AUTOMATED EXTERNAL DEFIBRILLATION (E-AED) PROVIDER COURSE

Participants Handbook

Version 2011/6.0 Nursing Service / 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 edited by:

Ms Wee Fong Chi Senior Nurse Educator, Nursing Service Dr Kenneth Heng Senior Consultant, Emergency Department April 2011

Previous version edited by:

Ms Wee Fong Chi Senior Nurse Educator, Nursing Service Dr Kenneth Heng Senior Consultant, Emergency Department Feb 2009, Nov 2008 Ms Prema Balan Senior Nurse Educator, Nursing Service Dr Tham Kum Ying Senior Consultant Emergency Department March 2006, May 2007

Original version Produced by: Edited by:

Ms Prema Balan Senior Nurse Educator, Nursing Service 1 May 2004 Dr Tham Kum Ying Senior Consultant, Emergency Department 13 October 2004

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COURSE STRUCTURE AND GENERAL COURSE CONTENTS

Topics Introduction Aims Expected Learning Outcomes MODULE 1 Unit 1 OVERVIEW OF CARDIAC ARREST Introduction to Cardiac Arrest Epidemiology of Cardiac Arrest Review of Chain of Survival Importance of Early Defibrillation EMERGENCY CARE WITH AN AUTOMATED EXTERNAL DEFIBRILLATOR (AED) Defibrillation Theory The Electrical and Conduction System of the Heart Cardiac Dysrhythmias CPR and Defibrillation Principles and Components of an AED Overview of AED Advantages of AED Indications for AED Use Contraindications to AED Use Safety Considerations Patient Preparation Defibrillation Pads and Placement Following the AED Voice Prompts Resuscitation Sequence Using the Heartstart XL M4735A AED Approach the victim-patient Basic Life Support AED Rhythm Analysis Defibrillation Interfacing with CPR Refractory VF/VT Handing over to the Physician End of Resuscitation DEFIBRILLATION PROTOCOL Medical Legal Aspects Overview of AED Resuscitation Protocol Roles and Responsibilities of the Rescuer Documentation OPERATION PROCEDURES OF AED AED Essentials (Demonstration and Practice) Description of AED Settings of AED Charging Procedures of AED Troubleshooting Care and Maintenance ASSESSMENT AND PRACTICE OF AED SKILLS Theory Assessment Written Test Practical Skills Assessment Demonstration of Operation and Controls of AED Practical Training of Case Scenarios Practical Skills Assessment Reference Page 3

MODULE 2 Unit 1

Unit 2

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Unit 3

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MODULE 3 Unit 1

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MODULE 4 Unit 1

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MODULE 5 Unit 1 Unit 2

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INTRODUCTION Studies showed 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 few resuscitation attempts are successful. 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).

AIMS A cardiopulmonary arrest is perhaps the gravest of all medical and surgical emergencies. It is anticipated that this program will enable the participant to: 1. Fulfill a specific, effective and organized role as a member of the life support team by understanding the fundamentals of early defibrillation. 2. Be equipped with the correct skills to perform automated external defibrillation in the management of a victim with cardiac arrest.

EXPECTED LEARNING OUTCOMES Upon completion of the program, the participant will be able to: 1. Identify the major heart rhythms and discuss when defibrillation is appropriate. 2. Describe the basic steps of emergency care with an automated external defibrillator (AED). 3. Demonstrate the correct application and operation of the automated external defibrillator (AED). 4. Demonstrate the correct steps in performing defibrillation including the safety precautions using an automated external defibrillator (AED) for an adult patient in cardiac arrest.

