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2010년 AHA
심폐소생술 가이드라인 설명회
Electrical Therapies
한림대학교 강동성심병원 응급의학과 조규종
Early defibrillation
 Critical to survival from sudden cardiac arrest

VF: the most frequent initial rhythm in witnessed SCA
(41% in King County, 52% in Tucson)

The treatment for VF: electrical defibrillation

Success of defibrillation: diminishes rapidly over time

VF tends to deteriorate to asystole within a few minutes
CPR alone: no effect
대한심폐소생협회
CPR + Defibrillation: Critical Combination
Collapse to CPR Interval (min)
Larsen MP et al. 1993
Valenzuela TD et al. Estimating effectiveness of cardiac arrest interventions: a logistic regression survival model.
Circulation. 1997;96:3308 –3313.
대한심폐소생협회
Two critical questions
CPR before defibrillation ?

Shock First Versus CPR First
number of shocks before resumes CPR ?

1-Shock Protocol Versus 3-Shock Sequence
대한심폐소생협회
Integrate CPR and AED Use
Cobb LA et al. Influence of cardiopulmonary resuscitation prior to defibrillation
in patients with out-of-hospital ventricular fibrillation. JAMA. 1999;281:1182–1188.
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Shock First vs. CPR First
 Swine VF model
 Pre-shock 90s CPR in Seattle
(Prolong VF: O2, energy source ↓ )
Berg RA et al. Crit Care Med 2004;32:1428-9
Cobb LA et al. JAMA. 1999;281:1182–1188.
Importance of high-quality CPR
대한심폐소생협회
Shock First vs. CPR First – 2005 AHA
 Witnessed arrest

AED / Defibrillator as soon as possible
 Not witnessed arrest

Pre-shock CPR (5 cycles, 2min) (Class IIb)

EMS response interval > 4-5 min: consider pre-shock CPR

Insufficient evidence in-hospital cardiac arrest
대한심폐소생협회
Shock First vs. CPR First
Who
Design
Intervention
(witnessed VF)
Baker PW et al.
RCT
(2008 Circulation)
Jacobs IG et al.
Survival
CI
(shock, CPR)
Pre-shock CPR
17.1 vs. 10.3%
0.56 (0.25-1.25)
5.1 vs. 4.2%
0.81 (0.25-2.64)
P = 0.048
(3 min)
RCT
(2005 Emerg Med Australas)
Pre-shock CPR
(1.5 min)
Hayakawa M et al.
Retrospective
Pre-shock CPR until
30 day CPC 1-2
(2009 Am J Emerg Med)
before/after
permission
14 vs. 28%
There is insufficient evidence to recommend pre-shock CPR
대한심폐소생협회
Shock First vs. CPR First – 2010 AHA
 Not witnessed arrest

CPR should be performed while checking the ECG &
preparing for defibrillation (class I, LOE B)
 In-hospital cardiac arrest

Insufficient evidence, Defibrillation should be < 3min

Team concept, simultaneous approach

(Pre-shock CPR + preparing for defibrillation)
대한심폐소생협회
1-Shock vs. 3-Shock – 2005 AHA
 VF/pulseless ventricular tachycardia (VT)

1 shock and immediately CPR (Class IIa)

Do not check the rhythm or pulse after shock (Class IIb)

Check the rhythm after 5 cycles of CPR
 First-shock efficacy & energy level
Biphasic > monophasic defibrillator
Monophasic 360J defibrillation (expert consensus)
대한심폐소생협회
1-Shock vs. 3-Shock – change effect
C:V ratio = 15:2
Rea TD et al. Circulation 2006;114:2760-5
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Defibrillation success vs. Hands-off time
 Observation: 868 shocks in 156 prehospital VF patients
Eftesol T et al. Circulation 2002;105:2270-3
대한심폐소생협회
1-Shock vs. 3-Shock – 2010 AHA
 VF/pulseless ventricular tachycardia (VT)

1 shock and immediately CPR (Class IIa, LOE B)

Do not after-shock rhythm check (Class I, LOE B)

Minimize hands-off time before shock (Class IIa, LOE C)

Immediate shock without rescue breathing (Class IIa, LOE B)
 First-shock efficacy & energy level
Biphasic > monophasic defibrillator
Monophasic 360J defibrillation (expert consensus)
대한심폐소생협회
Defibrillation Waveforms
 Defibrillation

Delivery of current through the chest to depolarize myocardial cells
and eliminate VF (300 – 500 millisec.)

