1. Defibrillation Contents from the  ONTARIO BASE HOSPITAL GROUP EDUCATION SUB-COMMITTEE

2. To be certified in Defib 1. Be employed by an Ontario Ambulance Service as a Paramedic 2. H ave approval of the Base Hospital Medical Director 3. Have a current BCLS basic rescuer certificate On completion of the SAED Course, the PCP will be certified to perform that controlled act under the direction of the Base Hospital Medical Director. Successful recertification must occur annually. The guidelines for certification, recertification and decertification have been developed by the Ontario Base Hospital Group (refer to the ALS standards).

3. Using the Semi-Automatic External Defibrillator (SAED) or Manual Defib and mannequin, you will be able to correctly perform the procedures for cardiac arrest including proper SAED pad placement, rapid defibrillation, trouble shooting and maintenance procedures. Emphasis will be placed on safe operation of the SAED while following approved protocols. The protocols will cover management of:  VSA patients with shockable rhythms e.g ?  VSA patients with non-shockable rhythms e.g?  Treatment of cardiac arrest associated with hypothermia  Treatment of cardiac arrest associated with blunt/pen trauma  Treatment of cardiac arrest associated with airway obstruction

4. Also critical in this module Safety Airway management Ventilation and 1 and 2 person CPR Reporting procedures for cardiac arrest Cardiac physiology and anatomy ECG monitoring and post arrest care

5. Defibrillation: You will be able to discuss types of cardiac arrest and their initial management defibrillation and the indications for use of the SAED possible outcomes of defibrillation safeguards necessary to ensure operator and patient safety when using the device

6. A paramedic is….. “A person employed by, or a volunteer in, an ambulance service who meets the qualifications as a paramedic as set out in the regulations, and who is authorized to perform one or more controlled medical acts under the authority of a Base Hospital Medical Director, but does not include a physician, nurse or other health care provider who attends on a call.”[1] The SAED/MDefib provider can only perform controlled acts under standing orders from a Base Hospital or as directed by Base Hospital Physician [1][1] Ambulance Act, Revised Statutes of Ontario, 1990, Chapter A. 19, August 16, 2002

7. Needed for a SAED program in Ontario  Base Hospital  Base Hospital Physician  Certified Ambulance Service  C entral Ambulance Communications Centre (CACC) Quality assurance program

8. MEDICAL / LEGAL CONSIDERATIONS Guidelines for protection against "negligence" when functioning as a Primary Care Paramedic include: 1.performing to one’s level of training within the Paramedic’s scope of practice outlined by the Base Hospital 2. complying with protocols 3. documenting accurately 4. checking equipment 5. reporting problems

9. Now to the fun stuff! Since 1988 prehospital care in Ontario has included automated and semi- automated defibrillation. As CPR and defibrillation work in tandem, a greater percentage of cardiac arrest victims can be saved if treated quickly following a collapse. As the diagram below illustrates, EVERY SECOND COUNTS

10. Remember this????

11. And this??

13. EARLY ACCESS to 911 system. To get medics moving. EARLY CPR to help circulated oxygen to the patient's heart and brain. EARLY DEFIBRILLATION May be AED on scene, such as health clubs, fd etc shocks to restore normal heart rhythm. EARLY ADVANCED CARE provided by als or hospital staff. Chain of Survival- Purpose

14. Remember….Time is Muscle!

15. Ventricular Fibrillation (VF) presents with chaotic electrical activity as the result of multiple ectopic foci originating in the ventricles. There are no organized QRS complexes. This lethal rhythm is seen in approximately seventy percent of sudden cardiac arrests. Fine and Coarse VF are differentiated by the amplitude of the activity. Fine VF has an amplitude of less than 5 mm (1 large square) whereas coarse VF is greater that 5 mm in amplitude Ventricular Fibrillation

16. Ventricular Tachycardia (VT) is characterized by a wide complex, rapid rate that is generally regular in nature. May be as slow as 140 and as fast as 340 May deteriorate to Vfib Can be with or without a pulse!! Ventricular Tachycardia

17. Causes of Vfib/Vtach electrical instability respiratory failure potassium imbalance electrocution near drowning irritation, inflammation or injury of electrical conduction system temperature extremes chest wall trauma

18. What is this?? Artifact!! (usually patient movement!) or 60 cycle interference from….. ??? or from Ambulance movement Or from Poor contact between skin and electrode, or defective cables, which cause chaotic and irregular deflections in the baseline which may be mistaken for ventricular fibrillation Intervention (Stop vehicle to analyze-DO NOT TOUCH PATIENT!) Every attempt must be made to correct or eliminate the presence of artifact before the rhythm is identified, and every precaution must be taken to ensure that what is seen as ventricular fibrillation is not artifact in disguise.