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MODULE 1: OVERVIEW OF CARDIAC ARREST Expected Learning Outcomes The participant will be able to: 1. Explain the 4 key links in the chain of survival for a cardiac arrest victim. 2. State the rationale for early defibrillation. 3. State the function of defibrillation in saving cardiac arrest patients. 1. Epidemiology of Cardiac Arrest As Singapore becomes more affluent, the disease patterns of our population resemble those 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 reached the hospital and were admitted, a proportion of them will sustain a cardiac arrest during hospitalization. Definition of Cardiac Arrest Sudden cardiac arrest occurs when the heart stops pumping suddenly - the patient loses consciousness immediately and stops breathing. In a significant number of cardiac arrests, there is a disturbance in the electrical rhythm of the heart known as ventricular fibrillation (VF). Unless a normal rhythm is restored, death will follow within a few minutes. Causes of Cardiac Arrest Common causes Acute myocardial infarction (AMI), also known as heart attack Other 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 2. Review of Chain of Survival The actions taken during the first few minutes following a cardiac arrest are critical. There are four basic life support actions: 1. early access 2. early cardiopulmonary resuscitation (CPR) 3. early defibrillation and 4. early advanced care

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Early Access Within the hospital, early access refers to Prompt recognition that the patient has sustained a cardiac arrest Calling for help (staff and doctors), alerting code blue Fetching the resuscitation trolley and AED. In the community, early access refers to Prompt recognition that the victim has sustained a cardiac arrest Calling 995 - Singapores emergency medical services hotline number
Early CPR CPR prolongs VF, preventing its deterioration to asystole and potentially protecting the victims heart and brain. The brain starts dying within four to six minutes when the heart stops pumping. CPR needs to be initiated as soon as possible to provide oxygen and blood flow to the brain and heart. CPR cannot restart the heart; it can only buy time. Early Defibrillation Defibrillation is the only definitive treatment for a patient in a cardiac arrest due to VF or pulseless ventricular tachycardia (VT). This is the first link in the chain of survival that can restart the heart in VF or pulseless VT. Defibrillation within the first minute of arrest can achieve a survival rate as high as 90%, but for every minute of delay the survival rate is reduced by 7% - 10%. Hence, the earlier defibrillation can be performed for a VF or pulseless VT victim, the higher the chances of restoration of normal rhythm and the higher the chances of survival. Early Advanced Care Advanced care consists of advanced airway management, advanced cardiac care and administration of drugs. It stabilizes the patients condition but it can only help the patient-victim if the preceding 3 links are expediently performed. Each link is closely dependent on the other in the treatment of patients with sudden cardiac arrest. Each link is also crucial in increasing the patients chance of survival. 3. Importance of Early Defibrillation VF is dangerous because it cuts off blood supply to the brain and other vital organs. VF is often treated successfully by applying an electric shock to the chest using a machine called a defibrillator - a procedure known as defibrillation. Defibrillation is the only definitive treatment for VF and pulseless VT. For every minute that a person remains in VF with no defibrillation provided, the chances of resuscitation drop by almost 10%. After 10 minutes, the chances of resuscitating a victim in cardiac arrest are near zero (Fig. 2).
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The goal of early defibrillation is to achieve the shortest possible arrest/collapse-to-shock time interval, preferably less than three minutes. The current AED defibrillator in TTSH is Philips Heartstart XL M4735A and delivers the shocks in the sequence of resuscitation for a VF victim: 1st shock CPR x 1 minute analyze rhythm 2nd shock CPR x 1 minute analyze rhythm 3rd shock CPR x 1 minute etc.

Until the machine no longer detects a shockable rhythm. Not all cardiac arrest victims-patients will survive despite the best of care; research shows that early defibrillation and CPR are the most important links in increasing the victim-patient chances of survival.

