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Jan.28.2021

Automated External Defibrillator (AED) (Home Health Care) - CE

ALERT

Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.

Refer to the American Heart Association (AHA) interim guidelines for resuscitation of the patient with coronavirus disease 2019 (COVID-19) or a person under investigation (PUI) (Box 1)Box 1.undefined#ref2">2

Apply an automated external defibrillator (AED) only to a patient who is unconscious, not breathing, and pulseless.

For a child younger than 8 years old, use AED pads designed especially for children.5 If pediatric AED pads are not available, use adult AED pads.5 Do not use pediatric AED pads on an adult.

Do not delay defibrillation in the presence of an implantable cardioverter defibrillator or pacemaker. Place pads to the side of the device, not directly over it.3

OVERVIEW

Defibrillation is defined as the therapeutic use of an electrical shock. The shock briefly stuns a heart that is beating irregularly and briefly terminates all electrical activity, including ventricular fibrillation (VF) and pulseless ventricular tachycardia. If the heart is viable, its normal pacemakers may eventually resume electrical activity and a return of spontaneous rhythm.

AEDs are dependable, advanced computerized machines that use voice and visual triggers to guide health care team members in safely defibrillating VF and pulseless ventricular tachycardia.

The AED incorporates a rhythm analysis system and attaches to a patient by two adhesive pads and connecting cables. The technology of the AED is available in several different devices. Most AEDs are stand-alone boxes with very simple three-step function and verbal prompts to guide the responder. All AEDs offer automated rhythm analysis using an algorithm based on pulse rate, amplitude, and width of electrocardiogram (ECG). Upon rhythm identification, some fully automated AEDs automatically provide the electric shock after a verbal warning. Semiautomated AEDs recommend a shock, if needed, and then prompt the responder to press the shock button.

The advantage of an AED is that laypersons or health care team members trained in basic life support, who have less training than advanced cardiac life support (ACLS) team members, can defibrillate (Figure 1)Figure 1. AEDs eliminate the need for training in rhythm interpretation and make early defibrillation practical and achievable. The disadvantage of an AED is that rhythm analysis and shock administration with an AED may result in prolonged interruptions in chest compressions. It is recommended to limit interruptions in chest compressions to no longer than 10 seconds,4 except in extreme situations such as moving the patient from a dangerous environment. The AHA does not recommend continued use of an AED when a manual defibrillator is available and when health care team members’ skills are adequate for rhythm interpretation.

AEDs are used to provide early defibrillation. The goal is to defibrillate as soon as possible to provide a higher chance of survival.4 To give the patient the best chance of survival, three things must happen: (1) notification of emergency medical services (EMS), (2) initiation of cardiopulmonary resuscitation (CPR), and (3) operation of an AED. Rescuers must always start CPR immediately and obtain an AED as soon as it is available. CPR should be provided while the AED pads are applied and until the AED is ready to analyze the rhythm. If two rescuers are present, notification of EMS and initiation of CPR can happen at the same time. For witnessed adult cardiac arrest when an AED is immediately available, the AED should be used as soon as possible.

For ease of placement and education, the AHA recommends the anterolateral pad position as the default electrode placement.4 For the anterolateral placement, the front pad is placed on the upper right sternal border directly below the clavicle; the rear pad is placed lateral to the left nipple under the axilla. These three alternative pad positions may be used based on individual patient characteristics:

  • Anteroposterior: The front pad is placed on the right part of the chest below the clavicle; the rear pad is placed on the back, approximately opposite the anterior pad.
  • Anterior–left infrascapular: The front pad is placed on the right part of the chest below the clavicle; the rear pad is placed on the back, left of spine at the bottom of the scapula.
  • Anterior–right infrascapular: The front pad is placed on the right part of the chest below the clavicle; the rear pad is placed on the back, right of spine at the bottom of the scapula.

All positions are equally effective in shocking successfully, with the most common being anterolateral. However, placement of AED electrode pads on the patient’s bare chest in any of the four pad positions is reasonable for defibrillation. Hirsute males should quickly be clipped before pad placement. Alternatively, pads should be applied and removed quickly to remove hair and then a new set of pads applied before continuing the procedure. For women with pendulous breasts, lateral pads should be placed under breast tissue. The recommended pad positions may vary depending on the manufacturer.4

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • If the patient has a device in the home, instruct him or her, the family, and caregivers on how to use the device and to follow the manufacturer’s instructions.
  • Encourage the family and caregivers to attend a basic life support class to learn CPR.
  • Advise the patient, family, and caregivers to keep emergency numbers taped to the phone or consider programming them into the speed dial function on both home and cellular phones. Stress the use of 9-1-1.
  • Instruct the patient, family, and caregivers to keep a list of medications that the patient is currently taking.
  • Encourage questions and answer them as they arise.

