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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).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
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). 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:
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
Rationale: Medication patches may reduce the effectiveness of the defibrillation attempt and result in complications.
Rationale: Turning on the power begins the verbal prompts to guide the rescuer through the next steps.
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.
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.
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.
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!”
Rationale: At this point the AED will resume analysis of the patient’s rhythm.
Rationale: Assessment of vital signs and level of consciousness determines the patient’s response to the procedure.
Rationale: Cleaning and maintaining the AED ensure that it is ready for emergency use when needed.
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