Fig. 2

Chances of restoring normal rhythm decreases rapidly when defibrillation is delayed

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MODULE 2: EMERGENCY CARE WITH AN AED UNIT 1 : Defibrillation Theory Expected Learning Outcomes The participant will be able to: 1. Identify the conduction disturbances in cardiac rhythm. 2. Identify the major heart rhythms and discuss when defibrillation is appropriate. 3. Perform BCLS in a simulated cardiac arrest situation with the use of an AED. 1. The Electrical and Conduction System of the Heart (Fig. 3) The heart has 4 chambers: 2 upper chambers known as left and right atria and 2 lower chambers known as left and right ventricles. Through the coordinated actions of the atria and ventricles, the chambers act as a pump that pump blood out into the aorta, then into the arteries and through the entire body. These chambers are stimulated by electrical impulses that travel through specialized pathways embedded in the heart, bringing about the pump action. These pathways in the heart are known as the conduction system of the heart: The electrical impulse originates in the sinoatrial (SA) node in the right atrium of the heart. This impulse travels along the pathway through the atria to a point midway between the atria and the ventricles, which is known as the atrioventricular (AV) node. Below the AV node, the pathway divides into two branches, the right and left bundle branches. The impulse reaches the Purkinje fibers that spread these impulses into the heart muscles, causing the ventricles to contract to pump blood out of the heart to the body. This system has a built-in-delay to allow for proper chamber filling, contraction, relaxation, and refilling for the next cycle.

Fig. 3 Conduction System of the Heart

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2.

Cardiac Dysrhythmias Diseased or damaged heart muscle can alter the electrical and conduction system, which may result in an abnormal heart rhythm that could interfere with circulation. Abnormal heart rhythms are known as dysrhythmias. Normal sinus rhythm (NSR) (Fig. 4a) In healthy hearts, the normal rhythm is known as sinus rhythm. It is a regular rhythm that occurs within a normal range of 60 to100 beats/minute and is without unusual variations. In a healthy person, he/she is in normal sinus rhythm, has a pulse and is not in cardiac arrest. When the AED detects NSR, it is recognized as no shockable rhythm.

Fig. 4a Normal sinus rhythm (NSR) Features: rate is between 60-100/min; one P precedes one QRS, which is followed by an upright T; QRS width is <3mm Ventricular Tachycardia (VT) (Fig. 4b) In a diseased heart, the ventricle can develop abnormally rapid contraction resulting in an abnormal, fast and regular rhythm known as ventricular tachycardia (VT). VT then suppresses the normal electrical and conduction system. In VT, the heart is unable 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 and this is known as pulseless VT. Rapid defibrillation can stop VT and is the major determinant for survival in pulseless VT victim-patient. When the AED detects VT, it is recognized as shockable rhythm.

Fig. 4b Ventricular tachycardia (VT) Features: rapid rate; no recognizable P or QRS or T but waveforms have some semblance of regularity compared to VF below Ventricular Fibrillation (VF) (Fig. 4c) In a diseased heart, the ventricle can develop a totally disorganized electrical rhythm known as ventricular fibrillation (VF). This results in a 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. Rapid defibrillation can stop VF and is the major determinant for survival in a VF victim-patient. When the AED detects VF, it is recognized as shockable rhythm. The newer generation of AED is able to detect and recognize fine VF as shockable rhythm.

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Fig. 4c Ventricular fibrillation (VF) Features: totally irregular and erratic waves in which there is no recognizable P or QRS or T Asystole (flat line, dead heart) (Fig. 4d) The heart does not have any electrical activity and has stopped pumping. The heart has no activity at all. All dysrrhythmias including VF and VT, degenerate into asystole when not treated. When the AED detects asystole, it is recognized as no shockable rhythm.

Fig. 4d Asystole 3. CPR and Defibrillation Defibrillation is the act of using an external electric current to stop all chaotic cardiac activity, thereby giving the normal pacemaker(s) e.g. SA node a chance to start the heart again. While defibrillation remains the definitive treatment for VF and pulseless VT, CPR buys time and increases the chances of successful resuscitation while waiting for the arrival of the defibrillator. 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. Hence, the earlier CPR is performed, the greater the chance of survival for the cardiac arrest victim-patient. CPR provides temporary artificial breathing and circulation. The amount of blood that CPR delivers to the brain is about 30% of cardiac output. 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.

