Resuscitation

What is the rate of compressions to rescue breaths for CPR?

30:2

Which can EMRs and EMTs operate?

AED

Advantages of AEDs

AEDs offer several advantages over manual defibrillation: Simplified training: Because AEDs are easier to operate, both initial training and continuing education are much simpler than with manual defibrillation. Speed of operation: AED operators regularly deliver a first shock faster than operators of manual defibrillators. Often, it is given within 1 minute of applying the AED. Safer, more effective delivery: The AED uses adhesive pads instead of paddles that must be held against the patient's chest. This "hands-free" approach is safer for EMS providers in regards to the risk of electrical shock. The adhesive pads are also more effective at delivering the shock to the patient since they cover a larger surface area than manual paddles do. More efficient monitoring: The large AED pads make better contact with the patient's body, even when the patient is sweaty. As a result, the sensors can detect the heart rhythms better, which reduces the chances of false or misleading readings.

AED do?

AOTA

What is a common cause of cardiac arrest?

AOTA

What may interfere with an AED's analysis of a patient's heart rhythm?

AOTA

Advanced Life Support

Advanced life support involves the administration of medications or other advanced therapies. Such treatments are generally outside of the EMR and EMT scopes of practice. This type of care is usually delivered by paramedics who can provide advanced life support (ALS). Advanced life support should be given as soon as possible, ideally within 8 minutes of the onset of cardiac arrest. Therefore, ALS providers should be called to the scene at once or EMTs should provide prompt transportation to the hospital emergency department. In some cases, EMTs may even request an intercept, begin transporting the patient, and meet the ALS team at a point en route to the hospital.

Using an AED

An AED is a sensitive instrument, and some items may interfere with the heart rhythm analysis. Patient movement is the most common cause of interference. Make sure that no one is touching the patient when the AED is in use. If the patient is in an ambulance, the vehicle must be stopped and the motor turned off before using the AED. Some radio transmissions and personal electronic devices may also cause interference. Besides interference, there are safety issues to consider when using an AED. To avoid injury when delivering shocks: Make sure everyone is clear from the patient. Do not let the patient or machine contact water or metal components.

Devices to Assist Circulation (continued)

An impedance threshold device does not provide mechanical compressions, but it does assist circulation in a different way. It uses a valve to limit the amount of air that will enter the chest and lungs during chest recoil, which draws more blood toward the heart. The device is placed between the cuffed endotracheal tube of an intubated patient and the airway adjunct being used to provide artificial ventilation. It may also be considered for use by the EMT in a non-intubated patient, but it is imperative to constantly maintain a tight mask seal in this case. NOTE: The routine use of an ITD (impedance threshold device) is not recommended during conventional CPR.

What abnormal heart rhythm is characterized by no pulse and is known as "flatline?"

Asystole

Mistakes in Performing CPR

Avoid these common mistakes when performing CPR: Chest Compression Mistakes Bending elbows. Not aligning shoulders directly above the patient's sternum. Giving compressions that are too shallow. Touching the patient's chest with your fingers instead of extending them. Pivoting at the knees instead of the hips. Providing compressions too slowly. Moving your hands from the compression site between compressions. Not allowing the chest to completely recoil between compressions. Interrupting compressions for greater than 10 seconds Leaning on the chest between compressions Ventilation Mistakes----------- Not maintaining adequate head tilt. Not providing an adequate seal for artificial ventilation. Failing to watch and listen for exhalation. Giving breaths too rapidly or too forcefully. Providing excessive ventilation

What is a common problem with AEDs?

Battery problem

Skill for Automatic External Defibrillation

Below is an example of providing emergency medical care for applying an AED. Be sure to follow all local protocols related to this skill.Show Image 1 Gather equipment. You will need:Show Image 2 Gloves and other personal protective equipment (PPE) as needed Airway adjuncts and suction unit, if needed Pocket mask AED AED adhesive pads Take appropriate infection control precautions. Confirm that the patient is apneic and pulseless. Have your partner initiate CPR while you prepare the AED.Show Image 3 Apply the adhesive pads firmly to the patient's chest. Typically, the pads include a diagram to show the correct location for their placement.Show Image 4 Turn on the AED. Direct your partner to stop CPR and make sure everyone is clear of the patient. Initiate the analysis of the heart rhythm. If needed, resume CPR. EMT personnel should transport the patient as soon as possible and perform ongoing assessment. They may also request ALS intercept, if needed.

