First Aid AUTOMATED EXTERNAL DEFIBRILLATION (E-AED) PROVIDER COURSE

Participants Handbook

Version TTSH/2011_3.0 Life Support Training Committee

Participants Name: ____________________ Department: _____________________

Copyright @ Tan Tock Seng Hospital and National University Hospital All rights reserved. No parts of this material may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, and recording or otherwise without the prior permission of Tan Tock Seng Hospital Current version updated by Current edited by Dr Kenneth Heng Senior Consultant, Emergency Department April 2011 Revised and edited by: Ms Wee Fong Chi Senior Nurse Educator, Nursing Service April 2009, 28 Feb 2009 Dr Kenneth Heng Senior Consultant, Emergency Department April 2009, 28 Feb 2009 Produced by: Edited by: Ms Wee Fong Chi Senior Nurse Educator, Nursing Service 18 Nov 2008 Dr Kenneth Heng Senior Consultant, Emergency Department 18 Nov 2008 Ms Wee Fong Chi Senior Nurse Educator, Nursing Service April 2011 Dr Kenneth Heng Senior Consultant, Emergency Department April 2011 Revised and edited by: Ms Wee Fong Chi Senior Nurse Educator, Nursing Service April 2009, 28 Feb 2009 Dr Kenneth Heng Senior Consultant, Emergency Department April 2009, 28 Feb 2009 Produced by: Edited by: Ms Wee Fong Chi Senior Nurse Educator, Nursing Service 18 Nov 2008 Dr Kenneth Heng Senior Consultant, Emergency Department 18 Nov 2008 Ms Wee Fong Chi Senior Nurse Educator, Nursing Service April 2011

Current version updated by Current edited by

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INTRODUCTION Studies show that 40-90% of sudden cardiac arrest in adults is caused by ventricular fibrillation (VF), an abnormal and chaotic heart rhythm that prevents the heart from pumping blood. The only definitive treatment for VF is defibrillation - the act of delivering an electric shock to the heart with a machine called a defibrillator. The most important factor in surviving VF is how quickly a defibrillator is used to shock the heart back into a normal rhythm. When defibrillation is performed within the first 5 minutes of VF arrest, the chances of survival exceeds 50%. However, the likelihood of successful defibrillation decreases by about 10% with each minute following cardiac arrest. After 10 minutes resuscitation attempts are usually unsuccessful. Recent technological advances in defibrillator design now make it possible for rescuers with limited training to provide defibrillation earlier following sudden cardiac arrest using an Automated External Defibrillator (AED).

EXPECTED LEARNING OUTCOMES Upon completion of the program, the participant will be able to: 1. Describe the basic steps of emergency care with a First Aid Automated External Defibrillator (AED). 2. Demonstrate the correct application and operation of the First Aid Automated External Defibrillator (AED). 3. Demonstrate the correct steps in performing defibrillation including the safety precautions using a First Aid Automated External Defibrillator (AED) for an adult patient in cardiac arrest.

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INTRODUCTION
Epidemiology of Cardiac Arrest As Singapore becomes more affluent, the disease pattern of our population resembles that of the developed nations. Heart disease is now the second commonest cause of death. Not only is there an increase in the number of persons with coronary artery disease (CAD) and acute myocardial infarction (AMI), the median age of the victims is also younger compared to the past. Among CAD and AMI victims who reach the hospital and are admitted, a proportion of them will sustain a cardiac arrest during hospitalization. Definition of Cardiac Arrest Cardiac arrest occurs when the heart stops pumping suddenly. When this happens, the casualty immediately loses consciousness and breathing stops. Causes of Cardiac Arrest Common causes Acute myocardial infarction (AMI), also known as heart attack is due to complete obstruction of blood flow in the coronary arteries. Acute coronary events i.e. severe but incomplete obstruction of blood flow in the coronary arteries Less common causes Drug overdose Suffocation Severe allergic reaction Disturbance in blood chemistry Electrocution

The most common heart rhythms associated with sudden cardiac arrest are: 1. Ventricular Fibrillation (VF) In a diseased heart, the ventricle can develop a totally disorganized electrical rhythm known as ventricular fibrillation (VF). This result in quivering of the ventricles, which is inadequate to pump blood properly and hence cannot provide adequate blood supply to the rest of the body. In this situation, the person loses his/her pulse immediately.

