1. 2010 년 AHA 심폐소생술 가이드라인 설명회 Electrical Therapies 한림대학교 강동성심병원 응급의학과 조규종

2. 대한심폐소생협회 Early defibrillation  Critical to survival from sudden cardiac arrest VF: the most frequent initial rhythm in witnessed SCA (41% in King County, 52% in Tucson) The treatment for VF: electrical defibrillation Success of defibrillation: diminishes rapidly over time VF tends to deteriorate to asystole within a few minutes CPR alone: no effect

3. 대한심폐소생협회 CPR + Defibrillation: Critical Combination Collapse to CPR Interval (min) Valenzuela TD et al. Estimating effectiveness of cardiac arrest interventions: a logistic regression survival model. Circulation. 1997;96:3308 –3313. Larsen MP et al. 1993

4. 대한심폐소생협회 Two critical questions  CPR before defibrillation ? Shock First Versus CPR First  number of shocks before resumes CPR ? 1-Shock Protocol Versus 3-Shock Sequence

5. 대한심폐소생협회 Integrate CPR and AED Use Cobb LA et al. Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation. JAMA. 1999;281:1182–1188.

6. 대한심폐소생협회 Cobb LA et al. JAMA. 1999;281:1182–1188.Berg RA et al. Crit Care Med 2004;32:1428-9 Shock First vs. CPR First  Swine VF model  Pre-shock 90s CPR in Seattle Importance of high-quality CPR (Prolong VF: O 2, energy source ↓ )

7. 대한심폐소생협회 Shock First vs. CPR First – 2005 AHA  Witnessed arrest AED / Defibrillator as soon as possible  Not witnessed arrest Pre-shock CPR (5 cycles, 2min) (Class IIb) EMS response interval > 4-5 min: consider pre-shock CPR  Insufficient evidence in-hospital cardiac arrest

8. 대한심폐소생협회 Who Design (witnessed VF) Intervention Survival (shock, CPR) CI Baker PW et al. (2008 Circulation) RCT Pre-shock CPR (3 min) 17.1 vs. 10.3%0.56 (0.25-1.25) Jacobs IG et al. (2005 Emerg Med Australas) RCT Pre-shock CPR (1.5 min) 5.1 vs. 4.2% 0.81 (0.25-2.64) Hayakawa M et al. (2009 Am J Emerg Med) Retrospective before/after Pre-shock CPR until permission 30 day CPC 1-2 14 vs. 28% P = 0.048 Shock First vs. CPR First There is insufficient evidence to recommend pre-shock CPR

9. 대한심폐소생협회 Shock First vs. CPR First – 2010 AHA  Not witnessed arrest CPR should be performed while checking the ECG & preparing for defibrillation (class I, LOE B)  In-hospital cardiac arrest Insufficient evidence, Defibrillation should be < 3min Team concept, simultaneous approach (Pre-shock CPR + preparing for defibrillation)

10. 대한심폐소생협회 1-Shock vs. 3-Shock – 2005 AHA  VF/pulseless ventricular tachycardia (VT) 1 shock and immediately CPR (Class IIa) Do not check the rhythm or pulse after shock (Class IIb) Check the rhythm after 5 cycles of CPR  First-shock efficacy & energy level Biphasic > monophasic defibrillator Monophasic 360J defibrillation (expert consensus)

11. 대한심폐소생협회 1-Shock vs. 3-Shock – change effect Rea TD et al. Circulation 2006;114:2760-5 C:V ratio = 15:2

12. 대한심폐소생협회 Defibrillation success vs. Hands-off time Eftesol T et al. Circulation 2002;105:2270-3  Observation: 868 shocks in 156 prehospital VF patients

13. 대한심폐소생협회 1-Shock vs. 3-Shock – 2010 AHA  VF/pulseless ventricular tachycardia (VT) 1 shock and immediately CPR (Class IIa, LOE B) Do not after-shock rhythm check (Class I, LOE B) Minimize hands-off time before shock (Class IIa, LOE C) Immediate shock without rescue breathing (Class IIa, LOE B)  First-shock efficacy & energy level Biphasic > monophasic defibrillator Monophasic 360J defibrillation (expert consensus)

14. 대한심폐소생협회 Defibrillation Waveforms  Defibrillation Delivery of current through the chest to depolarize myocardial cells and eliminate VF (300 – 500 millisec.) Lowest effective energy needed to terminate VF Shock success: termination of VF for at least 5 sec.  Monophasic waveform defibrillators Deliver current of one polarity  Biphasic waveform defibrillators Almost all AEDs and manual defibrillators today

