Using an AED on Infants – New AHA Guidelines
According to the 2010 Guidelines for CPR and Emergency Cardiovascular Care, the use of an AED in infant patients is now a class IIb recommendation. This new information has been reviewed in Circulation as well as the Highlights publication put out by the American Heart Association.
One area you will not find this information is in the new Heartsaver materials. The AHA has not included this recommendation in the lay rescuer course materials including the manuals and course videos. Many instructors have asked why this topic has been omitted after so much discussion during the guidelines release.
Remember, guidelines do not necessarily make a distinction between Healthcare Provider CPR and Heartsaver CPR. The AHA has separated the courses into two different curriculums to meet the needs of the healthcare providers and the community lay rescuers.
Because use of an AED in infants is a class IIb recommendation, meaning the benefit may be greater than or equal to the risk and they recommend additional studies, the AHA has adopted the guidelines but has been very clear that a “more advanced defibrillator” is preferred over AED for use in infants. The AHA has also noted that cardiac arrest in infants most often caused by respiratory problems and as such AED use is less likely to be effective than it is in adults. Since the decision of which device should be used is best left up to advanced providers, the only classes that address this new guideline are ACLS, PALS, and Healthcare Provider CPR.
Instructors are encouraged to teach the current AHA curriculum and not deviate from the content outlined in the instructor lesson maps. Heartsaver courses are designed to provide the most basic content in the fewest amount of steps possible to ensure students leave with the skills and confidence necessary to perform when it matters most.
For more information on AED use in infants and pediatric patients visit the American Heart Association website and download the 2010 Guidelines for CPR and Emergency Cardiovascular Care.
References:
2010 American Heart Association Guidelines for CPR and ECC - Part 6: Electrical Therapies, Pages S710-S711
Highlights of the 2010 American Heart Association Guidelines for CPR and ECC - Pediatric BLS, Pages 19-20
CPR FAQ’s - Questions a Student Might Ask
How Safe is a Safety Harness?
You are dispatched to a priority 2 fall at UNR. Dispatch informs you that there is a building under construction and the patient fell from a third floor and is hanging from a safety harness. You arrive to find a construction worker hanging from a support beam by his safety harness approximately 25 feet above the ground. You are able to talk to the man and he says that he isn’t hurt but his legs are starting to “go to sleep”. The jobsite foreman informs you that he fell approximately 6 minutes ago and that he fell about 5 feet until his harness stopped him. RFD arrives within moments but is unable to reach him with their equipment. They call for a ladder truck to respond to the scene. You are fairly certain that this will be an AMA since there doesn’t seem to be any injuries. While awaiting the RFD ladder truck someone yells out “I think he’s unconscious!” You look up to see the man hanging lifeless in his harness. His coworkers are yelling to him but he doesn’t respond. You are helpless, awaiting the arrival of the ladder truck. The ladder truck arrives within minutes and sets up to rescue the man but it takes 4 minutes before they reach him. They carry down a lifeless patient to you and your partner. Your initial assessment reveals a man in his early 30’s that is unconscious and unresponsive. He is pulseless and apneic. You immediately start CPR and move into the ambulance. You do the usual treatments and procedures in route to Renown but to no avail. You hand the patient off to the physician at Renown and he is pronounced dead several minutes later.
What happened? Why did this young and seemingly healthy man die from such a short fall? Suspension trauma is a rare but we should be aware of the dangers associated with safety harness use. Death or injury secondary to the use of a safety harness is called, “suspension trauma.” The cause of death or syncope from suspension trauma is “orthostatic intolerance.” Orthostatic intolerance can be caused by several things. A common cause of orthostatic intolerance is standing with the knees locked for long periods of time. When the knees are locked there is not much need for the leg muscles to remain tight so they relax. This allows blood to pool in the legs and thus resulting in hypotension and syncope. When this occurs, the person will quickly become supine and blood is returned to the heart and the symptoms are resolved.
There are several types of safety harnesses out there but most of them support the majority of the person’s weight with leg straps. When a person falls and is suspended by the harness, the body is usually in an upright position with the legs hanging below. The legs become relaxed and the harness impedes venous return to the inferior vena cava. This results in a large amount of blood pooling in the lower extremities which lowers the amount of circulating blood to a potentially lethal level and also creates a relative “compartment syndrome.” When a person’s blood pressure falls, creating an unconscious state it would normally result in a supine position. When hanging in a harness, this doesn’t happen. Instead, the body is suspended upright with no way to correct the situation. There have been many documented cases of death from suspension trauma however not all of them occur while the person is still suspended. There is another potentially lethal situation here called “post rescue death.” Because of the relative “compartment syndrome” the blood in the person’s legs is deoxygenated and may also be contaminated with very high levels of sodium and potassium. If the person is brought to the ground and immediately moved to a supine position, the rush of “bad” blood from the legs can cause cardiac arrest.