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VF Features: an uncoordinated, totally irregular heart rhythm resulting in no blood being pumped from the heart. If this rhythm is not treated promptly, it will lead to the following rhythm; 2. Asystole: a flat line or a dead heart.

Asystole

THE IMPORTANCE OF EARLY CPR & EARLY DEFIBRILLATION 1. The majority of people suffering from cardiac arrest have VF. VF is the most common initial rhythm in cardiac arrest. If untreated, it progress to asystole and death of the casualty. 2. Immediate or rapid defibrillation is the only effective treatment for VF. The probability of successful defibrillation decreases over time - death rate increases by 7-10% for every minute without defibrillation. 3. VF degenerates to asystole within 8-10 minutes. 4. Minimal chance of success if the casualty goes into asystole. 5. While defibrillation remains the definitive treatment for VF, CPR buys time and increases the chances of successful resuscitation while waiting for the arrival of the defibrillator. 6. By performing chest compression and providing ventilation, CPR keeps oxygenated blood flowing to the brain and heart until defibrillation or other advanced care can restore normal heart action. 7. Hence, the earlier CPR is performed, the greater the chance of survival for the cardiac arrest patient. 8. CPR provides temporary artificial breathing and circulation. 9. The amount of blood that CPR delivers to the brain is about 30% of cardiac output.

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10. While defibrillation is the only effective way to resuscitate a victim in VF, early CPR can double the victims chance of survival if it is combined with early defibrillation.

FUNCTION OF AUTOMATED EXTERNAL DEFIBRILLATION (AED) The AED is a device that delivers electrical shock to restart the pumping action of the heart. Its aim is to increase the survival rate of casualties suffering from sudden cardiac arrest caused by VF. The function of the AED is to interpret the heart rhythm and advise the operator whether or not a shock is required. A computer algorithm in the AED identifies a shockable rhythm. It will then advise the operator SHOCK or NO SHOCK through a voice prompt and text message. The AED cannot check whether the casualty has a pulse but it can detect any normal or abnormal electrical activity. A shockable rhythm is usually VF and the AED has a chance to convert the heart rhythm back to normal rhythm. A non-shockable rhythm is usually asystole and the AED will not shock the victim/patient because it will not have a chance of reviving the heart. A nonshockable rhythm may also be normal sinus rhythm after successful defibrillation.

Indications for AED Use Use the AED in a cardiac arrest victim-patient who: 1. Is unresponsive, and 2. Is not breathing, and 3. Has no pulse. Contraindications to AED Use The AED should not be used if: 1. The patient is responsive or breathing or has a pulse. Preparation 1. Verify cardiac arrest: assess responsiveness, open airway, check breathing, check pulse and start CPR accordingly. Perform quality CPR by allowing the chest to completely recoil before the next compression. Compress the chest at a rate equal to 100/minute. 2. Bare patients chest and remove clothing. 3. Dry the chest if it is sweaty or wet. 4. Care should be taken to place the defibrillation pads at least 4 fingers breadth away from an implanted pacemaker or cardioverter defibrillator (ICD). 5. Shift metal jewelry or medication patch on the chest out of the way of the defibrillation pads. 6. Shave the chest (affected areas) if the hairs are preventing adequate contact between the pads and patients skin.
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7. When the AED arrives, attach the AED defibrillation pads.

