SAEDRefresher Training

Fate Factors

• Age of the patient

• Underlying medical condition

• Witnessed arrest, or was there a delay in discovery

• Cardiac rhythm that causes the arrest

(Ventricular Fibrillation is the most common)

System Factors

• Time from the collapse to CPR• Time from the collapse to definitive

cardiac care• The most important element of

definitive care is CPR, followed by defibrillation (if the patient is in VF or VT > 160.)

SAED should be brought to the side of any patient with:

• Chest pain or palpitations

• Respiratory distress

• Altered mental status

• Syncope

• Seizures

• Anaphylactic reaction

Signs and Symptoms of a MI

• Rapid heart rate• Weak or absent pulse• Skin: cool, pale, moist• Cyanosis• Altered levels of

consciousness• Unconsciousness

• Fatigue• Sweating• Dizziness• Palpitations• Nausea &/or vomiting• Thirst• Shortness of breath

History

• S. A. M. P. L. E.• S = Signs and symptoms• A = Allergies• M = Medications• P = Past Medical History• L = Last meal• E = Events Preceding

• O. P. Q. R. S. T.• O = Onset• P = Provocation• Q = Quality• R = Radiates• S = Severity• T = Time

Indication for Use of the SAED

• Apneic and pulseless patient of any age.

When Not to Use the SAED…AKA- Contraindications

• Metal surfaces

• Wet surfaces

• Moving vehicle

• Explosive environment

Goal of Defibrillation• To provide electric To provide electric shock to alleviate shock to alleviate ventricular ventricular fibrillation to fibrillation to restore the hearts restore the hearts normal pacemaker.normal pacemaker.• To provide rapid To provide rapid treatment in treatment in cardiac arrest and cardiac arrest and to restore to restore circulationcirculation

Semi Automatic External

Defibrillator Procedures

Ensure Scene Safety

Conduct a scene size-up Conduct a scene size-up to determine if there is to determine if there is water, or hazardous or water, or hazardous or flammable chemicals flammable chemicals

present!present!

SAED Procedures• Establish unresponsiveness• Establish breathlessness• Activate/verify Paramedic response• Establish pulselessness - if

unwitnessed or no CPR being performed, initiate CPR for up to 2 minutes. (30:2)

SAED Procedures

• Apply SAED pads to chest– 1 SAED trained

person (approved by sponsor hospital) must operate defibrillator

Procedures• Expose patient’s chest by

removing clothing.• If necessary, remove chest

hair.• Dry chest if wet.• If NTG patch remove/wipe.• If implantable

defibrillator/pacemaker @ R clavicle, place 2” from device.

ProceduresAttach the defibrillation pads

White White -angle between the sternum and the right clavicle

RedRed -left lateral below apex of the heart

Procedures

• Clear patient from head to toe• Initiate analysis of the rhythm• If shock is indicated, assure

patient is clear and verbalize “STAND CLEAR” It is your responsibility to ensure that no one is contacting patient directly or indirectly!

Procedures

• Deliver the shock and initiate effective CPR for 5 cycles (2 minutes)

Procedures

• If pulse is present, check breathing

• If breathing inadequate (<12/min) assist with BVM and O2

• If breathing is adequate use supplemental high flow O2

• If NO pulse present, then…

….Re-AnalyzeIf the analysis results in this If the analysis results in this

message:message:

•Check Pulse and breathingCheck Pulse and breathing•Resume basic life support as Resume basic life support as indicatedindicated

(Voice prompts will guide you)(Voice prompts will guide you)•Arrange for immediate Arrange for immediate transport of patient.transport of patient.

Transport!

• When three shocks have been delivered or no shock is advised, package and transport the patient

• No longer limited No longer limited number of shocksnumber of shocks

• Contact Medical Control

• DO NOT SHOCK IN A DO NOT SHOCK IN A MOVING AMBULANCEMOVING AMBULANCE

Special Considerations

• Traumatic arrest

• Hypothermia

Traumatic Arrest

• Patients with multi-system traumatic injuries or penetrating injuries to the head, neck, or torso. Patients in traumatic arrest do not usually respond to defibrillation.

• Medical Control should be consulted

Hypothermia• VF with profound hypothermia (core body

temperature, <85˚F) does not respond well to defibrillation.

• First responders are often not equipped to detect body core temperatures, defibrillation should be limited to three shocksthree shocks if indicated.

• If the hypothermic patient does not respond after three shocksthree shocks, stop defibrillation attempts.

• Resume CPR and re-warming efforts and transport.

You’ve Decided Not to Work a Patient, Now What Do You Do?

STEP 1 - Assessment

• Any patient found to be PULSELESS and APNEIC may be presumed dead and no resuscitation initiated if any of the following apply:– Decomposition, transection, incineration, post

mortem dependent lividity with rigor*.

Presumption vs. Pronouncement

• Presumption– Acceptance or belief based

on reasonable evidence

– Assumption

– Evidence is probable but not conclusive

• Performed by EMS when patient meets established criteria

• Pronouncement– Authoritative

declaration

• Performed by Physician or in certain circumstances an RN

Who?

