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AED and CPR Overview and Implementation for Special Cases

AEDs are simple to use. If you are a trained responder who finds someone unconscious and not breathing normally or not breathing at all, the procedure for use is simple.

Cardiopulmonary resuscitation (CPR) is a procedure used in emergency situations on a person who has suffered cardiac arrest, has nearly drowned, or is in a life-threatening condition, possibly due to the progression of complications from an adverse health event.

Use CPR when the patient has an undetectable heartbeat and is not breathing—include rescue breathing and chest compressions. Rescue breathing supplements oxygen to the lungs, and chest compressions circulate oxygenated blood to the vital organs and brain. The purpose of CPR is to artificially circulate blood to the patient’s brain and heart until medical professionals achieve the restoration of a normal heart and lung function with the aid of a cardiac defibrillator, medications, and other advanced medical interventions.

Automated External Defibrillators
More than a quarter million Americans die from sudden cardiac arrest every year—a death every two minutes. Patients in sudden cardiac arrest are nonresponsive and not breathing normally or at all. There may also be signs of poor to no circulation. More than 20,000 of those patients might be saved through the use of a "chain of survival," including CPR and the portable lifesaving device known as an automated external defibrillator (AED).

AEDs allow trained non-medical personnel to deploy usage upon the collapse of a person who is not breathing, is unconscious, and appears to be in sudden cardiac arrest. If individuals are trained to use the AED as they are trained in CPR, broadly as first responders, the American Heart Association notes that up to 50,000 people might be saved each year.

Automated external defibrillators work by detecting cardiac rhythm and are only indicated for and intended for use among victims of sudden cardiac arrest. Should normal rhythm be interrupted by abnormal heart rhythms such as ventricular fibrillation or pulseless ventricular tachycardia, the AED can deliver an electrical shock to treat the arrhythmia.

OSHA states that for every minute of defibrillator delay for sudden cardiac arrest, chances of survival diminish by 7 to 10 percent.

The Cardiac Arrest Survival Act of 2000 provides Good Samaritan protection exempting anyone from liability when using an AED to save someone’s life (42 U.S.C. 238q). These acts vary by state, but generally, they limit the liability of rescuers using AEDs and others involved in the AED program. Please read the Good Samaritan Act for your state for details.

AEDs are simple to use. If you are a trained responder who finds someone unconscious and not breathing normally or not breathing at all, the procedure for use is simple:

  • Assess scene for hazards.
  • Call 911 or activate the emergency response team.
  • Determine patient status: breathing or not breathing, level of consciousness, and pulse or signs of circulation.
  • Explain to the 911 operator or emergency operator that a person has collapsed. Tell the operator that an AED is there and that you know how to use it.
  • Place the AED next to the collapsed person's shoulders.
  • Turn on the AED.
  • Follow the verbal and visual AED instructions.

Make sure that you stick around after the emergency responders arrive so that any institutional reports may be accurately filled out.

Note. AEDs are not meant to be used on patients less than 55 pounds or who are under the age of eight.

Types of Defibrillators
There are different kinds of defibrillators in use today. They include the manual external defibrillator, manual internal defibrillator, automated external defibrillator (AED), implantable cardioverter-defibrillator (ICD), and wearable cardiac defibrillator.

  • Manual external defibrillator: These defibrillators require more experience and training to effectively handle them. Hence, they are only common in hospitals and a few ambulances where capable hands are present. In conjunction with an ECG, the trained provider determines the cardiac rhythm and then manually determines the voltage and timing of the shock—through external paddles—to the patient's chest.
  • Manual internal defibrillator: The manual internal defibrillators use internal paddles to send the electric shock directly to the heart. They are used on open chests, so they are only common in the operating room. It was invented after 1959.
  • Automated external defibrillator (AED): These are defibrillators that use computer technology, thereby making it easy to analyze the heart's rhythm and effectively determine whether the rhythm is shockable. They can be found in medical facilities, government offices, airports, hotels, sports stadiums, and schools.
  • Implantable cardioverter-defibrillator: Another name for this is automatic internal cardiac defibrillator (AICD). They constantly monitor the patient's heart, similar to a pacemaker, and can detect ventricular fibrillation, ventricular tachycardia, supraventricular tachycardia, and atrial fibrillation. When an abnormal rhythm is detected, the device automatically determines the voltage of the shock to restore cardiac function.
  • Wearable cardiac defibrillator: Further research was done on the AICD to bring forth the wearable cardiac defibrillator, which is a portable external defibrillator generally indicated for patients who are not in an immediate need for an AICD. This device is capable of monitoring the patient 24 hours a day. It is only functional when it is worn and sends a shock to the heart whenever it is needed. However, it is scarce in the market today.

When Not to Use a Defibrillator
Defibrillation is not indicated if the heart rhythm has completely stopped, as in asystole, or sometimes called "flat line," or has pulseless electrical activity (PEA). Also, defibrillation is not indicated if the patient is conscious or has a pulse. Inappropriately given electrical shocks can cause dangerous arrhythmias, such as ventricular fibrillation.

