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1
Case 2
Witnessed VF:Treated With an AEDand CPR© 2001 American Heart Association
2
Case ScenarioCase 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?
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Learning ObjectivesLearning Objectives
Provider—in role of lone rescuer—able to describe Management of VF collapse with AED, gloves, mask 1st action steps: start = collapse of victim CPR sequence: CPR, phone 911, get AED AED sequence: AED at victim’s side to no shock indicated 2nd rescuer arrives: how to include? Special AED situations: how to manage
• Children <8 years• Wet environment• Implanted pacemaker/defibrillator• Medication patches
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Background: VF and Defibrillation
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
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Background: Defibrillation and Time
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
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20
40
60
80
100
1 3 6 10
Survival
Minutes: collapse to 1st shock
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Probability of Survival Is Related to 2 Intervals: (1) Collapse to Defibrillation and (2) Collapse to CPR
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
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Probability of Survival Is Related to 2 Intervals: (1) Collapse to Defibrillation and (2) Collapse to CPR (cont’d)
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, AZ2
1Eisenberg et al. Ann Emerg Med. 1993;22:1652-1658.2Valenzuela et al. Circulation. 1997;96:3308-3313.
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Background: Know Your AED Background: Know Your AED
1122
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ON
Operation of AEDs: 4 Universal Control Steps
Operation of AEDs: 4 Universal Control Steps
1. POWER ON the AED
2. ATTACH pads
3. ANALYZE rhythm
4. SHOCK (if advised)
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Primary ABCD Survey Primary ABCD Survey
Focus: Basic CPR and Defibrillation• Check responsiveness• Activate emergency response system• Call for defibrillator
A = Airway: open the airwayB = Breathing: check breathing, provide
positive-pressure ventilationsC = Circulation: check circulation, give
chest compressionsD = Defibrillation: assess for and shock
VF/pulseless VT
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AED Treatment Algorithm (Start)
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:•Airway: open airway•Breathing: check breathing
(look, listen, and feel)
• Provide 2 slow breaths(2 seconds per breath)
•Circulation: 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)
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AED Treatment Algorithm (End)
AED Treatment Algorithm (End)
• Start rescue breathing (1 breath every5 seconds)
• Monitor signs of circulation* (every 30 to 60seconds)
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 rescuerscheck for normal breathing, coughing, or movement(typically assessed after 2 rescue breaths delivered tothe 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 Defibrillation (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
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AED SafetyAED 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
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Special SituationsSpecial Situations
Age: victim <8 years old? Water: victim lying in water? Pacemaker or implanted
defibrillator: treatment interference?
Transdermal medication patches: blocking pad placement?
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What’s New in the ECC Guidelines 2000?
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 byhuman clinical trials
FairFair
GoodGood
BestBest
(Walcott et al. Circulation. 1998;98:2210-2215) A= monophasic (damped sinusoidal [Edmark])B= biphasic (quasisinusoidal [Gurvich])C= biphasic (truncated exponential)
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What’s New in the ECC Guidelines 2000?
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 supportequivalent effectiveness
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What’s New in the ECC Guidelines 2000?
What’s New in the ECC Guidelines 2000?
New Class IIa Recommendations Goal: interval from collapse to 1st shock
<3 min in >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