• OEMS states the person on scene with:– Highest level of currently valid EMS

certification– Has direct voice communication for medical

orders– Affiliation with an EMS organization present

on scene

• Will be responsible for, and have the authority to direct, resuscitative activities

Does Presumption Require a Paramedic Response?

• NO!• EMTs may presume so

long as they meet the above criteria AND the patient meets one of the specific criteria outlined in Regional Guidelines

• When in doubt ask!

When may you presume death?

• The following conditions are the ONLY exceptions to the initiating and maintaining resuscitative measures in the field on a clinically dead patient:

1) Traumatic injury or body condition clearly indicating biological death

2) Pronouncement by a licensed Connecticut physician or authorized registered nurse

3) A valid DNR bracelet is present4) At a mass casualty incident

Traumatic injury or body condition clearly indicating biological death

• Decapitation• Decomposition or

putrefaction• Transection of the

Torso• Incineration• Dependent Lividity

with Rigor *• Injury incompatible

with life *

Decapitation

• The complete severing of the head from the patients body.

Decomposition or Putrefaction

• The skin is bloated or ruptured, with or without soft tissue sloughed off, or there is the odor of decaying flesh. The presence of at least one of these signs indicated death occurred at least 24 hours earlier.

Transection of the Torso

• The body is completely cut across below the shoulders and above the hips through all major organs and vessels. The spinal column may or may not be severed.

Incineration

• Ninety percent of body surface area full thickness burns as exhibited by ash rather than clothing and complete absence of body hair with charred skin.

Dependent Lividity With Rigor

• When clothing is removed there is a clear demarcation of pooled blood within the body, and major joints are immovable

• Requires additional confirmation:– Respirations are absent- check for 30 seconds– Pulse is absent- check for 30 seconds– Lung sounds and breathing movements are absent-

check for 30 seconds– Heart sounds are absent- check for 30 seconds– Both pupils are non-reactive– Contact Medical Control for Physician’s order to

withhold resuscitation

Injury Incompatible With Life

• Does not meet any obvious death criteria but includes:– Head injury with brain

matter exposed

– Complete exsanguination

– Complete cervical spine severance

• Establish Med Control EARLY!

MD on Scene?

• A physician present on scene, with an ongoing relationship with the patient, may decide if resuscitation should be started.

• If the MD decides to start resuscitation, usual medical control procedures will be followed.

RN on scene?

• A registered nurse from a home health care or hospice agency present on scene, with an ongoing relationship with the patient, and who is operating under orders from the patient’s private physician, may decide if resuscitation should be started.

• If the RN decides to start resuscitation, usual medical control procedures will be followed.

DNR• A valid DNR bracelet is present when:

– Is on the wrist or ankle– Is intact; it has not been cut or broken– Has the correct logo; stylized hand in “stop”

position and words “EMS ALERT”– Is the correct color—Orange– Has an expiration date which has not elapsed– Medic Alert style bracelets are acceptable

Valid DNR bracelet…

• Contact home healthcare/hospice agency.• They will make pronouncement and arrange

with family for disposition of body.• Medical Examiner/police involvement not

required.

• Living Wills or “Health Care Declaration” customarily deals with end of life issues if patient becomes incapacitated: feeding tubes, mechanical ventilation, etc.

• Living Will is not recognized by EMS providers.

• Contact Medical Control if issues arise.

DNR vs. Living Will

At a mass casualty incident

• If clinical death is determined prior to patients arrival in the treatment area.

Special Considerations…

• Whenever any likelihood of survival exists, resuscitation should proceed unless the patient has been clearly identified not to receive resuscitation.

• Victims of hypothermia should be resuscitated.

• Children under 14 should be resuscitated.• Family comfort should be considered

Step 2 - Medical control

• Establish medical control

• Explain to the physician the circumstances: history, last time seen, obvious death criteria met

Step 3 - Documentation

• Record time and MD name

• Complete physical assessment

• Scene survey• Past medical history• History of present

injury/illness• Condition when

resuscitation was not initiated

Documentation Issues

• PCR must be completed for:– clinically dead patient who has resuscitation performed

and for then discontinued, or was simply withheld.

• All medical control orders will be noted on the PCR.

• If access to patient is not allowed by law enforcement or fire officials it must be noted on the PCR.

• PCR must be turned into the Pre-Hospital Medical Director.

Documentation Issues

• In cases of dependent lividity with rigor, the following details documented on the PCR:– Breathing absent when airway was repositioned

and assessed for at least 30 seconds– Carotid pulse absent upon palpation for at least

30 seconds– No audible heart sounds after examination with

stethoscope for at least 30 seconds– Pupils of both eyes non-reactive

Step 4 - Leaving the Scene

• Protect body from being viewed by the public.

• Turn scene/body over to police or medical examiner.

• Family comfort should be considered.

• If presumed/pronounced patient already in ambulance, contact hospital for authorization to bring body to hospital.

Questions

• Document Well