Defibrillation Pads and Placement 1. Open package containing the defibrillation pads with attached cable and connector. 2. With the patient chest prepared, carefully pull off the protective backing from the pads. 3. Place one pad in upper-right sternal border just below the clavicle. Place the other pad to the left of the nipple in the mid axillary line. With a female victim-patient, place it just below and to the left side of the breast. Do not place it over the breast. 4. Smooth the pads firmly onto the chest to ensure maximal contact and adhesion. This increases shock efficiency and reduces the possibility of burns caused by trapped pockets of air between the pads and the skin.

Upper-right sternal border just below the right clavicle

Below the left nipple in the mid axillary line

5. It is important to place the pads in the appropriate position on the chest to ensure maximum efficacy. Reversing the pads may compromise efficacy. 6. After the pad placement, follow the voice prompts. Notes: If the patient is under 25kg or 8 years old, use the Infant/Child pads cartridge. With the Infant/Child pads cartridge inserted, the Heartstart 1st Aid AED will automatically reduces the defibrillation energy from adult dose of 150 joules to 50 joules.

Safety Considerations
It is the responsibility of the AED rescuer to: 1. Verify that the patient is in cardiac arrest before using the AED.

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2. Ensure that the area around the patient is clear. The patient should, preferably, not be placed on wet or metallic surface when the AED is used because water and metal are good conductors of electricity. If there is water or metal between the patient and the rescuer/bystander, electricity can be transmitted to the rescuer/bystanders. 3. If patient is on a 1. wet surface, remove the victim to a dry area 2. metallic surface, place blankets between the victim-patient and the metal contact. 4. Ensure that no one comes into contact with the patient during defibrillation, the rescuer must ensure that all CPR stops and no one is touching the patient as electricity can be transmitted. 5. Life support providers must take precautions to minimize sparking during defibrillation. 6. The defibrillator should not be used in the presence of flammable gases, alcohol and explosive environment. Such environment is potentially unsafe and can result in accidental shocks to the rescuers or start a fire.

MEDICAL PROTOCOL The AEDs are programmed according to local medical guidelines on defibrillation. 1. Verify cardiac arrest no response, no breathing and pulse. 2. Commence CPR (30 compressions:2 ventilations) while awaiting AED. 3. Prepare chest area for placement of defibrillation pad. 4. Continue CPR until AED is attached to casualty. 5. If the AED detects a shockable rhythm, it will charge up according to the pre-set energy level. 6. CPR advised for 1 minute: Following every shock or If defibrillator detects a non-shockable rhythm and the casualty has no pulse. If the defibrillator detects a non-shockable rhythm.

7. Check pulse

Successful Defibrillation 1. If pulse is present after a shock and I minute of CPR, maintain an open airway by placing the patient in the recovery position. Do not disconnect the AED but continue to monitor the patient every 5 minutes until handed over to medical personnel. Unsuccessful Defibrillation 1. It is important to note that defibrillation may not be successful in all situations, especially if the patient has arrested for some time.
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2. Check pulse if No Shock is advised. If pulse is absent, continue CPR for one minute before subsequent analysis by the AED or until the arrival of the ambulance / medical team.

When to Stop Defibrillation 1. When prompted by the AED. 2. When a doctor directs the resuscitation to cease or when ambulance arrives. 3. When the patient has been successfully resuscitated.

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CPR-AED Sequence
CPR Establish unresponsiveness Tap on Shoulders Hello-hello, are You Ok? AED Turn ON the AED and follow the voice prompts

Call for Help, Call 995 for Ambulance Activate Code Blue / Call Dr

Remove the patients clothing

A Airway Head-Tilt-Chin-Lift

Attach AED Pads on Victim-Patient

B Breathing Look, Listen, Feel

AED: Analyzing, Do not touch patient

No breathing

AED: Shock Advised

AED: No Shock Advised

C Check for Pulse

Rescuer: Stand Clear!