So what does this mean for us? Well if you are the lucky one that gets this call there are a few things you can do. If the person is still conscious but hanging in a harness you can instruct them to pump their legs up and down or ride an imaginary bike which will cause the muscles to contract and squeeze the blood out of their legs. If the person is unconscious they need to be rescued quickly (probably by fire). According to OSHA 29 CFR 1926.502 employers are required to provide for “prompt rescue of employees in the event of a fall or shall assure that employees are able to rescue themselves.” This may be by calling 911 or the employer may have a “Fall Rescue Team.” If this is the case, work with the team as they probably know more about harness safety and rescue than we do. After the initial rescue the patient needs to be handled very carefully. If they still have a pulse, some experts advise not moving the patient to a supine position immediately to deter a rush of “bad blood” into the central circulation. However other experts advise that if the patient is hypotensive, the brain may not be perfused requiring the need for positioning in trendelenburg. You may elect to transport with the head up and the patients legs hanging over the sides of the gurney if you feel it is appropriate. If the person doesn’t have a pulse or at any time during the rescue develops cardiac arrest they should be promptly placed in a supine position and CPR initiated. Regardless of how the person presents to you after rescue, transport is necessary to rule out damage to the heart, kidneys, lungs and brain as even in the absence of symptoms, damage could occur.
Eric Bridges EMT-P
MEDICATION AND OTHER ERRORS IN EMS
When we review charts and Occurrence Reports we find that there are many different types of errors made as we care for patients. Happily, errors do not happen every day and not all errors result in harm to the patient; but then you also have to wonder how many errors are made that we never catch? The most important thing to remember is that most errors are preventable.
Some common errors in EMS that have resulted in legal action across the nation are:
• Delays in patient care because of an inability to find the patient’s location
• Equipment that doesn’t work or a lack of knowledge on the provider’s part of how it works
• Medication errors
• Esophageal intubation
• Vehicle crashes
• AMA of a patient that is not competent
What can we do as EMS providers to prevent errors?
• Look at your map book and know traffic patterns for different times of the day. If you can’t find a location, call into dispatch early and get help.
• Occupy your downtime productively: Having nothing to do produces boredom or anticipation. Both boredom and anticipation are exhausting and exhaustion can lead to errors.
• Check your vehicle and all of your equipment before you start your shift: Is everything there? Does it work? Do you know how to use it? If you have questions on equipment, ask a supervisor, or the education department.
• Maintain your knowledge base and competency: Attend the monthly CE programs, subscribe to journals, research current trends on the internet and use your education money to attend conferences. Check your mailbox for updates and changes in protocols and equipment.
• Always use the five rights when giving a medication (right patient, right drug, right dose, right time, right route). Don’t rely on the fact that every medication container will always be in the same spot in your med box; look at the label and the strength EVERY time you give a medication. Verify patient medication allergies; check medication name on package; check medication name on container (syringe, vial, ampule, bottle); check/validate expiration dates; check total container quantity; draw the correct dosage and verify the drawn dosage. If you are uncertain about a drip calculation or a dosage calculation, have your partner check and verify your math. Don’t ever give a medication that someone else has drawn up.
• Use multiple methods of confirming tube placement but ALWAYS rely on the best: ETCO2. Secure the tube well, continuously monitor the patient’s cardiac and SPO2 status and immobilize the patient so the patient doesn’t dislodge the tube. Frequently reassess your tube and patient and recheck tube placement after every patient move.
• Take care of yourself and your partner: Fatigue, hunger, thirst, illness, preoccupation and complacency can all lead to errors. It is your responsibility to know when you can no longer perform optimally.
• Document all of the aspects of competency and capability of the patient to make the decision to refuse care. This is one protocol you should know inside and out and never skimp on documentation. You want to document on each of the seven points in the protocol and if the patient refuses to sign or walks away, be sure you document that action. Before allowing any patient to sign AMA be sure you have checked for and documented any possible organic reason for his refusal or that would make him incompetent to sign AMA (hypoglycemia, intoxication, dementia, head injury, hypotension, etc.)
• Work as a team: Teamwork can decrease certain types of errors. Acting alone or without support can lead to patient care problems on a number or levels.
• Communication is key to making positive differences: Confirm medication orders, reaffirm protocols, and repeat information back to the patient to be sure it was heard correctly. If you are ever unsure of your treatment or want further advice with a patient, don’t hesitate to contact a base station physician.
Every error of any magnitude should be reported. Reporting an error immediately protects you and the organization. Sentinel events are errors that have a higher likelihood of causing harm to a patient, attracting media coverage, going on up the chain of command as a complaint, or ending in litigation against the organization and/or the care provider.
In the words of the African American poet, Nikki Giovanni, “Mistakes are a fact of life. It is the response to the error that counts.”
Diane Rolfs, MS RN