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MODULE 2: EMERGENCY CARE WITH AN AED UNIT 2 : Principles and Components of an AED Expected Learning Outcomes The participant will be able to: 1. State the indications and contraindications for use of an AED. 2. State the safety considerations in the use of an AED. 1. Overview of Automated External Defibrillators The generic term automated external defibrillators (AED) refers to external defibrillators that incorporate a rhythm analysis and recognition system. Some devices are fully automated and some are semi-automated or shock-advisory defibrillators. A fully automated defibrillator requires the rescuer to attach the defibrillation pads and turn on the device. The AED then analyses the rhythm. If VF (or VT above a pre-set rate) is present, the AED charges its capacitors and delivers a shock. The rescuer is not involved in the defibrillation process as the AED is fully automated to deliver the shock. A semi-automated or shock-advisory defibrillator requires the rescuer to attach the defibrillation pads and turn on the device. The AED then prompts the rescuer to start the machine analysis of the rhythm. If VF (or VT above a pre-set rate) is present, the AED prompts the rescuer to charges the capacitors and delivers a shock. All AED are attached to the patient by two adhesive pads and a connecting cable. The multifunction electrode pads can be used to: 1. Record the rhythm i.e. act as ECG electrodes. 2. Pace the heart i.e. act as pacing electrodes. 3. Deliver the electric shock i.e. act as defibrillation paddles.

For hospital use, most defibrillators have manual and semi-automated modes. There are several brands of such combination machines - they are all equally effective; their differences lie in their design, userfriendliness and cost. Tan Tock Seng Hospital uses the Philips Heartstart XL M4735A defibrillator (Fig.5). In this model, the manual defibrillator has to be disabled in order for the AED cable to be connected and to work.

Fig. 5 Heartstart XL M4735A Defibrillator

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In the Heartstart XL defibrillator, the manual defibrillator has to be disabled in order for the AED cable to be connected and work. (Fig. 5.1) 1. Disable the manual defibrillator by turning clockwise.

2. Insert AED cable; a click sound is heard.

3. Align the grey colored adapter on the multifunction defib pads with the pads patient cable. Slide into position. 4. Apply multifunction defib pads; - one (sternal) to be placed to the right of the upper sternum just below the right clavicle. - one (apex) to the left of the nipple in the mid axillary line.

5. Turn on the device. It will then prompt the rescuer to press an analyze button to initiate rhythm analysis. When the AED identifies a shockable rhythm, it will charge the capacitors automatically and use a voice prompt to advise the rescuer to press the shock button to deliver the shock.

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6. The AED will allow the rescuer to activate the shock button only when the AED identifies a shockable rhythm. 7. Ensure everybody is away from patient contact before pressing the shock button.

The time interval from activating rhythm analysis to recognition of shockable rhythm to charging the capacitors to delivery of a shock averages from 10 to 15 seconds. 2. Advantages of AED The AED analyzes and identifies a shockable rhythm and it does not require a rescuer to do so. The training for AED users only involves recognition of cardiac arrest, proper attachment of the device and adherence to the memorized treatment sequence. This approach allows hands off defibrillation and hence is safer. Adhesive defibrillation pads may also offer consistently better paddle placement during a prolonged resuscitation attempt. Even with minimally-trained personnel, early defibrillation is practical and achievable. Indications for AED Use Use the AED in a cardiac arrest patient who: Is unresponsive, and Is not breathing, and Has no pulse. Contraindications to AED Use The AED should not be used if: The patient is responsive or breathing or has a pulse. The rescuer is not trained in using the Philips Heartstart XL M4735A AED (hospital protocol). The AED does not identify a shockable rhythm, the rescuer must not tamper with the shock button in an attempt to over-ride the AED.

3.

4.