What is cardiopulmonary resuscitation?

Bringing the heart and lungs "back to life"

What should be done if a patient has been down longer than 5 minutes and CPR has not yet been performed?

CPR 5 cycles

Early CPR

CPR is short for cardiopulmonary resuscitation. Breaking down these words helps to describe the procedure: Cardio means heart. Pulmonary means lungs. Resuscitation means to restore to life. Therefore, cardiopulmonary resuscitation is bringing the heart and lungs "back to life." Immediate, uninterrupted CPR may double or triple a patient's chance of survival from cardiac arrest. Therefore, it is important to get trained CPR providers to the scene as quickly as possible, ideally within 2 minutes. Many people can be trained in CPR, including family members, general citizens, and emergency medical and other health care providers. Having a greater number of lay CPR providers is helpful in improving response time.

Pulse

CPR should be used only when the patient shows no signs of circulation. If the patient has a pulse, even a weak or irregular one, do NOT begin chest compressions. It is important to note that the requirements of CPR differ for EMS professionals and lay providers. Lay rescuers are taught to look for visible signs of circulation, but they are not trained to check for a pulse. They may begin chest compressions if the patient appears breathless and does not otherwise respond. If you come upon a bystander performing CPR, he or she may not be able to tell you information about the patient's pulse.

Which term refers to when a person's heart stops beating?

Cardiac Arrest

Rapid Defibrillation

Defibrillation is the process by which an electrical shock is sent to the heart to restore the heart to its normal rhythm. Defibrillation does not restart the heart. Rather, it stuns the heart so that any potentially fatal rhythm is stopped. Then, if the heart has not suffered too much damage, normal rhythm and blood flow are resumed. CPR with early defibrillation is the most important factor in increasing rates of patient survival. The earlier defibrillation can be performed, the better - within 3-5 minutes of the onset of cardiac arrest is ideal. For every minute that defibrillation is delayed, survival rates decrease 7%-10%. In any case, CPR should continue to be performed until a defibrillator becomes available. You will learn more about defibrillation in future lessons.

Steps Preceding CPR

During primary assessment, an EMS professional evaluates the patient's level of consciousness (LOC), airway, breathing, and circulation--in that order. This is done in a matter of seconds. Before beginning CPR, you must first determine that the patient is: Unresponsive Apneic Pulseless All three conditions must be met in order for CPR to be provided. If that is the case, all further assessment stops until the life threat is under control.

Ethical Issues in Resuscitation

EMS professionals must be able to decide when it is appropriate to provide resuscitative care. In some cases, even if the patient has no pulse, treatment should be withheld. If the patient has a do not resuscitate (DNR) order, you must check that it is valid and follow its directive to the best of your ability. However, the written DNR order must be shown to you; do not accept only the oral instruction of a family member. If the DNR order is not present or valid, you are obligated to perform the resuscitation. Similarly, if there is a conflict between the DNR order and the wishes of a family member, it is best to proceed with treatment until the problem can be resolved. To protect against a claim of negligence, it is better for you to err on the side of providing care rather than withholding it. Unfortunately, sometimes it is just too late for resuscitation to even have a chance to work. And once you begin CPR, you must keep providing it until the patient recovers, another rescuer takes over, you are too exhausted to continue, or you receive a "no CPR" order from a physician or other authority. CPR should NOT be started in cases involving: Obvious mortal wounds Rigor mortis Obvious decomposition A line of lividity Stillbirth When dealing with family members in these difficult circumstances, it is important to always employ a high degree of professionalism. Remain calm and convey empathy and compassion in your responses.