19. Anticipating Cardiac Arrest Patient complaining of chest discomfort: past history of MI, Nitroglycerin (NTG) taken with minimal or no relief heart rate 120 beats per minute Electrical Instability of the Ventricles Decreased cardiac output

20. What is defibrillation? Defibrillation is the delivery of Direct Current (DC) through the heart muscle. Defribrillation depolarizes the entire myocardium. This is generally followed by a brief period of asystole. The aim is that following defibrillation the heart will repolarize uniformally and that the heart’s intrinsic pacemaker, the SA node, will resume pacing the heart. Remember CPR does not return the hearts rhythm to normal.

21. What is the defibrillator? Energy source Conduits (paddles or cables for pads) Defibrillator is a capacitor that stores NRG Consists of capacitor, high voltage power supply and delivery conduits (pads or paddles)

22. General Considerations Wet patients (drowning etc) Medication patches Implanted pacemakers Young patients Excessive chest hair

23. Monophasic vs Biphasic Monophasic defibrillators deliver the energy in one direction and therefore require higher energy to defibrillate the heart. Biphasic defibrillators deliver energy in two directions. For half the shock energy is delivered in one direction then the energy is delivered in the opposing direction for the latter half of the shock. This allows for lower peak energies to be delivered.

24. The success of defibrillation depends on: Time elapsed since arrest Quality of electrical contact between treatment electrode and chest wall Myocardial oxygenation during CPR Chest wall size Defibrillating energy The total number of shocks delivered The time interval between successive shocks (chest wall impedance to electrical flow drops with successive shocks-max 2 minutes between).

25. Monitor/Defibrillators must be brought in on the following call types : VSA Unconscious/decreased level of consciousness Collapse, falls Syncopal episode e. Chest pain f. Stroke/TIA g. Shortness of breath h. Seizures i. Overdose j. Electrocution k. Drowning/scuba diving incidents l. Hypothermia and heat related illness m. Unknown

26. Quality Assurance The cardiac monitor/defibrillator must be checked and appropriate documentation filled out in accordance with local policy and procedure at the beginning of each shift Two examples: Self-Test Charge and discharge test at 10-50J What does the machine say to show success in these two tests?

27. Troubleshooting Paramedics must learn to recognize the most common problems that can occur when treating cardiac arrest patients with a SAED. These include: Poor electrode contact on patient's chest. Diaphoretic patients need to be dried off. Excessive body hair may also cause poor electrode contact, hair may need to be trimmed. Extra sets of adhesive pads should be readily available. Before placing electrodes, always be sure to remove anything on the surface of the patient's chest. This includes bandages, NTG patch(s), and other objects that might interfere with the placement of the electrodes on the patient's skin surface. If you encounter an implanted pacemaker, place the treatment electrode two to four inches away from the pacemaker site and as close to the normal pad placement as possible.

28. Troubleshooting cond If you encounter persistent problems with a set of electrodes, please follow local service policy for reporting malfunctions. Failed or low battery: replace with charged spare battery as soon as possible. Remember to continue CPR during battery exchange – Plug monitor into AC power if available and appropriate. Loose cable-electrode connections. Check to see that connectors are properly snapped into place both at the machine and on the pads. Always carry spare electrodes Monitor/cable movement. Patient movement during lifting, moving, and transport may cause motion artifact. Reporting Equipment Problems: Report any equipment problems as per local service protocols.

29. Interacting With The AED Trained Fire Department (F.D.) Upon arrival, Paramedics will take over responsibility for the patient care Obtain report from the Fire Department staff.(called a D Form) Any transfer of care, including changing to the Paramedic SAED, should take place during a period of CPR. Can complete whole algorithm on their machine Have the Firefighter who is operating the AED turn off machine and remove their treatment electrodes as per their protocol Connect Paramedic SAED to the patient Complete the SAED protocol The Firefighter will complete a medical assist report (D form or MAR form) and submit their report according to their Fire Department protocol

30. Documentation Complete the ACR. Pertinent documentation should include: time of arrest, witnessed/unwitnessed arrest, HPI, duration of CPR, physical findings, treatments, patient response to treatments, vital signs, PMHx, Rx, allergies) and detailed documentation of times (call time, arrival, departure, ER arrival).