Now that the generalities have been discussed, let's take a look at more specific implementation of CPR and defribillators.

CPR With Rescue Breathing for Children and Adults
When used on adult patients, CPR with rescue breathing includes both chest compressions and breaths. The rescuer should:

  • Make sure the area is safe, then tap the individual on the shoulder and shout "Are you OK?" to ensure that the person needs help.
  • Call 911 immediately and then begin chest compressions.
  • Ask another witness to locate and retrieve an automated external defibrillator if one is available. Follow the directions on the AED and use it as soon as it arrives.
  • Placing both hands in the middle of the chest, one on top of the other, the rescuer should press down hard and perform 30 compressions.
  • Tilt the patient's head back, lift the chin and pinch the nose closed—cover the patient's mouth with his or her own and blow hard until the patient's chest rises.
  • Give two breaths, each lasting one second, and then return to chest compressions.
  • Alternate 30 compressions and two breaths until professional help arrives.

CPR for children is the same as CPR for adults; however, if a child younger than eight has collapsed, do not leave the child alone until you have done CPR for about two minutes. After two minutes of care, then call 911.

CPR for Infants and Children Under Six Months
CPR for infants, or children under six month of age, is slightly different. The rescuer should:

  • Check surrounding area for safety. Shout "Are you OK?" and tap the child's shoulder to determine if they are unresponsive. For infants, flick the bottom of the foot to elicit a response.
  • Do not leave the infant alone until you have done CPR for about two minutes. After two minutes of care, then call 911.
  • Ask another witness to locate and retrieve an automated external defibrillator if one is available. Follow the directions on the AED and use it as soon as it arrives.
  • Place two or three fingers of one hand (usually the middle and index finger) just below the nipples at the center of the chest and give 30 gentle chest compressions, which should compress the chest at least 1.5 inches.
  • After 30 compressions, lift the child's chin and cover the child's nose and mouth with his or her own, making a complete seal.
  • Deliver two rescue breaths, each lasting one second, which causes the chest to rise, before resuming chest compressions.

CPR and AED Implementation for Pregnant Women
Two lives are at stake when a pregnant woman goes into cardiac arrest. By understanding the physical changes brought about by pregnancy, you can respond appropriately to maternal emergencies.

Here is a quick reference guide to first aid modifications for the mother-to-be.

Maternal Cardiopulmonary Resuscitation (CPR)
Although most characteristics of maternal resuscitation are similar to the standard adult resuscitation, several aspects are uniquely different.

  • Call 911 (or EMS) or direct someone else to call. Tell the operator that there is a pregnant woman in cardiac arrest. This alerts the EMS to take specific measures, such as sending additional providers. Immediate perimortem cesarean delivery (PMCD), or resuscitative hysterotomy, should be anticipated, at the site of the cardiac arrest, within four to five minutes of the arrest.
  • Start CPR with the woman flat on her back in a supine position. A tilt of her body can significantly impact the force of the chest compressions, consequently decreasing the chance of a successful resuscitation.
  • High-quality chest compressions occur when the woman is supine on a hard surface. If a backboard is used, care should be taken to avoid delays in the initiation of CPR, reduce interruptions in CPR, and prevent line or tube displacement.
  • One-person CPR: Follow the basic life support (BLS) sequence—C-A-B (chest compressions-airway-breathing)—push hard and fast in the center of the chest at a rate of at least 100 compressions per minute with a depth of 2 in (5 cm). Perform this in cycles of 30 compressions and two breaths. The chest compressions are delivered the same way for a pregnant woman as for a non-pregnant woman.
  • Two-person CPR: Use C-A-B-U (chest compressions-airway-breathing-uterine displacement) if two or more rescuers are at hand. Continuously perform manual left uterine displacement (LUD) when the uterus is felt at or above the umbilicus (approximately 20 weeks pregnant) to help restore blood flow to the heart by reducing aortocaval compression, the compression of the inferior vena cava and abdominal aorta by the gravid uterus. Historically, a left lateral tilt of 30° has been used to displace the uterus; however, the heart shifts laterally during this tilt. Therefore, use the left lateral tilt if manual LUD is unsuccessful.
  • If recovered, the pregnant woman should be placed on her left side to increase blood flow to the heart and baby.

AED in Maternal Resuscitation
The best way to save the baby is to save the mother. Rapid defibrillation, when indicated, can be life-saving. Use the AED as per standard protocol. The guidelines are the same for the pregnant patient as they are for the non-pregnant patient. Resume compressions immediately after the delivery of the electric shock.

This article is not all-inclusive. Please feel free to contact the author to add information you think would be helpful in an emergency situation.

References
For more information on defibrillation and diseases that require a defibrillator, please visit these websites:

This article originally appeared in the February 2018 issue of Occupational Health & Safety.

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