1 Case 2 Witnessed VF: Treated With an AED and CPR © 2001 American Heart Association

2 Case Scenario  You’re on a flight to Hawaii  A flight attendant asks “Would a healthcare provider please come to the middle galley?”  At middle galley: 2 flight attendants are doing chest compressions and pocket-mask ventilations on a 55-year-old man  Lying to one side: an opened, partially deployed AED  What would you do next?

3 Learning Objectives Provider—in role of lone rescuer—able to describe  Management of VF collapse with AED, gloves, mask  1 st action steps: start = collapse of victim  CPR sequence: CPR, phone 911, get AED  AED sequence: AED at victim’s side to no shock indicated  2 nd rescuer arrives: how to include?  Special AED situations: how to manage Children <8 years Wet environment Implanted pacemaker/defibrillator Medication patches

4 Background: VF and Defibrillation  VF: rhythm causing “all” sudden cardiac arrest  VF: useless quivering of heart  no blood flow  VF treatment: only one therapy works  defibrillation  Defibrillation success: chances drop every minute

5 Background: Defibrillation and Time  Approximately 50% survival after 5 minutes  Survival reduced by 7% to 10% per minute (if no CPR)  Rapid defibrillation is key  CPR prolongs VF, slows deterioration Minutes: collapse to 1st shock

6 Probability of Survival Is Related to 2 Intervals: (1) Collapse to Defibrillation and (2) Collapse to CPR Collapse to start of CPR: 1, 5, 10, 15 (min) Collapse to defibrillation interval (min) Probability of survival to hospital discharge

7 Probability of Survival Is Related to 2 Intervals: (1) Collapse to Defibrillation and (2) Collapse to CPR (cont’d)  Graph displays probability of survival to hospital discharge in relation to interval to defibrillation For 4 given intervals: collapse to start of CPR (1, 5, 10, 15 min)  Example: If time to defibrillation = 10 min and time to CPR = 5 min, probability of survival = 18%  Data from King County, WA (n=1667 witnessed VF arrests) 1 Additional cases (n=205) from Tucson, AZ 2 1 Eisenberg et al. Ann Emerg Med. 1993;22: Valenzuela et al. Circulation. 1997;96:

8 Background: Know Your AED

9 ON Operation of AEDs: 4 Universal Control Steps 1. POWER ON the AED 2. ATTACH pads 3. ANALYZE rhythm 4. SHOCK (if advised)

10 Primary ABCD Survey Focus: Basic CPR and Defibrillation Check responsiveness Activate emergency response system Call for defibrillator A = Airway: open the airway B = Breathing: check breathing, provide positive-pressure ventilations C = Circulation: check circulation, give chest compressions D = Defibrillation: assess for and shock VF/pulseless VT

11 AED Treatment Algorithm ( Start ) Yes, Breathing Not Breathing Unresponsive Unresponsive—911—AED: Check if unresponsive Call 911 (or emergency response number) Get AED Identify and respond to special situations Start the ABCDs: A irway: open airway B reathing: check breathing ( look, listen, and feel) Provide 2 slow breaths (2 seconds per breath) C irculation: check for signs* If breathing is adequate: place in a recovery position If breathing is inadequate: start rescue breathing (1 breath every 5 seconds) Monitor signs of circulation* (every 30 to 60 seconds)

12 AED Treatment Algorithm (End) Start rescue breathing (1 breath every 5 seconds) Monitor signs of circulation* (every 30 to 60 seconds) Memory aid for “no shock indicated”: Check for signs of circulation * If signs of circulation* present: check breathing If inadequate breathing: start rescue breathing (1 breath every 5 seconds) If adequate breathing: place in recovery position If no signs of circulation,* analyze rhythm: repeat “shock indicated” or “no shock indicated” sequences * Note: Signs of circulation : lay rescuers check for normal breathing, coughing, or movement (typically assessed after 2 rescue breaths delivered to the unresponsive, nonbreathing victim). Perform CPR (until AED arrives and is ready to attach): Start chest compressions (100/min) Combine compressions and ventilations Ratio of 15 compressions to 2 breaths Check for signs of circulation.* If absent: Press ANALYZE Attempt to defibrillate Repeat up to 3 times Attempt D efibrillation (AED on scene): POWER ON the AED first! ATTACH AED electrode pads (stop chest compressions for pad placement) ANALYZE (“Clear!”) SHOCK (“Clear!”) up to 3 times if advised After 3 shocks or after any “no shock indicated”: Check for signs of circulation* If no signs of circulation:* perform CPR for 1 minute No CirculationYes, Circulation

13 AED Safety  With every analysis and shock: no one touches patient!  Verbal: warning to bystanders— “I’m clear” “You’re clear” “Everybody’s clear”  Visual: check “all clear”  Physical: add hand gestures  Only then press to shock

14 Special Situations  Age: victim <8 years old?  Water: victim lying in water?  Pacemaker or implanted defibrillator: treatment interference?  Transdermal medication patches: blocking pad placement?

15 What’s New in the ECC Guidelines 2000? Biphasic waveform defibrillators: great promise Different waveforms: acceptable  Most common: monophasic (DpSn) (A)  Seldom used: monophasic (TrEx)  Multiple new brands: biphasic (B and C) All are currently acceptable New waveforms: “OK” if supported by human clinical trials Fair Good Best (Walcott et al. Circulation. 1998;98: ) A= monophasic (damped sinusoidal [Edmark]) B= biphasic (quasisinusoidal [Gurvich]) C= biphasic (truncated exponential)

16 What’s New in the ECC Guidelines 2000?  Different waveforms: success at different shock energies: Escalating shock energy (200 J; 200 J-300 J; 360 J) = OK Nonescalating shock energy (200 J-200 J-200 J) = OK Key: scientific data must support equivalent effectiveness

17 What’s New in the ECC Guidelines 2000? New Class IIa Recommendations  Goal: interval from collapse to 1st shock 90% of arrests (for in-hospital and ambulatory care areas)  AEDs = key to make this possible  Conclusion: all ACLS providers should be trained in CPR and AED defibrillation