The Automatic External Defibrillator in Cardiac Arrest

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1 Focus on CME at Memorial University of Newfoundland The Automatic External Defibrillator in Cardiac Arrest The recent release of new advanced cardiac life support guidelines have led to some changes in how physicians approach and manage superventricular and ventricular dysrhythmias. This article will examine the automatic external defibrillator and its use in the resuscitation of cardiac arrest victims. By Mike Hatcher, MD, FRCPC Presented at Internal Medicine Grand Rounds, Memorial University of Newfoundland, November The work-up and management of patients with dysrhythmias, which present either as acute Dr. Hatcher is assistant professor of medicine, Memorial University, and provincial director, ACLS education, Heart and Stroke Foundation of Newfoundland, St. John s, Newfoundland. threats to life or as less ominous problems, represents a cornerstone in the practice of emergency medicine. On a daily basis, we are challenged to manage these cases effectively and definitively. With new developments in pre-hospital care and pharmacology, we are challenged to maintain our skill sets and offer these patients care that is based on our best available evidence. The fall of 2000 saw the first international guidelines conference on cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). The conference marked the first intercontinental collabora- The Canadian Journal of CME / April

2 % Success Chances of success reduced 7% to 10% each minute Time Figure 1. Composite data illustrating relationship between probability of survival to hospital discharge (indicated as success in figure) after VF cardiac arrest and interval between collapse and defibrillation. tion and examination of all available evidence in the domain of ECC. This article will review ventricular fibrillation (VF) and cardiac arrest, as well as how the automatic external defibrillator has become a key link in the chain of survival. Ventricular Fibrillation When a patient is in cardiac arrest, or has no discernible pulse, there are only four possible reasons: VF, pulseless ventricular tachycardia (pulseless VT), pulseless electrical activity (PEA) and asystole. Of these, the two most readily treated are VF and pulseless VT. VF is a chaotic, disorganized electrical storm, which, if left untreated, will result in an unsalvageable patient. The only effective treatment for VF is immediate defibrillation. The most important predictor of outcome is the rapidity with which a patient who is in VF is defibrillated. 1 The survival from VF decreases approximately 10% for each minute that there is a delay in d/c countershock therapy (Figure 1). 2 With this in mind, the assumption of VF in an arrested patient, with a goal to early defibrillation, has become a priority. Technology has now allowed for the development of automatic external defibrillators (AEDs), and their deployment has become a focus of the American and Canadian heart and stroke associations. 116 The Canadian Journal of CME / April 2001

3 AEDs: The Evidence The first clinical use of an AED was described in 1979 by Diack and colleagues, who reported 35 successful conversions of VF to sinus rhythm. 3 Subsequent research has demonstrated the efficacy and safety of AEDs in the management of out-ofhospital cardiac arrest. 4-9 The deployment of AEDs has extended beyond professional paramedical services, and now includes what has come to be known as targeted first responders. These are individuals who may have been trained in CPR only, but whose skill set will now include the use of an AED. In the United States, which has greater experience with public access to defibrillation (PAD) programs, there is evidence that supports the deployment of an AED at sites that have one cardiac arrest per five years. This also is the case in areas where an emergency medical services (EMS) team s response time is greater than five minutes. 10 The success of training targeted first responders in AED use has been demonstrated in several cities. One such place is Chicago s O Hare airport. In this airport, AEDs have been placed in strategic locations, with targeted responders consisting of airport employees and customs and immigration officials. During a 12-month period, between June 1999 and June 2000, there were 20 AED incidences at the airport 13 of which were VF, nine of which resulted in lives saved, for a 69% survival rate. This is extremely impressive for a disease that traditionally has had less than a 5% survival rate. Figure 2. Example of a defibrillator.