31. Documentation Con’t Forward the completed ACR to the Base Hospital as per local Base Hospital policy. The Base Hospital will audit 100% of SAED calls. If there are concerns, The the crew may receive feedback on the call in the way of a written call evaluation if there are concerns.. Please feel free to discuss calls with the Base Hospital staff Remember too according to ambulance act, you need to do a VSA report (a special form of incident report)

32. Transfer of Care to Hospital Assure an orderly transfer of patient care to the hospital team. Provide a brief report of clinical information including: Time down (e.g., time of arrest) witnessed/unwitnessed arrest, HPI duration of CPR Treatments patient response to treatments vital signs PMHx Rx (meds) pertinent Allergies.(pertinent)

33. Caring for Family and Bystanders Even though Tthe primary concern of the Paramedic is the patient, but it is both appropriate and necessary to communicate effectively with the other people at the scene: family, friends and spectators. Respect the patient's and family's right to privacy. Isolate the patient from spectators whenever possible. Briefly inform the family of the patient's status and condition during and after resuscitation. It is important to identify the patient, establish the relationship of those present, accurately restate the events leading up to the cardiac arrest, briefly outline the efforts by the ambulance crew (CPR and whether the patient was defibrillated), and portray the patient's present condition - briefly and objectively.

34. The procedure -Step 1- Anticipation of Scene -think through your roles- who is doing what Run through the algorithm with your partner Take in all your necessary equipment If you are on a call with a patient experiencing ACS, anticipate an arrest!

35. The procedure -Step 2- Scene Observe for any hazards in the environment such as water or flammable gases or liquids. Move patient only if necessary. Transport all the equipment needed to manage the cardiac arrest to the patient's side. Position the patient for effective CPR and defibrillation. Position team members and the defibrillator based on assessment of available space, layout and workspace

36. Procedure Step 3 - Patient : Check Patient and Start CPR L.O.C. Assess responsiveness C - Circulation: Assess and manage Start cardiac compressions A - Airway Assess and manage Position and suction B - Breathing: Assess and manage Ventilation with Bag-valve-mask

37. Cardiac Arrest Algorithm Read the indications!  Read procedure section

38. Step 4 & Step 5: Step 4 : Turn on machine before or after attaching treatment electrodes according to local protocols. Step 5 :Prepare Patient and Attach Electrodes

39. Pad Placement Two options - anterior –posterior (sandwich) is best, closer distance but more difficult due to size of patient (best if you can log roll them) - Apex-sternum – more common

40. Defib Pad Placement Attach anterior pad to R shoulder below the clavicle R of the sternum Lateral pad is anterior axillary line at the level of the base or apex of heart -ensure good contact- shave if required

41. Pad placement Sternum pad to the right of the sternum, with the top edge just touching the bottom of the right clavicle. Apex pad to the left lateral chest at the mid-axillary line (approximately at the nipple line). An implanted pacemaker may require you to move the pad two to four inches away from the pacemaker site. Unless there is too much hair to get an acceptable tracing, Taking additional time to clip chest hair at the pad sites may not be worth the effort, as every second counts Note:Improper positioning or connection of the pads and cables will result in either An error message or "CHECK ELECTRODES" signal from the SAED. Less energy delivered to the myocardial cells resulting in fewer cells being depolarized and lowering the chances for a successful defibrillation. Skin burns

42. Step 6 Rhythm analyses! The "ANALYZE" button is pressed and rhythm analysis is activated. Everyone must be clear of the patient! The SAED will also advise you to clear with a voice prompt, "ANALYZING NOW, STAND CLEAR". Everyone must be away from the patient before rhythm analysis starts. Assessment: All those present must remain clear during the analyzing assessment. Rhythm assessment may take up to 5 seconds

43. Analyze and Shocking If Vfib or Vtach >180 (depends on machine) is detected, the machine will charge to the preset J setting The “Shock” button will flash when it is charged and ready You NEED TO WATCH THE PATIENT AND SAY CLEARLY “ I am clear you are clear everyone is clear”, BEFORE YOU PUSH THE BUTTON! After shock(s) has been delivered back on chest ASAP. If you receive a “No Shock Indicated” (NSI) –check pulse then begin CPR Resume CPR as per protocol for two minutes and re-analyze Three cycles on scene and one enroute (Three on floor and one out the door!)

44. Some info for Paramedic Again, defibrillation may be interfered with by other equipment Notify partner/other helpers of procedure Watch for skin burns Ensure everyone clear when you defib!

45. Defibrillation Must be 25 lbs pressure with paddles or good contact with skin on pads to ensure good contact and success of defibrillation Can also defib anterior/posterior but more difficult and cumbersome in the VSA patient (imagine large VSA patient)

46. LP 12/Zoll Familiarization Ensure you know how to : change energy settings “dump” a charge retrieve a code summary 2 ways set clock test machine at start of shift what various cables are called etc: See Monitor familiarization list on website