Note: If the patient is a child, apply the paediatric pads. The Heartstart Pediatric Plus Pads (M3717A) which are available in the paedicatric E trolley are designed only for use with manual defibrillator and on smaller patients, weighing less than 10kg (22 pounds) or patient of 1-8 years of age. Not for use with AED or in AED mode
5. Safety Considerations Safety is very important for the patient, the AED rescuer and bystanders. Hence, AED must only be used by trained and authorized personnel who are able to maintain their knowledge and skills. It is the responsibility of the AED rescuer to Verify that the victim-patient is in cardiac arrest before using the AED.

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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 bystanders. If victim is on a - wet surface, remove the victim to a dry area - metallic surface, place blankets between the victim and the metal contact. Ensure that there is no open oxygen source directed at the victims chest e.g. patient-victims oxygen mask should be on his / her face and not on the chest. Ensure that no one comes into contact with the patient during defibrillation, the rescuer must ensure that CPR stops and no one is touching the patient as electricity can be transmitted. Life support providers must take precautions to minimize sparking during defibrillation. *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.

6.

Patient Preparation 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. Bare patients chest and remove clothing. Dry the chest if it is sweaty or wet. Care should be taken to ensure the defibrillation pads should place at least 4 fingers breadth away from an implanted pacemaker if the patient has a permanent pacemaker. Shift metal jewelry or medication patch on the chest out of the way of the defibrillation pads. Shave the chest (affected areas) if the hairs are preventing adequate contact between the pads and patients skin. When the AED arrives, attach the AED defibrillation pads. Defibrillation Pads and Placement Defibrillation pads are adhesive pads that can be attached to the AED cable and hence to the machine. Defibrillation pads are specific to the brand and model of AED. 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 (Fig. 5). 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.

7.

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Upper-right sternal border just below the right clavicle

Below the left nipple in the mid axillary line

It is important to place the pads in the appropriate positions on the chest to ensure maximum efficiency. Reversing the pads may compromise efficiency. Do not place the pads over the any of the 3-lead ECG electrodes. Place the pads 4 fingers breadth away from the electrodes. Continue CPR while apply pads to minimize interruptions to CPR.

8. Following the AED Voice Prompts After pads placement, the voice prompt says, push analyze. The rescuer stops CPR, pushes the analyze button to which the voice prompt will reply, Analyzing now, do not touch patient. All contacts with the patient including CPR must be avoided in order to obtain accurate rhythm analysis and interpretation. Depending upon the brand of AED, assessment can take from five to fifteen seconds. The AED will notify the rescuer that shock is indicated using a text message, visual display, and a voice prompt Shock advised. The AED will automatically charge itself to a pre-set energy level, which is 150J for the Heartstart XL M4735A AED. When the AED is charged and ready, the voice prompt says, Stand clear, push to shock. The rescuer looks around and shouts, All / stand clear, then presses the shock button to deliver the shock. When the shock is discharged, the voice prompt will say, Shock delivered. If the Heartstart XL M4735A AED does not detect a shockable rhythm, the voice prompt says, No shock advised. Check patient, check pulse. If needed press pause and begin CPR. When the pause button is pressed, the timer begins to count down accordingly. CPR should be started / resumed before pushing the analyze button to assess the rhythm. Repeated defibrillation with the AED can go on until the advanced care team / medical team arrive or as specified by a pre-existing resuscitation protocol.

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MODULE 2: EMERGENCY CARE WITH AN AED UNIT 3 : Resuscitation Sequence Using the Heartstart XL M4735A AED