4 In our own Canadian experience, the Windsor Casino conducted a five-year study, from September 1994 to September During this time period there were 23 sudden cardiac events, with a mean age of 61. Seventy-one per cent of patients who had a presenting rhythm of VF or VT were discharged from the hospital neurologically intact. Currently, there is a PAD program that officially started in November 1997, whereby the city of Windsor has one defibrillator for every 2,564 people. The city s stated goal is to have a 20% survival rate over the ensuing five years, to This is outstanding, and again highlights the success rate of these devices when deployed correctly. (This data was obtained from presentations at the Guidelines 2000 conference in San Diego in September 2000.) There are PAD trials ongoing in the United States and Canada, which, when completed, will hopefully lend more support for the widespread deployment of these devices. Most major airlines are currently installing AEDs on their aircraft and will train their staff to use such a device. We should become familiar with these devices and knowledgeable about their use. Figure 3. A paramedic uses a defibrillator on a patient. As providers of emergency medical services, we should consider the deployment of AEDs a priority. These devices truly save lives and have become a turning point in the progress of treating VF and VT. AED Training The Heart and Stroke Foundation of Canada currently offers AED training courses to the general public and health-care organizations. These devices are extremely easy to use, with voice prompts for action and two buttons (on the basic models) on the device (Figure 2). The simplest devices have an on button, which, when activated, prompts the user to attach the defibrillation pads and diagrams show the user where the pads go on the patient s chest. The device notifies the user when it is analyzing the patient s rhythm and, if a shockable rhythm is present, prompts them to: (i) stand clear of the patient; and (ii) push a flashing button or otherwise identified button to deliver shock energy. To highlight the simplicity of this training, J. W. Gundrey s group from the University of Washington s division of cardiology conducted a study, wherein sixth-grade students with no prior AED training were given the device in a simulated environment with a (Resci-Annie) mannequin. 11 Essentially, they were looking at the students response times versus paramedic response times, in terms of figuring out how to 118 The Canadian Journal of CME / April 2001

5 turn the device on and place the pads on correctly. This was a mock cardiac arrest situation, and 15 children were compared to 22 paramedics. At the end of the study, mean times for defibrillation were 90 seconds and 67 seconds for the children and paramedics, respectively (a 23-second difference). Pad placement was correct 100% of the time, and all children when prompted to stand clear of the patient by the training device did so. This shows that, with minimal training, these devices are safe and easy to use. In addition, AEDs will not arm themselves, nor discharge in the presence of a non-shockable rhythm. They will continually re-evaluate the patient should VF recur during transfer, and will prompt the user to more action should it become necessary. In summary, the volume of literature attesting to the success of AED use is vast, and as providers of emergency *After the first day of therapy, significantly more patients (p < 0.05) on Prevacid 30 mg (n = 402) compared to omeprazole 20 mg (n = 418) reported no daytime heartburn (48.7% vs. 37.6%) and nighttime heartburn (62% vs. 52%) in an 8-week randomized, double-blind study in patients with endoscopically diagnosed reflux esophagitis. 1 Consult Product Monograph for dosage recommendations. Figure 4. A paramedic uses a defibrillator on a patient. Prevacid is indicated for short-term treatment of reflux esophagitis and maintenance therapy of healed reflux esophagitis. Most common side effects ( > 3%) in short-term studies are headache and diarrhea. Doses higher than 30 mg per day should not be administered to patients with impaired hepatic function and the elderly.

6 medical services, we should consider their deployment a priority. These devices truly save lives and have become a turning point in the progress of treating VF and VT. Use of the AED As previously stated, the only definitive treatment for VF is immediate defibrillation. With this in mind, in its new guidelines the Heart and Stroke Foundation has adopted the phone-first approach in the activation of the chain of survival. For the layperson, the new CPR guidelines have removed the acquisition of the skill of pulse checking in suspected cardiac arrest patients. It has been demonstrated that the time taken to perform an accurate pulse check by a layperson, and even by that of a trained healthcare professional, may be in excess of the recommended 30 seconds. Even when performed correctly, it has been demonstrated that up to 10% to 15% of the time, trained professionals may inaccurately identify the presence of a pulse in an arrested patient. When an unconscious patient is assessed by a health-care provider, looking for a pulse could result in the withholding of CPR in a patient that is truly in cardiac arrest. The withholding of CPR and the inaccurate identification of cardiac arrest also would delay the use of an AED to help the patient survive. 12 Once an AED is available at the scene of a cardiac arrest, its use is quite simple. As demonstrated in Figures 3 and 4, the device is first removed from its case and the on button is pushed. Most devices will then prompt the user to attach the defibrillation pads in clearly diagrammed positions on the patient s bare chest. Directions come from a pre-recorded voice message within the device or from a printed liquid crystal display (LCD), depending on the type of device in use. The user will be prompted to connect the defibrillation pads to a highlighted port on the device. At this point, the AED will begin analyzing the patient s rhythm. If a shockable wave form is detected and analyzed, the user will be advised that VF, or a shock, is needed and the device will arm itself. Once the capacitors have changed, the user and any bystanders will be voice prompted to stand clear and avoid any contact with the patient s body. Following this, the user will be prompted to push a discharge button, which will deliver an unsynchronized shock to the patient in the hopes of terminating VF. These devices will not arm themselves in the presence of a non-shockable rhythm and, thus, are not capable of discharging or being discharged on a patient who is not in VF. In addition, most devices have an ongoing monitoring system, which prompts the user to go through the sequence of clearing bystanders from patient contact and arms itself again if the patient should go back into cardiac arrest. After each shock, the responder is prompted to reassess the patient and check for signs of life. The simple process of assessment, pad placement, analysis and discharge for the purposes of terminating VF is a simple and easy process to teach and to learn. It offers the only hope of survival in patients who sustain out-of-hospital cardiac arrest. As such, training people to use and deploy these devices must become a priority. Summary The use of AEDs has become a key link in the chain of survival for patients who suffer out-ofhospital cardiac arrest. The deployment of these devices to areas of mass gatherings or to areas wherein advanced life support (ALS) response 120 The Canadian Journal of CME / April 2001