15. 대한심폐소생협회 Types of waveforms amp 20 40 -10 0 48 12 msec Peak currents A

16. 대한심폐소생협회 Monophasic vs. Biphasic defibrillator Schneider T et al. Circulation 2000;102:1780-7  RCT: 150J biphasic AED vs. 200-360J monophasic AED

17. 대한심폐소생협회  Lower-energy biphasic waveform shocks (≤ 200 J) Equivalent or higher shock success (1 st success rate > 90%) RCTs: short-term outcome ↑, no survival change No specific energy recommendation  Multiphasic waveforms defibrillator Triphasic, quadriphasic waveform vs. biphasic waveform Lack of human study Monophasic vs. Biphasic defibrillator

18. 대한심폐소생협회  Safe & efficient biphasic defibrillation Biphasic defibrillator > monophasic defibrillator 부재 시 Monophasic defibrillator 사용 가능 (Class IIb, LOE B) Manufacturer’s recommended energy dose (Class I, LOE B) 모를 때 defibrillation at maximal dose (Class IIb, LOE C)  Pediatric biphasic defibrillation Initial 2 J/kg (success rate 48%), 2 - 4 J/kg (Class IIa, LOE C) 2 J/kg, 4 J/kg, consider < 10 J/kg or adult maximum dose (Class IIb, LOE C) Biphasic defibrillation – AHA 2010

19. 대한심폐소생협회 Fixed and Escalating Energy  Commercially available biphasic AEDs either fixed or escalating energy levels  Optimal energy level : unknown  Definitive recommendation : not possible  Selected First shock Manufacturer’s recommendation: 120 J to 200 J  Subsequent shock At least equivalent or higher (Class IIb, LOE C)

20. 대한심폐소생협회 Current-based Defibrillation  Defibrillation Delivery of current to the heart Energy based defibrillation: variable current due to thoracic impedance Current based defibrillation: encouraged Optimal current for defibrillation: under investigation (30-40 A) Lerman BB et al. J Am Coll Cardiol 1988;12:1259-64

21. 대한심폐소생협회 Electrode Placement  4 pad positions: reasonable for defibrillation (Class IIa, LOE B)  Apex-anterior: default placement (Class IIa, LOE C)  Lateral pad: under the breast Anterior - both infrascapular

22. 대한심폐소생협회 Electrode Placement  Implantable ICD / Pacemaker Avoid placing the pad over the device (Class IIb, LOE C)  Transdermal medication patch Do not place pads directly Remove patches and wipe (Class IIb, LOE C)  Water Wipe chest before attaching pads (Class IIb, LOE C)  Victim on snow or ice AEDs can be used (Class IIb, LOE C)  Very hairy chest Remove some hair

23. 대한심폐소생협회 Electrode size & Transthoracic Impedance  Transthoracic impedance Adult : 70 – 80 ohm Use conductive materials to reduce impedance : gel pads, electrode paste with paddles, self-adhesive pads  Adult : 8 – 12 cm in diameter (Class IIa, LOE C)  Small electrode (4.3cm) Harmful, myocardial necrosis  Use the largest pads without overlap.

24. 대한심폐소생협회 AED (Automated External Defibrillator)  PAD (public access defibrillation) Programs Since 1995, AHA recommended Early CPR & shock delivery by AEDs & trained lay rescuers AHA Recommendations Organizing, planning Training of anticipated rescuers / frequent retraining/practice Link with the local EMS system Process of continuous quality improvement

25. 대한심폐소생협회  Successful PAD Programs Survival of OHCA ↑ Time from collapse to delivery of 1 st shock (< 3~5min) Airports, Casinos 1 st responder programs with police officers Targeted public area (recreation center, shopping mall, office building, community center etc.) General public area AED (Automated External Defibrillator)

26. 대한심폐소생협회 Nationwide dissemination of AEDs AEDs 9,906 AEDs 88,265 Kitamura T et al. N Eng J Med 2010;362:994-1004

27. 대한심폐소생협회 Community-based PAD programs Folke F et al. Circulation 2009;120:510-7  Reasonable AED location At least 1 OHCA every 2 yrs (Europe) or 5 yrs (USA) At least 1 predicted OHCA during the study period (>250 adults over 50 yrs, present for >16 hrs/day) every 100m 2

28. 대한심폐소생협회  CPR & AED use by first responders (Class I, LOE B)  Public location where SCA is likely to occur (Class I, LOE B) Airports, casinos, sports facilities  Plan to reduce time from collapse to shock (Class IIa, LOE B) Establish response plan, train & retrain likely responders, Maintain equipments, coordinate local EMS systems  Continuous Quality Improvement (Class IIa, LOE C) Performance of the emergency response plan Responder performance, Patients outcome AED function, Battery and Electrode pad status  Home AED: no survival benefit (only one study) PAD programs – 2010 AHA

