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Case 2

Witnessed VF:Treated With an AEDand CPR© 2001 American Heart Association

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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

0

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

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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