Authority to Use AEDs

EMS providers may use AEDs only under certain conditions. They must complete the proper training, meet the requirements of state laws and regulations, and be authorized by the system's medical director. To ensure that a system is providing effective AED services, medical direction must be involved with all aspects of the AED program. In addition to initial training, medical direction is responsible for continuing education and skills maintenance for EMS professionals. Most EMRs and EMTs will not actually use an AED very often. Therefore, it is typically recommended that an AED operator refresh his or her skills every 90 days. Medical direction should continuously look for feedback for quality improvement. Every time an AED is used, the medical director or the appointed representative should review the case. Reviews may focus on written reports as well as data recorded by the AED machine. Such reviews may lead to faster ways to get cardiac arrest patients into the system, enhanced AED training, better coordination with ALS backup, and other improvements in the chain of survival.

Devices to Assist Circulation

Even when CPR is performed correctly, the blood flow from chest compressions is not as good as normal cardiac output. Some EMS agencies allow EMTs to use optional devices to assist with circulation. Emergency medical providers should follow the guidelines of their agency and scope of practice in their state. A mechanical piston device uses a gas-powered plunger to depress the patient's sternum. The patient is placed supine on a backboard. The piston device is positioned above the patient, with the plunger centered over the part of the sternum where chest compressions should be applied. The device is then attached to the backboard and set up to deliver a specific rate and depth of compressions. With a load distributing band, or vest CPR, a wide band is applied around the chest. The band constricts to put inward pressure on the chest, which in turn compresses the heart. It can be powered by pneumatics or electricity. In some models, it may be attached to the backboard, and it is lighter than the mechanical piston device. Manual chest compressions remain the standard of care for the treatment of cardiac arrest. Devices may be used as a reasonable alternative in specific settings where delivery of high quality manual compressions are challenging or dangerous for the provider. For Example: Prolonged CPR and CPR in a moving ambulance.

AED adhesive pads can be applied over heavy chest hair.

F

An AED should never be applied to an infant less than 1 year of age.

F

Defibrillation restarts the heart.

F

During post-cardiac arrest care, close coordination by the patient's health care team is not important as long as a good care plan exists.

F

The blood flow from chest compressions is as good as normal cardiac output.

False

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If the patient has a do not resuscitate (DNR) order, you must check that it is valid and follow its directive to the best of your ability. Before beginning CPR, you must first determine that the patient is unresponsive, apneic, and pulseless. Chest compressions are also needed in CPR in order to circulate blood. Effective compressions are given hard and fast, at a rate of about 100 compressions per minute. Since a patient who needs CPR is apneic, artificial ventilation is required. Some EMS agencies allow EMTs to use optional devices to assist with circulation, such as a mechanical piston device, load distributing band, or an impedance threshold device.

Recognition of Cardiac Arrest and Activation of EMS System

Lay people must immediately recognize the emergency and activate the EMS system. Public education programs, such as CPR for the layperson, can be offered to identify patients in cardiac arrest sooner. In addition, a universal telephone number such as 911, speeds access to the EMS system. This simple number reduces time delays. It is easy to remember without looking up, and it has fewer digits to dial than a traditional telephone number.

What circulation-assisting device constricts to put inward pressure on the chest, which in turn compresses the heart?

Load distributing band, or vest CPR

In which of these situations is it safe to deliver shocks with an AED?

Neither the patient nor the AED is contacting water or metal.

Types of AEDs

One type of AED is fully automated. With this type of AED, the operator determines that the patient is in cardiac arrest and attaches the machine to the patient. After the operator turns on the power, the machine takes over and does all the rest. The machine analyzes the heart rhythm and figures out if a shock is needed. If so, it charges automatically and delivers the appropriate electrical shock. The other type of AED is semi-automated. This type of AED is most common and preferred. It performs the same tasks as a fully automated AED, but the operator controls the delivery of the shock. In some cases, the operator must push a button to analyze the patient's heart rhythm. In other cases, the analysis is initiated automatically when the power is turned on. In either case, when the analysis is complete, the AED "speaks" through a computer voice synthesizer or displays a message to tell the operator if a shock is advised. If so, the operator must then push another button to deliver the shock. Some devices also show the heart rhythm on the display as it is being analyzed.