7 times can be expected to be greater than five minutes has been demonstrated to save lives. As health-care providers, we should become knowledgeable about their use and be proactive regarding their deployment and availability to the general public. The corresponding skill set needed to use AEDs, as has been shown, is elementary. The hope is that patients who would have once been unsalvageable because of long pre-hospital times due to defibrillation will now have a CME fighting chance at survival from cardiac arrest. References 1. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care International Consensus on Science. Part 1: Introduction to the International Guidelines 2000 for CPR and ECC: A Consensus on Science. 2. Larsen MP, Eisenberg MS, Cummins RO, et al: Predicting survival from out-of-hospital cardiac arrest: A graphic model. Ann Emerg Med 1993; 22: Diack AW, Welborn WS, Rullman RG, et al: An automatic cardiac resuscitator for emergency treatment of cardiac arrest. Med Instrum 1979; 13: Weaver WD, Hill D, Fahrenbruch CE, et al: Use of the automatic external defibrillator in the management of out-of-hospital cardiac arrest. N Engl J Med 1988; 319(11): Auble TE, Menegazzi JJ, Paris PM: Effect of out-of-hospital defibrillation by basic life support providers on cardiac arrest mortality: a metaanalysis. Ann Emerg Med 1995; 25(5): Shuster M, Keller JL: Effect of fire department first-responder automated defibrillation. Ann Emerg Med 1993; 22(4): Hoekstra JW, Banks JR, Martin DR, et al: Effect of first-responder automated defibrillation on time to therapeutic interventions during out-ofhospital cardiac arrest. The Multicenter High Dose Epinephrine Study Group. Ann Emerg Med 1993; 22(8): Joyce SM, Davidson LW, Manning KW, et al: Outcomes of sudden cardiac arrest treated with defibrillation by emergency medical technicians (EMT-Ds) or paramedics in a two-tiered urban EMS system. Prehosp Emerg Care 1998; 2(1): White RD, Asplin BR, Bugliosi TF, et al: High discharge survival rate after out-of-hospital ventricular fibrillation with rapid defibrillation by police and paramedics. Ann Emerg Med 1996; 28: White RD, Hankins DG, Bugliosi TF: Seven years experience with early defibrillation by police and paramedics in an emergency medical services system. Resuscitation 1998; 39: Gundry JW, Comess KA, De Rook FA, et al: Comparison of naive sixthgrade children with trained professionals in the use of an automated external defibrillator. Circulation 1999; 100(16): Eberle B, Dick WF, Schneider T, et al: Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a Abbott Laboratories, Limited Saint-Laurent, Québec H4S 1Z1 Product Monograph available on request.

8 Closed head injuries Quick pulse. Resuscitation Facts 1996; 33(2): CRITERIA LOREM IPSUM DEL ATARE MAGNETIC RESONANCE IMAGING Lorem ipsum cranium del nelliat 4 units Confused ipsum solor trauma loss Norem fuguiat 1,200 µg nella solor iniat Ipsum cranium del nelliat bengal tiger Lorem fuguiat nella solor iniat 120 mg/mmol Confused ipsum solor trauma loss Acute subdural hematomas usually result from a venous hemorrhage caused by a rupture of a cortical vein. They are commonly associated with cerebral contusions, and about 50% are associated with skull fractures. 122 The Canadian Journal of CME / Month 1997

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