29. 대한심폐소생협회 Automated Rhythm Analysis  Microprocessors : Frequency, Amplitude, Slope or Wave morphology Integration (Shock: VF, monomorphic VT, polymorphic VT)  Other check loose electrodes, poor electrode contact, spontaneous movement of the patient, quality of CPR

30. 대한심폐소생협회 AED Use in Children  Ventricular fibrillation in children Less common than adults (5 – 15 %)  AED Use in children Biphasic AED > Monophasic AED 2 - 4 J/kg (Class IIa, LOE C), initial 2 J/kg for easy teaching 4 J/kg or higher (<10 J/kg) for subsequent attempts (Class IIb, LOE C) 1 - 8 yrs: pediatric dose attenuation (Class IIa, LOE C) (Use standard AED if not have this system) pediatric AED > standard AED (Class IIb, LOE C)

31. 대한심폐소생협회 In-Hospital Use of AEDs  No randomized trials, limited evidence  In-hospital use of AED (Class IIb, LOE C) Goal : early defibrillation ≤ 3 min. from collapse In areas where staff have no rhythm recognition skills or defibrillators are used infrequently  Training & monitoring First-responding personnel Collapse-to-shock intervals and resuscitation outcomes

32. 대한심폐소생협회 Fibrillation Waveform Analysis  Aims To predict success of defibrillation by analyzing VF waveform  The value of VF wave form analysis Uncertain to guide defibrillation management (Class IIb, LOE C)  “defibrillate” asystole is beneficial ? Not useful to shock asystole (Class III, LOE B)

33. 대한심폐소생협회 Fire Hazard  Several case reports By sparks from poorly applied defibrillator paddles O 2 -enriched atmosphere (disconnected ventilator) Avoid defibrillation in an O 2 -enriched atmosphere (Class IIb, LOE C)  Self-adhesive defibrillation pads with good contact To minimize the risk of sparks during defibrillation  Use gel pad for manual paddles Risk for sparks with the pastes and gels (Class IIb, LOE C)

34. 대한심폐소생협회 Synchronized Cardioversion  Shock delivery timed with the QRS complex  Indication SVT - reentry, atrial fibrillation / flutter / tachycardia Monomorphic VT  Not effective : Automatic focus Junctional tachycardia, multifocal atrial tachycaria  Not used : only defibrillation VF, pulseless VT, polymorphic (irregular) VT

35. 대한심폐소생협회 Synchronized cardioversion - SVT  Biphasic energy dose, adult (Class IIa, LOE A) Atrial fibrillation: 120 to 200 J (increase stepwise fashion) Atrial flutter & other SVT: 50 to 100 J (increase stepwise fashion)  Monophasic energy dose, adult (Class IIa, LOE B) Atrial fibrillation : begin 200 J (increase stepwise fashion)  Cardioversion of SVT in children (Class IIb, LOE C) Initial 0.5–1 J/kg, up to 2 J/kg (increase stepwise fashion)

36. 대한심폐소생협회  Adult monomorphic VT (Class IIb, LOE C) Monophasic or biphasic 100 J (increase stepwise fashion)  Child monophasic VT (Class I, LOE C) Initial 0.5–1 J/kg, up to 2 J/kg (increase stepwise fashion)  Any doubt: monomorphic or polymorphic VT Do not shock delivery, perform unsynchronized defibrillation Synchronized cardioversion - VT

37. 대한심폐소생협회 Pacing – 2010 AHA  Not recommended for asystole (Class III, LOE B)  Symptomatic bradycardia Prepare TCP (Transcutaneous pacing) Not respond to atropine (Class IIa, LOE B) Immediate pacing Severely symptomatic bradycardia (Class IIb, LOE C) Transvenous pacing Not respond to drugs or TCP (Class IIa, LOE C)

38. 대한심폐소생협회 Maintaining Devices  Maintain devices in a state of readiness (Class I, LOE C)  User checklists To reduce equipment malfunction To reduce operator errors To properly maintain defibrillator or power supply

39. 대한심폐소생협회 Summary – 2010 AHA  The recommendations for electrical therapies to improve survival from SCA / life-threatening arrhythmias  Whenever defibrillation is attempted High-quality CPR to minimize interruptions in chest compressions Immediate resumption of chest compressions after shock delivery  Single shock + immediate CPR for VF  Use of biphasic waveforms Further data is needed to refine recommendations for energy levels