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No more unwitnessed out-of-hospital cardiac arrests in the future thanks to technology

      To the Editor,
      Nearly half of out-of-hospital cardiac arrest (OHCA) are unwitnessed.
      • Fukuda T.
      • Matsubara T.
      • Doi K.
      • Fukuda-Ohashi N.
      • Yahagi N.
      Predictors of favourable and poor prognosis in unwitnessed out-of-hospital cardiac arrest with a non-shockable initial rhythm.
      Most of these patients die because the chain of survival is not activated, and cardiopulmonary resuscitation (CPR) is not promptly initiated. Early recognition, the first link of the chain of survival, is critical to enable rapid emergency medical services (EMS) activation, prompt CPR initiation, and early defibrillation.
      • Semeraro F.
      • Greif R.
      • Böttiger B.W.
      • et al.
      European Resuscitation Council Guidelines 2021: Systems saving lives.
      Technology is being increasingly used in OHCA. Apps to alert first responders effectively shorten time to CPR initiation and improve outcomes.
      • Semeraro F.
      • Greif R.
      • Böttiger B.W.
      • et al.
      European Resuscitation Council Guidelines 2021: Systems saving lives.
      • Scquizzato T.
      • Pallanch O.
      • Belletti A.
      • et al.
      Enhancing citizens response to out-of-hospital cardiac arrest: A systematic review of mobile-phone systems to alert citizens as first responders.
      However, their efficacy is limited if the first link of the chain of survival is broken.
      We describe four technologies, including mobile devices, wearables, and artificial intelligence, to aid the recognition of unwitnessed OHCA and facilitate rapid intervention (Fig. 1). Such innovative technologies can measure biometrics signals, including heart rate, electrocardiogram, respiratory rate, motion, and activity
      • Krittanawong C.
      • Rogers A.J.
      • Johnson K.W.
      • et al.
      Integration of novel monitoring devices with machine learning technology for scalable cardiovascular management.
      and could be potentially implemented in the chain of survival in the short future.
      Figure thumbnail gr1
      Fig. 1“BeamFuture” - Four technologies, including mobile devices, wearables, surveillance cameras, and artificial intelligence, to aid the recognition of unwitnessed out-of-hospital cardiac arrest and facilitate rapid intervention.
      The first possibility is to use wearable devices to alert EMS automatically in case of unwitnessed OHCA. Some smartwatches can detect falls and monitor heart rate.

      Use fall detection with Apple Watch, 2021. (Accessed October 23, 2021, at https://support.apple.com/en-us/HT208944).

      When the smartwatch wearer falls and remains motionless, with or without detecting the absence of heart rate, the smartwatch automatically alerts EMS unless the wearer manually stops the process within seconds.
      Second, surveillance cameras installed worldwide are increasing and could be leveraged to detect OHCA automatically.
      • Scquizzato T.
      Cardiac arrest detection through artificial intelligence-based surveillance camera: A working prototype.
      • Douma M.J.
      Automated video surveillance and machine learning: Leveraging existing infrastructure for cardiac arrest detection and emergency response activation.
      When an OHCA occurs in remote or uncrowded places, such as parking lots and quiet streets during off-peak hours, OHCA recognition is delayed. Real-time advanced video analysis techniques allow detecting a sudden fall and absence of movement. Therefore, it is potentially possible to detect a cardiac arrest and trigger an alert.
      Third, agonal breathing is common after cardiac arrest.
      • Bobrow B.J.
      • Zuercher M.
      • Ewy G.A.
      • et al.
      Gasping during cardiac arrest in humans is frequent and associated with improved survival.
      Using smartphones and smart speakers for contactless, passive detection of abnormal breathing represents an innovative way to identify cardiac arrest.
      • Chan J.
      • Rea T.
      • Gollakota S.
      • Sunshine J.E.
      Contactless cardiac arrest detection using smart devices.
      Considering that many unwitnessed OHCAs occurs at home where smart speakers are increasingly present, the adoption of these systems could be of significant impact.
      An additional benefit could be obtained if these systems are integrated into a network of first responders allowing the simultaneous activation of EMS and nearby first responders.
      • Semeraro F.
      • Greif R.
      • Böttiger B.W.
      • et al.
      European Resuscitation Council Guidelines 2021: Systems saving lives.
      • Scquizzato T.
      • Pallanch O.
      • Belletti A.
      • et al.
      Enhancing citizens response to out-of-hospital cardiac arrest: A systematic review of mobile-phone systems to alert citizens as first responders.
      Fourth, cardiac arrest prevention is another crucial but complex aspect. Patients may show signs of physiological deterioration before cardiac arrest. Wearable devices continuously monitoring biometrics signals
      • Krittanawong C.
      • Rogers A.J.
      • Johnson K.W.
      • et al.
      Integration of novel monitoring devices with machine learning technology for scalable cardiovascular management.
      may alert patients, hours or minutes in advance, of an impending life-threatening cardiac event. This will allow to recognize patients at risk of cardiac arrest and to alert EMS on time in the hope of preventing cardiac arrest.
      • Khundaqji H.
      • Hing W.
      • Furness J.
      • Climstein M.
      Smart shirts for monitoring physiological parameters: Scoping review.
      Unwitnessed OHCA remains an unsolved problem. We imagined a future where unwitnessed OHCA will be survivable, and technology will likely play a central role. Research is needed to determine the feasibility and effectiveness of mobile and wearable technology to detect unwitnessed OHCA, facilitate early intervention, and improve chances of survival. We invite clinicians and researchers worldwide to act now so that no one will die in 2050 due to an unwitnessed OHCA.

      Declaration of Competing Interest

      No relationship exists between any of the authors and any commercial entity or product mentioned in this manuscript that might represent a conflict of interest. No inducements have been made by any commercial entity to submit the manuscript for publication. All within 3 years of beginning the work submitted. TS is ILCOR Social Media Working Group member. FS is the Chair-Elect of the European Resuscitation Council, Chair of the ILCOR Social Media Working Group, ILCOR BLS Working Group member, Scientific Committee member of Italian Resuscitation Council.

      Acknowledgments

      We are very grateful to Serena Notartamaso, PhD, prolific researcher and amazing artist, for drawing our vision of the future (Fig. 1) by blending science with art. The hand and brain together to show us the vision of the future.

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