In the case of cardiac arrest, who can administer medications and other advanced therapies?

Paramedics

Know 7

Patient movement may interfere with the AED's heart rhythm analysis. Some radio transmissions and personal electronic devices may also cause interference. To avoid injury when delivering shocks, make sure everyone is clear from the patient and do not let the patient or machine contact water or metal components. For a witnessed arrest, apply the AED immediately. For a non-witnessed arrest, perform CPR for about 5 cycles of 30 compressions and 2 rescue breaths and then apply the AED. Patients with transdermal medication patches, pacemakers, or heavy chest hair require minor adjustments for the placement of the AED pads.

Post-Cardiac Arrest Care

Post-cardiac arrest care is important to increase the patient's chances of survival with good quality of life. This care starts immediately after the patient returns to spontaneous circulation (ROSC) and may extend for months. Some of the objectives of post-cardiac arrest care include: Optimize cardiopulmonary function and delivery of blood to vital organs. Prevent a reoccurring of cardiac arrest. Reduce the risk of multi-organ injury and support organ function if needed. Assess the prognosis of recovery Assist survivors with rehabilitation when required. Post-cardiac arrest care requires a multidisciplinary approach. Teams of healthcare providers should evaluate the patient's condition and create a comprehensive care plan. The plan must be prioritized and executed properly to optimize the patient's outcome, and to prevent the early stoppage of care. Because patients' conditions can vary widely, the care plans likewise will vary widely and thus requires close coordination by the patient's healthcare team.

When to Apply the AED

Recall that defibrillation follows CPR in the chain of survival. The sequence of administering CPR and defibrillation depends on whether the cardiac arrest is witnessed or not. A witnessed arrest occurs when someone sees the patient go into cardiac arrest. In the case of a witnessed arrest, if CPR is in progress or downtime is less than 4-5 minutes, apply the AED immediately. It is considered a non-witnessed arrest if the patient has been down longer than 5 minutes and CPR has not yet been performed. In this case: Perform CPR for about 5 cycles. Then apply the AED. Resume CPR immediately after delivering a shock. If it is not known how long the patient has been down, assume that it has been longer than 5 minutes. Click the following link for more information on CPR Procedures.

What is the most common cause of cardiac arrest in infants?

Respiratory shock

Airway Control and Ventilation

Since a patient who needs CPR is breathless, artificial ventilation is required. Establish and maintain a patent airway, using airway adjuncts as needed. Provide artificial ventilation with a bag-valve mask or pocket mask. Whenever possible, use supplemental oxygen. Avoid giving an excessive rate or depth of ventilation. The positive pressure produced by artificial ventilation decreases the size of the pulmonary arteries, which carry blood from the heart to the lungs. This causes less blood flow to the lungs for oxygenation and decreased cardiac output. In this case, the overall blood flow that can be generated with CPR is also reduced.

Special AED Situations

Some special situations require adjustments when using the AED. Wetness Recall that the patient and the machine must not contact water during defibrillation. If the patient is in water, do not attempt to use the AED until the patient is removed from the water. If the patient is lying on damp ground, you may use the AED, but keep as much distance as possible between the rescuers and the patient. If the patient is simply wet, dry the chest before applying the adhesive pads for the AED, including the area between the pads. Similarly, for a patient with a transdermal medication patch, remove the patch and wipe off any paste that remains so the skin is dry prior to applying the AED pads. Interference For patients with pacemakers, make sure that the adhesive pads do not touch the pacemaker. For patients with heavy chest hair, shave small areas before applying the adhesive pads, if possible. It is a good idea to carry a razor with the AED at all times for this purpose. If a razor is not available, an alternate method is to apply one set of pads, pull them off to remove some of the hair, and then apply another set.

Signs of Successful CPR

Successful CPR is not determined by whether or not the patient ultimately lives. Rather, it means that CPR skills are performed correctly. The goal of CPR is to provide critical amounts of blood to the cells in vital organs in the first few minutes after cardiac arrest and prevent them from dying. This prolongs the time a patient can survive until defibrillation and advanced cardiac life support become available. Signs of success for CPR include: Patient's chest rises and falls with each ventilation. Carotid artery pulsates each time sternum is compressed. Patient may spontaneously gasp or breathe. Pupils may react or appear to be normal. Skin color may improve or return to normal. Heartbeat may return. Arms and legs move. Swallowing is attempted.