Expected Learning Outcomes The participant will be able to: 1. 2. 3. 1. Demonstrate the assessment of a patient requiring the use of an AED. Prepare and demonstrate defibrillation including the safety precautions when using an AED during cardiac arrest. Demonstrate the approach for a single rescuer using an AED. Approach the victim-patient Survey the scene quickly to ensure that the environment is safe. Check responsiveness. If no response, call for help, activate code blue. Get resuscitation trolley and AED. Basic Life Support Open the airway with head-tilt-chin lift Check breathing. If no breathing. Check carotid pulse (do not spend more than 10 seconds doing this) If no pulse, start CPR if AED defibrillator is not yet available. Continue and do not interrupt CPR until a defibrillator arrives. If no pulse but AED defibrillator is present, attach AED to patient-victim as described below. AED Rhythm Analysis Remove the defibrillation pads from its packaging and apply them to the patients chest. Connect the defibrillation pads to the AED cable. Disable the manual defibrillator and connect the AED cable. Switch the machine to AED mode and follow the voice prompts. Stop CPR briefly for rhythm analysis to ensure accurate recognition of VF or VT. Defibrillation *Once the AED identifies a shockable rhythm i.e. VF or VT, the voice prompt will say shock advised and the AED will charge itself automatically to the pre-set energy level. Continuation of chest compressions while the defibrillator is charged, this will minimize the pre-shock pause. *Look all around and shout, stand clear to ensure that no one is touching the patient. *Push the shock button. *Start CPR for 1 minute before analyzing rhythm again. Interfacing with CPR Stop CPR after 3 cycles of 30 compressions:2 ventilations (1 minute) and push the analyze button to perform rhythm analysis again. If the AED identifies a shockable rhythm, the above defibrillation steps marked * are repeated. Ensure that no one pushes the shock button when CPR is in progress.

2.

3.

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6.

Refractory VF / VT Stop CPR after 3 cycles of 30 compressions:2 ventilations (1 minute) and push the analyze button to perform rhythm analysis again. If the AED identifies a shockable rhythm, the above defibrillation steps marked * are repeated. A single shock immediately followed by 1 minute* of uninterrupted CPR do not check for pulse, do not check for VF conversion. (*stop CPR if patient shows signs of circulation and regaining consciousness) If the rhythm converts to sinus rhythm, CPR should still be continued for 1 min to enhance cardiac output as most patient do not have adequate cardiac contraction in the immediate post-conversion phase. An exception is if the patient regains signs of life e.g., moving, struggling in that case, STOP CPR and check pulse. This pattern of 1 shock 1 min of CPR analysis is repeated until the AED voice prompt says, no shock advised i.e. the AED no longer detects a shockable rhythm. When the AED voice prompt says, no shock advised, the rescuer should check for pulse. If the rescuer is in doubt about the rhythm or about presence of pulse, start / continue with CPR and analyze rhythm again 1 minute later. Handing over to the Senior Doctor The medical team / senior doctor may arrive at any point in time during the above resuscitation sequence. Check with the senior doctor in the team whether he / she would like to continue with AED or to switch back to manual defibrillator mode. The multifunction electrode pads can be used for manual defibrillation mode. If the first doctor to arrive is a junior doctor, suggest to him/her to stay with the AED mode until the arrival of a more senior / experienced doctor. Offer your assistance accordingly. At an appropriate interval, give a verbal summary of events to the medical team / physician. End of Resuscitation At the end of the resuscitation, attach the printed rhythm strip to the clinical notes as per normal ward protocol. Push summary button and print out a summary of events. For TTSH registered nurses: Attach this summary to the In-hospital AED Resuscitation form. Complete the In-hospital AED Resuscitation form and send to Chairman, Life Support Training Committee. For doctors: Attach this summary to patients clinical notes.

7.

8.

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CPR-AED Sequence
CPR Establish unresponsiveness Tap on Shoulders Hello-hello, are You Ok? AED Connect AED cable

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

Attach AED Pads on Victim-Patient

A Airway Head-Tilt-Chin-Lift

Turn on AED

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 Check Breathing Push Analyze CPR x 1 minute

