Automated External Defibrillation

“Chain of Survival”

• Early access
• Early CPR
• Early defibrillation
• Early advanced life support
Defibrillation is “Part of BLS”

• Basic Life Support includes CPR and defibrillation

• Early defibrillation with an automated external
defibrillator (AED) has established benefit
• The principle of early defibrillation suggests that the first
person to arrive at the scene of a cardiac arrest should
have a defibrillator
• This principle is now internationally accepted

Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care p. I-68
Electrical Conduction System of the
Heart
Atrioventricular Node
Left Atrium
Bundle of His
Internodal Pathways

Left Bundle Branch

Sinoatrial Node

Right Atrium

Left Ventricle

Right Bundle Branch

Right Ventricle Purkinje Fibers

Normal Conduction Pathway in the Heart
and the ECG
Sinoatrial (SA) Node
Atrioventricular (AV) Node

Left Bundle Branches

Right Bundle Branch

Purkinje Fibers

P T

QRS P= Atrial Depolarization

QRS = Ventricular Depolarization
T= Ventricular Repolarization
 Normal Sinus Rhythm

Sinoatrial Node

12:56 29MAR96 PADDLES X1.0 HR = 74

Ventricular Tachycardia

12:57 29MAR96 PADDLES X1.0 HR = 214

Ventricular Fibrillation

12:57 29MAR96 PADDLES X1.0 HR = ---

Defibrillation: The Only Effective
Treatment for Ventricular Fibrillation

300 JOULES DEFIB 20:29 01APR96 PADDLES X1.0 HR = ---

“Thanks, I needed that!”
Why Early Defibrillation?

• VF most frequent initial rhythm in sudden cardiac arrest

• Defibrillation most effective treatment
• Probability of defibrillation success diminishes with time
• VF tends to rapidly deteriorate into asystole

Textbook of Advanced Cardiac Life Support, Chapter 20, 1990; p. 287

Asystole

15:17 29MAR96 PADDLES X1.0 HR = ---

 Resuscitation Success vs. Time*
100

90

80

70 Success rates decrease

7-10% each minute
60
%
Success 50

40

30

20

10

0 1 2 3 4 5 6 7 8 9 Adapted from text: Cummins

* Non-linear RO, Annals Emerg Med. 1989,
Time (minutes) 18:1269-1275.
 Early Defibrillation Effectiveness
• Rural and urban U.S. studies
• Substantial increases in survival
30
Before
25
After
20
% Survival

15

10

0
King County Iowa Southeast Northeast Wisconsin
Washington Minnesota Minnesota

Textbook of Advanced Cardiac Life Support, Chapter 20, 1990, p. 289

Early Defibrillation by Police and
Paramedics—Rochester, MN

Survival to
Number hospital discharge
First shocked 31 18 (58%)
by police
First shocked 53 23 (43%)
by paramedics
Overall survival to hospital discharge = 49%

White RD, et al. Annals of Emerg Med. 1996;28:480–485.

Time to Defibrillation—
The Clock is Ticking

Recognize cardiac arrest 1 min.

Activate internal emergency response 1 min.
Call EMS / dispatch vehicle 1 min.
Aid car sent—arrives on scene 6 min.
Locate victim and deliver shock 2 min.
Total Elapsed Time = 11 min.
AEDs are Well Suited for Use by
Non-Traditional Responders
• Today’s AEDs are more practical for use
in the workplace and public places
– Voice prompts are more intuitive

– Non-rechargeable batteries are the norm

– AEDs do daily self tests and are virtually

maintenance free
Early Defibrillation
by Security Officers: Casino Study

• Landmark study: AED use by nontraditional

responders in out-of-hospital cardiac arrest
• Security Officers in various gaming casinos
were trained to use AEDs
• Goal: to deliver first shock within 3 minutes of
patient collapse

Valenzuela TD, et al: NEJM 2000; 343: 1206-09.

Valenzuela TD, et al: NEJM 2000; 343: 1206-09.
Results

Mean time from collapse to 4.4 min.

first shock
Mean time from collapse to 9.8 min.
medic arrival
All VF patients surviving to 53%
hospital d/c
Witnessed VF patients 59%
surviving to hospital d/c

Valenzuela TD, et al: NEJM 2000; 343: 1206-09.

Survival Rates for Witnessed VF

100

90

80 74%
70
Percent

60
49%
50

40

30

20

10
7%
0
Shock <3 min. after Shock >3 min. after National
collapse (26/35) collapse (27/55) Average

Valenzuela
Valenzuela TD,TD, et al:
et al: NEJM
NEJM 2000;
2000; 343:
343: 1206-09.
1206-09.
Automated External Defibrillators

• Analyze patient ECG

– only for unconscious, pulseless victims with
no spontaneous breathing and no signs of circulation

• Determine via computer algorithm shockable or

non-shockable rhythm
• Advise operator “SHOCK” or “NO SHOCK”
• Shock ventricular fibrillation and certain
ventricular tachycardias
LIFEPAK® 500
Automated External
Defibrillators
How to Defibrillate

• Verify the victim is unconscious, not breathing,

without a pulse or signs of circulation
• Turn on AED and attach electrodes
• ANALYZE heart rhythm
• Follow the voice prompts and screen messages
Defibrillation Electrode Placement

Anterior

Lateral

Anterior-lateral placement
Next time, remove his shirt!
Defibrillation Electrode Placement

Correct electrode position Incorrect electrode position

• Correct electrode position optimizes the amount of

current flowing through the ventricles
Safety First

• Attach the defibrillator only to someone not

breathing and without a pulse or signs of circulation
• Make sure no one is touching the victim
• Be sure the electrodes are firmly adhered to
the victim’s chest
• Move oxygen away from the rescue effort before
defibrillation
You should have said “clear”!
Who is Using AEDs Today?

• Flight Attendants • Police

• Firefighters • Golf Pros

• EMTs • Lifeguards

• Corporate Emergency • Health Club Employees

Response Teams

• Security Officers
Advantages of AEDs

• Eliminates need to recognize rhythms

• Personnel with less training can defibrillate
• May reduce time to therapy—access to more
treatable rhythms
• Makes early defibrillation practical and achievable