CPR should be performed as quickly as possible following cardiac arrest.

T

Maintaining the AED

The AED is a vital piece of equipment for patient care. If it is not maintained properly, it could lead to a liability claim against you and your agency. Follow the guidelines of the manufacturer and your agency for AED maintenance. Most agencies have a checklist of items that the AED operator should complete at the beginning of each shift. The checklist ensures that the AED is working properly and you have all the supplies you need. The checklist also provides documentation of your maintenance. It is especially important to make sure the battery is charged and that there is an extra one with the device. Battery failure has been one of the most common problems with AEDs. In addition to scheduled maintenance, always treat the AED with care. Do not handle it roughly or expose it to unnecessary jarring. Also, do not expose it to wetness.

Nonshockable Heart Rhythms

The AED will detect abnormal heart rhythms for which shock is not advised. Recall that defibrillation does not restart the heart. Instead, it stuns the heart to stop the potentially fatal rhythm and then hopefully a normal rhythm will be able to return. In some cases, though, nothing can be done to re-establish the normal rhythm. Defibrillation is not appropriate for patients with pulseless electrical activity or asystole. In pulseless electrical activity (PEA), the heart has an organized rhythm, but there is no cardiac output or pulse. A number of conditions may result in this rhythm: The heart muscle may be so weak that it fails to contract. The heart muscle may simply not respond to the electrical activity. So much blood may have been lost that there is nothing left to pump. In any of these cases, the damage is too great for a normal heart rhythm to resume. Asystole is also known as "flatline." In this condition, the heart has stopped generating any electrical impulses, so it does not contract and there is no pulse. Chances of successful resuscitation are not good in this case because no electrical activity exists to resume a normal heart rhythm.

Chain of Survival

The American Heart Association created the Chain of Survival to illustrate important steps to take during cardiac arrest. The patient in arrest has the best chance of living if all the links in the chain come together. The steps are time-sensitive and should be implemented by the rescuer as quickly as possible. The five links in the Chain of Survival are: Recognition of cardiac arrest and activation of EMS system Early CPR Rapid defibrillation Advanced life support Post-cardiac arrest care

Clinical and Biological Death

The cardiovascular and respiratory systems work together to supply body tissues with oxygen and remove waste products from the body. When a patient stops breathing, respiratory arrest occurs. Cardiac arrest occurs when the heart stops beating. And when respiratory arrest and cardiac arrest both occur at the same time, clinical death results. When the heart stops beating, no blood can flow to body cells. Without a supply of oxygen, organ damage begins quickly. Brain damage begins 4 minutes after the patient suffers cardiac arrest. The damage becomes irreversible in 5-10 minutes. Biological death occurs when body cells die.

Heart Rhythms that Require Shock

The most important part of the AED is the computer chip that is programmed to analyze the heart rhythm and recommend whether or not to deliver a shock. Defibrillation is appropriate for patients with ventricular fibrillation and ventricular tachycardia. Ventricular fibrillation (VF or V-Fib) is the most common rhythm in sudden cardiac arrest. It is a chaotic, unorganized heart rhythm. The quivering motions prevent the heart muscle from contracting properly to pump blood. Without cardiac output, blood cannot circulate to sustain life and there is no pulse. Ventricular tachycardia (V-Tach) is a more organized rhythm, but it is very rapid and inefficient. As a result, the heart does not refill properly and cardiac output is severely reduced. This rhythm can easily degenerate into ventricular fibrillation. However, ventricular tachycardia is still capable of producing a pulse, and some patients may remain responsive. If so, they are not appropriate candidates for defibrillation since they have a pulse.

Under what conditions should CPR be performed?

The patient is unresponsive, not breathing, and has no pulse.