AED General Pattern

Analyze Shock CPR x 1 minute

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MODULE 3: DEFIBRILLATION PROTOCOL UNIT 1 : Medical Legal Aspects Expected Learning Outcomes The participant will be able to: 1. List the key steps in the AED resuscitation protocol. 2. List the steps to manage the medical legal risks involved in using the AED. 3. Discuss the professional behavior expected of an AED rescuer. 1. Overview of AED Resuscitation Protocol Formulated protocols should be followed; however, if none are available, the following treatment sequence is suggested: Verify cardiac arrest: assess responsiveness, call for help / activate code blue, open airway, check breathing, check pulse. Perform CPR until defibrillator arrives. Attach the multifunction AED defibrillation pads Deliver the 1st shock according to the AED instructions / voice prompts. After the 1st shock, ignore the voice prompt and perform CPR for 1 minute. After 1 minute of CPR, push analyze button. Continue this pattern of 1 shock 1 minute CPR analysis until a "no shock" indication is received or until the advanced care team / medical team arrives to take over management. Print a summary of events at the end of resuscitation for documentation and audit.

2.

Roles and Responsibilities of the Rescuer Managing Medical Legal Risks The rescuer must hold valid BCLS and AED provider certificates. The current period of validity is 2 years for each of the courses. AED recertification 2 yearly. The AED provider is trained and licensed to operate the AED only. Do not attempt to over-ride the AED instructions and do not attempt to operate the manual defibrillator. Comply with the written AED protocol. At the end of the resuscitation, print the summary, complete the In-hospital AED Resuscitation form and send both to Chairman, Life Support Training Committee for review and audit. Respond to the feedback from Chairman, Life Support Training Committee accordingly. If the AED rescuer has any doubts about his/her own competency, discuss this with an instructor / nursing officer as soon as possible.

Initial Response at Scene 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. Scene assessment and control - ensure that bystanders do not crowd around the patient. The presence of the patients relatives, friends or bystanders, the use of a defibrillator in a resuscitation situation can stress the AED rescuer and may compromise the safety of those present.
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In the hospital Ensure that medical assistance / emergency button has been activated. If two rescuers are present, assign tasks - defibrillation has priority. Fetch AED and resuscitation trolley.

Priority of Defibrillation Respond immediately when the call for assistance is sounded. Verify that patient is in cardiac arrest and set up defibrillator/AED quickly to assess for the presence of VF/VT.

Professional Conduct during Resuscitation In the hospital On arrival at the victim-patients side, firmly invite all visitors and family members out so that there is sufficient space to perform resuscitation. Be confident in what you are doing. Avoid disagreeing and arguing with your colleagues. Critical differences in opinions about treatment options should be discussed calmly and professionally during the resuscitation. If the difference in opinion concerns a minor issue, defer the discussion until the resuscitation has ended. 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 / doctor / rescuer trained in CPR and ask bystanders to stand clear of the victim. Maintain a confident presence during the situation. Regular communication with family members is essential. The AED rescuer should quickly inform them about what he/she intends to do and how he/she is doing it e.g. The machine is checking the heart rhythm, I am going to shock the victim now. Please stand clear. Maintain a calm and professional attitude at all times. Do not quarrel or fight with bystanders. If the resuscitation is not going well, bystanders may become agitated and aggressive. Respond by speaking to them calmly and firmly that interference with the resuscitation may compromise the victims chance of survival. If the resuscitation is interrupted by bystander(s), make a mental note of the time and the person(s) involved. Throughout the resuscitation, do not use derogatory terms, swear words or uncouth language that may be misconstrued. 3. Documentation It is the responsibility of the rescuer to document all incidents and information related to the use of the AED. At the end of resuscitation: For doctor: press the summary button to print the entire CPR / defibrillation event before switching off the machine. Attach this summary to the patients clinical notes. For TTSH registered nurses: press the summary button to print the entire CPR / defibrillation event, before switching off the machine. Attach this summary to the In-hospital AED Resuscitation form. Complete the Inhospital AED Resuscitation form and send to Chairman, Life Support Training Committee, Emergency Department.