Check Pulse

No pulse Commence chest compressions & ventilations of 30:2 (for at least 1 minute prior to AED use)

Press shock button

Pulse Present

No Pulse

CPR x 1 minute Arrival of AED Analyze Check Breathing CPR x 1 minute

AED General Pattern

Analyze Shock CPR x 1 minute

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Using the HeartStart Defibrillator M5067A Step 1: Verify cardiac arrest No response No breathing No pulse Call for help / activate EMS.

Start CPR (30 compressions:2 ventilations) while waiting for AED. (BCLS as per NRC 2011 guidelines)

Step 2: PULL the green handle Pull to activate the defibrillator. Remove the hard cover form the pads cartridge and set it aside. Follow the AED voice instructions. *One can also turn ON the defibrillator by pressing the green On/Off button.

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Remove all clothes from patients chest. Clean and dry skin, if needed.

Step 3: Peel off film seal and remove pads.

Peel each pad from yellow plastic liner.

Step 4 Place the pad in upper-right sternal border and lower-left ribs over the apex of the heart. Smooth the pads firmly onto the chest to ensure maximal contact and adhesion. Continue CPR while applying pads, do not interrupt CPR.

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 As soon as the AED detects that the pads are attached to the patient, it will automatically analyzes the patients rhythm. Analyzing Do not touch the patient

Wait until flashing.

the orange light stops

Step 5: PRESS the shock button If a shock is indicated: Press flashing orange shock button. Before you press the button, make sure no one is touching the patient. When you press the Shock button, the AED tells you that the shock has been delivered. Then it tells you it is safe to touch the patient, instructs you to begin CPR, and prompts you to press the flashing blue i-button for CPR. For CPR coaching

Press CPR.

flashing blue button to start

Voice coaches rescuer through CPR steps. When it is time to pause; the AED tells you to stop CPR, so that it can analyze the patients heart rhythm. If the AED identifies a shockable rhythm, it will prompt you to shock the patient. This pattern of 1 shock 1 min of CPR analysis is repeated until the AED voice prompt says, no shock advised.

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If a shock is NOT indicated: The AED tells you it is safe to touch the patient and instructs you to perform CPR if needed. If pulse and respiration are present, maintain an open airway by placing patient in the recovery position (if not contraindicated). Monitor the patient until handing over to the medical personnel.

ROLES & RESPONSIBILITES OF THE RESCUER 1. Respond immediately when call for assistance is heard. 2. Verify that the patients is in cardiac arrest. In the community If two rescuers are present, one should call 995 and fetch the AED and the other begins CPR. If you are alone and have immediate access to a telephone, call 995 and call for help to fetch the AED before beginning CPR. Non clinical areas of the hospital (TTSH) e.g., food court One rescuer begins CPR and one to fetch the AED from the security office. Activate Emergency Department for medical assistance.

3. Scene control Ensure all surrounding bystanders do not crowd around casualty. The importance of scene control cannot be stressed strongly enough. In the presence of the casualtys family members, friends or bystanders, the use of a defibrillator in a resuscitation situation can create stress to the AED operator and may compromise the safety of those present.

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If two rescuers are present, assign tasks - defibrillation takes priority.

4. Professional conduct Maintain a calm and professional attitude at all times. Do not quarrel or fight with bystanders. Throughout the resuscitation, do not use derogatory terms, swear words or uncouth language that may be misconstrued. In the community, identify yourself as a nurse / rescuer trained in CPR and ask bystander to stand clear of the patient. If the resuscitation is not going well, bystanders may become agitated and aggressive. Speak to them calmly and firmly explaining that interference with the resuscitation may compromise the patients chance of survival. If the resuscitation is interrupted by bystander(s), make a mental note of the time and the person(s) involved. 5. Give a summary of what has happened and what has been done to the emergency service; emergency physician or the paramedics.

DOCUMENTATION
1. It is the responsibility of the rescuer to document all incidents and information related to the use of the AED. 2. For TTSH personnel: Fill up the First Aid AED Resuscitation form and send to Chairman, Life Support Training Committee, Emergency Department.

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