Causes of Cardiac Arrest

There are many causes of cardiac arrest. Some of the more common ones include these conditions: Heart disease Stroke Trauma Respiratory shock Drowning Electrocution Drug overdose Other medical conditions, such as allergic reactions and prolonged seizures In infants and children, respiratory shock is the most common cause of cardiac arrest.

What is a chaotic, unorganized heart rhythm called?

VF

Under what conditions can defibrillation re-establish normal heart rhythm?

Ventricular fibrillation (VF or V-Fib) and ventricular tachycardia (V-Tach)

Chest Compressions

When a patient's heart has stopped chest compressions are also needed in order to circulate blood. When you push on the chest, it increases pressure in the chest cavity. It may also squeeze the heart and simulate a contraction. The result of this action is that blood is forced out of the heart and into circulation. When the pressure is released, the heart fills with blood again. The cycle continues with each compression to keep oxygenated blood flowing to the brain and vital organs. Using good technique for chest compressions helps to increase the success of CPR. Effective compressions are given hard and fast, at a rate of 100 to 120 compressions per minute. It is also important to minimize interruptions. Complete 30 compressions before giving 2 rescue breaths, and then continue the cycle until a defibrillator becomes available, another rescuer takes over, or the patient is revived.

When does biological death occur?

When body cells die

know4

When respiratory arrest and cardiac arrest both occur at the same time, clinical death results. Common causes of cardiac arrest include heart disease, stroke, trauma, drug overdose, and other medical conditions. In infants and children, respiratory shock is the most common cause of cardiac arrest. Recognition of cardiac arrest and activation of the EMS system is the first link in the chain of survival. Lay people must recognize the emergency and immediately activate the EMS system. Early CPR is the second link in the chain of survival. Immediate, uninterrupted CPR may double or triple a patient's chance of survival from cardiac arrest. Rapid defibrillation is the third link in the chain of survival. Defibrillation with CPR is the most important factor in increasing rates of patient survival. Advanced life support (ALS) is the fourth link in the chain of survival. ALS involves the administration of medications and other advanced therapies typically beyond the scope of practice for an EMR or EMT. Post-cardiac arrest care is the fifth and final link in the chain. Post-cardiac arrest care requires a multidisciplinary approach to care that starts immediately after the patient returns to spontaneous circulation and can extend for months.

Public Access Defibrillation

With manual defibrillation, a paramedic or physician must interpret the patient's heart rhythm, decide if electric shocks are needed, and then hold paddles against the patient's chest to deliver the shock. This skill requires extensive training and can be performed only by qualified ALS providers. When every minute counts in a cardiac arrest, the patient often cannot wait for a provider with this skill to get to the scene. An automatic external defibrillator (AED) is much simpler to operate than a manual defibrillator. The AED is programmed to interpret the heart rhythm and indicate if a shock is required, just as a paramedic or physician would do. The person using the AED only has to determine that the patient has no pulse and then follow the steps to operate the device. With the advent of the AED, much broader use of defibrillation has now been made possible. AEDs can be operated by the public as well as EMS professionals, including both EMRs and EMTs. As a part of public access defibrillation (PAD), AEDs are becoming available on airplanes, in shopping malls, in office buildings, and in many other public places.

Know6

With the advent of the AED, much broader use of defibrillation has now been made possible. AEDs offer several advantages over manual defibrillation, including: simplified training; speed of operation; safer, more effective shock delivery; and more efficient monitoring. With the fully automated AED, the operator determines that the patient is in cardiac arrest and attaches the machine to the patient. After the operator turns on the power, the machine takes over and does all the rest. The semi-automated AED performs the same tasks as a fully automated AED, but the operator controls the delivery of the shock. This type of AED is most common and preferred. Defibrillation is appropriate for patients with ventricular fibrillation and ventricular tachycardia. It is NOT appropriate for patients with pulseless electrical activity or asystole. Most agencies have a checklist of items that the AED operator should complete at the beginning of each shift. The checklist ensures that the AED is working properly and you have all the supplies you need.

What describes a do not resuscitate (DNR) order?

Written

What is correct technique when performing CPR?

maintaining headtilt

What should be assumed in a non-witnessed arrest?

more than 5

When should chest compressions be given?

no pulse