PROCEDURE

  1. Perform hand hygiene and don gloves and appropriate PPE based on the patient’s signs and symptoms and indications for isolation precautions.
  2. Assess the patient’s unresponsiveness and call for help.
  3. Obtain permission to touch the patient, as appropriate.
  4. Assess for the absence of respirations and lack of circulation (no pulse, no respirations, no movement).
  5. Call 9-1-1 or instruct a family member or caregiver to call 9-1-1.
  6. Remove clothing from the patient’s chest and make certain that the area where the AED pads are to be placed is dry.
  7. Remove medication patches if they are in the way of pad placement and clean the medicine from the skin before applying the sticky pads.3
    Rationale: Medication patches may reduce the effectiveness of the defibrillation attempt and result in complications.
  8. If time allows, remove excess hair before pad placement.
  9. Confirm that the patient is unresponsive, not breathing, and pulseless.
  10. Open the AED and press the On button to turn on the power (Figure 2)Figure 2. Proceed with the next steps as instructed by the AED.
    Rationale: Turning on the power begins the verbal prompts to guide the rescuer through the next steps.
  11. Ensure that the patient’s chest is bare and dry. Attach the device and place the AED pads in the correct positions.
    Rationale: The patient’s skin should be dry because moisture under the pads may create a small burn on the skin or decrease the effectiveness of the shock.4
    Do not attach pads to wet skin or over a medication patch.
    If the patient has an implantable cardioverter defibrillator or pacemaker, place the pads to the side of the device, not directly over it.3
    For a female patient with pendulous breasts, place the lateral pad under breast tissue.
    For a child, adult pads may be used as long as they do not overlap. Place one pad anteriorly and one pad posteriorly.
    1. Place the first AED pad on the upper right sternal border directly below the clavicle.
    2. Place the second AED pad lateral to the left nipple with the top of the pad a few inches below the axilla (Figure 3)Figure 3.
    3. Ensure that the cables are connected to the AED.
  12. Inspect the AED pads’ adhesion to the patient’s chest. If the pads are not in good contact with the skin, remove the pads and apply a new set.
    Rationale: Poor pad-to-skin contact reduces the effectiveness of the shock, causes skin burns, or increases the chance of shocking those involved in the rescue efforts.
    Do NOT reuse pads. Always apply a new set of pads.
  13. Allow the AED to analyze the heart rhythm.
    1. Press the analysis button, if prompted.
    2. Wait for the AED to analyze the rhythm.
      Rationale: AEDs analyze most heart rhythms using lead II. If the AED pads are placed as directed, the patient’s heart rhythm is analyzed in lead II.
      Brands of AEDs differ; familiarity with the model is important.
  14. Before pressing the shock button, announce loudly to stand clear of the patient and perform a visual check to ensure that no one is in contact with the patient.
    Rationale: Not touching the patient, when directed, prevents artifact errors and prevents shock from being delivered to bystanders.
    Do NOT touch the patient after the AED prompts to stop touching the patient. Direct all people to cease touching the patient by announcing “Clear!”
  15. Immediately begin chest compressions after the shock and continue for 2 minutes.1
  16. After 2 minutes of CPR, listen for the AED prompt not to touch the patient.
    Rationale: At this point the AED will resume analysis of the patient’s rhythm.
  17. If prompted to shock again, repeat steps to allow the AED to analyze the rhythm; announce loudly to stand clear of the patient and perform a visual check to ensure that no one is in contact with the patient before pressing the shock button.
  18. Continue 2-minute cycles of CPR and listen for AED prompts until the patient regains a pulse or the EMS team arrives.1
  19. If the patient regains a pulse, obtain vital signs and assess his or her level of consciousness.
    Rationale: Assessment of vital signs and level of consciousness determines the patient’s response to the procedure.
  20. Wait for EMS to transport the patient to an acute care facility.
  21. Ensure that the AED is cleaned and the electrodes and pads are replaced.
    Rationale: Cleaning and maintaining the AED ensure that it is ready for emergency use when needed.
  22. Discard or store supplies, remove PPE, and perform hand hygiene.
  23. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

  • Cardiac rhythm converts to stable rhythm.
  • Pulse and respirations are reestablished.

UNEXPECTED OUTCOMES

  • Cardiac rhythm does not convert to a stable rhythm.
  • Skin burns occur under AED pads.
  • Health care team member receives a shock during defibrillation.

DOCUMENTATION

  • Exact location of patient
  • Time of onset of arrest
  • Event initiating the arrest, if known
  • Times and number of AED shocks
  • Use of CPR
  • Patient’s response to AED shocks
  • Education
  • Unexpected outcomes and related interventions

REFERENCES

  1. Beesems, S.G. and others. (2016). Minimizing pre- and post-shock pauses during the use of an automatic external defibrillator by two different voice prompt protocols. A randomized controlled trial of a bundle of measures. Resuscitation, 106, 1-6. doi:10.1016/j.resuscitation.2016.06.009 (Level II)
  2. Edelson, D.P. and others. (2020). Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association. Circulation, 141(25), e933-e943. doi:10.1161/CIRCULATIONAHA.120.047463. Retrieved December 29, 2020, from https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.047463 (Level VII)
  3. National Institutes of Health (NIH), National Heart, Lung, and Blood Institute. (n.d.). Defibrillators. Retrieved December 29, 2020, from https://www.nhlbi.nih.gov/health/health-topics/topics/aed (Level VII)
  4. Panchal, A.R. and others. (2020). Part 3: Adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 142(16 Suppl. 2), S366-S468. doi:10.1161/CIR.0000000000000916 Retrieved December 29, 2020, from https://www.ahajournals.org/doi/10.1161/CIR.0000000000000916 (Level VII)
  5. Topjian, A.A. and others. (2020). Part 4: Pediatric basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 142(16 Suppl. 2), S469-S523. doi:10.1161/CIR.0000000000000901 Retrieved December 29, 2020, from https://www.ahajournals.org/doi/10.1161/CIR.0000000000000901 (Level VII)

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports

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