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MODULE 4: OPERATION PROCEDURES OF AED UNIT 1 : AED Essentials Expected Learning Outcomes The participant will be able to: 1. List the operating problems of an AED and describe how to troubleshoot problems as they emerge. 2. Explain the reason for maintenance of AED. 1. Description of AED Most AED work on the 1-On, 2-Analyze, 3-Shock system, with the numbers labeled clearly on the relevant buttons. Once the AED defibrillation pads are placed on the patients chest, and the rescuer pushes the analyze button, the AED will analyze the cardiac rhythm. Unlike a manual defibrillator, where a trained person is required to interpret Ventricular Fibrillation or Pulseless Ventricular Tachycardia, the AED does the evaluation. When the AED detects a shockable rhythm, the AED alerts the rescuer and automatically charges to 150J energy. If no shock is required, the AED will not be able to deliver a shock. Most AED will not allow the rescuer to tamper with the shock button to over-ride the AED. The ability of the AED to perform this type of analysis, make the decision about whether to shock and its built-in safety features is one of its most appealing features. Settings of AED American Heart Association Guidelines Energy level: 360J for monophasic defibrillators. Lower energy levels required for biphasic defibrillators: 120J -200J. The Philips Heartstart XL M4735A AED uses biphasic technology and the recommended energy is 150J. AED are reliable, simple to operate, is relatively lightweight and requires little routine maintenance. With competition, most brands and models are attractively priced. Recording facilities within the AED are essential to facilitate evaluation and audit. Charging Procedures of AED Specific operation varies with AED model. Users / rescuers should be familiar with the operation steps for the AED they use. Tan Tock Seng Hospital is using the Philips Heartstart XL M4735A AED, when not in use; the defibrillator should always be maintained on charging. Troubleshooting Most AED will give prompts to the nature of the problem and directions to fix problem Stay calm and follow the voice prompts for directions. Most frequent problems are defibrillation pads-related.

2.

3.

4.

Check the following: Skin is prepared appropriately before pads placement (dry the chest and shave the chest area if necessary).
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 5.

Pads are not expired or pads may have dried out due to improper storage condition. Pads cable is well connected to the AED cable. AED cable is connected to the machine. Power supply / battery. Minimize any excessive movement Use another AED machine if the first set continues to malfunction.

Care and Maintenance Daily Checking the status indicator to ensure unit is ready for use. Refer to device operation manual for additional troubleshooting information. Refer to the hospital Bio-Mechanical Engineers for advice if necessary. Annually Confirm proper functioning of unit Checking accessory integrity Specific Organizations policy Manufacturers recommendations

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MODULE 5: ASSESSMENT AND PRACTICE OF AED SKILLS UNIT 1 : Theory Assessment Expected Learning Outcomes The participant will demonstrate ability to: 1. 2. 3. 4. 5. Apply the principles of basic cardiac life support in the theory test. Explain the relationship between cardiac arrest and VF. Describe the components of an AED. Describe the basic steps of emergency care with an AED. Discuss the role of CPR when delivering emergency care with an AED.

Pass Criteria for Written Test 1. The pass mark for the written test is 75%.

UNIT 2: Practical Skills Assessment Expected Learning Outcomes The participant will be able to: 1. 2. 3. 4. 5. 6. List the 4 steps for operating an AED. Perform the integration of an AED into basic life support. Demonstrate the care delivered after each shock. Demonstrate the care delivered after a no shock advisory. Demonstrate the approach for a single rescuer with an AED. Discuss the performance of maintenance checks on the AED

Demonstration of Operation and Control of AED Practical Training of Case Scenarios Pass Criteria for Practical Skills Assessment 1. Participants who do not observe safety precautions when performing defibrillation will FAIL defibrillation. 1.1 Safety precaution 1: shouts All / Stand Clear and ensures that every member in the resuscitation team is not in contact with the patient-manikin during defibrillation. 1.2 Safety precaution 2: confirms rhythm before defibrillating. Participants who do not pass the written test and/or practical assessment will be retested and reassessed on the same day.

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Bibliography
1. Hazinski, MF (eds) 2010. Highlights of the 2010 American Heart Association Guidelines for CPR and ECC: 1-27. 2. National Resuscitation Guidelines 2011

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