hospital discharge is higher compared to normothermic patients (27%
vs 50%) [81,82]. Administration of up to 3 shocks is recommended,
with further dosing guided by the clinical response, when core
temperature is less than 30°C [83]. High-altitude base camps such as
Mt Everest or Aconcagua also have seasonal fluctuations in the
population, easy tourist access, and a daily population up to more than
1000 [84]. Visitors to these areas should be assessed for risk of
coronary heart disease and seek individual pretravel advice to reduce
the incidence of sudden cardiac arrest. An effective chain of survival in
such base camps would include AEDs [76,85]. Mechanical CPR could
be helpful if no helicopter rescue is available and terrestrial rescue is
technically difficult or rescue time is more than 30 minutes [86].
4. Conclusions
Only few studies exist on out-of-hospital defibrillation in rural areas,
but most show a better outcome from OHCA after implementation of
AED and PAD. Automated external defibrillation and PAD programs can
only be successful if implemented into the chain of survival of a 2-tier
EMS. An ALS team should be available within a reasonable time. Public
access defibrillation and first responders trained in AED could represent
a cost-effective alternative to additional ALS teams. More studies on AED
and PAD in rural areas are required.
Acknowledgments
The authors do not have any institutional or commercial affiliations that
might pose a conflict of interest regarding the publication of this
manuscript. There is no other conflict of interest related to this manuscript.
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