Lowest effective energy needed to terminate VF

Shock success: termination of VF for at least 5 sec.
 Monophasic waveform defibrillators

Deliver current of one polarity
 Biphasic waveform defibrillators

Almost all AEDs and manual defibrillators today
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Types of waveforms
A
40
20
-10
0
4
8
12
msec
amp
Peak currents
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Monophasic vs. Biphasic defibrillator
 RCT: 150J biphasic AED vs. 200-360J monophasic AED
Schneider T et al. Circulation 2000;102:1780-7
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Monophasic vs. Biphasic defibrillator
 Lower-energy biphasic waveform shocks (≤ 200 J)

Equivalent or higher shock success (1st success rate > 90%)

RCTs: short-term outcome ↑, no survival change

No specific energy recommendation

 Multiphasic waveforms defibrillator

Triphasic, quadriphasic waveform vs. biphasic waveform
Lack of human study
대한심폐소생협회
Biphasic defibrillation – AHA 2010
 Safe & efficient biphasic defibrillation

Biphasic defibrillator > monophasic defibrillator
부재 시 Monophasic defibrillator 사용 가능 (Class IIb, LOE B)

Manufacturer’s recommended energy dose (Class I, LOE B)

모를 때 defibrillation at maximal dose (Class IIb, LOE C)

 Pediatric biphasic defibrillation

Initial 2 J/kg (success rate 48%), 2 - 4 J/kg (Class IIa, LOE C)

2 J/kg, 4 J/kg, consider < 10 J/kg or adult maximum dose
(Class IIb, LOE C)
대한심폐소생협회
Fixed and Escalating Energy
 Commercially available biphasic AEDs

either fixed or escalating energy levels
 Optimal energy level : unknown
 Definitive recommendation : not possible
 Selected First shock

Manufacturer’s recommendation: 120 J to 200 J
 Subsequent shock

At least equivalent or higher (Class IIb, LOE C)
대한심폐소생협회
Current-based Defibrillation
 Defibrillation

Delivery of current to the heart

Energy based defibrillation: variable current due to thoracic impedance

Current based defibrillation: encouraged

Optimal current for defibrillation: under investigation (30-40 A)
Lerman BB et al. J Am Coll Cardiol 1988;12:1259-64
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Electrode Placement
Anterior - both infrascapular
 4 pad positions: reasonable for defibrillation (Class IIa, LOE B)
 Apex-anterior: default placement (Class IIa, LOE C)
 Lateral pad: under the breast
대한심폐소생협회
Electrode Placement
 Implantable ICD / Pacemaker

Avoid placing the pad over the device (Class IIb, LOE C)
 Transdermal medication patch

Do not place pads directly

Remove patches and wipe (Class IIb, LOE C)
 Water

Wipe chest before attaching pads (Class IIb, LOE C)
 Victim on snow or ice

AEDs can be used (Class IIb, LOE C)
 Very hairy chest

Remove some hair
대한심폐소생협회
Electrode size & Transthoracic Impedance
 Adult : 8 – 12 cm in diameter (Class IIa, LOE C)
 Small electrode (4.3cm)

Harmful, myocardial necrosis
 Use the largest pads without overlap.
 Transthoracic impedance

Adult : 70 – 80 ohm

Use conductive materials to reduce impedance

: gel pads, electrode paste with paddles, self-adhesive pads
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AED (Automated External Defibrillator)
 PAD (public access defibrillation) Programs

Since 1995, AHA recommended

Early CPR & shock delivery by AEDs & trained lay rescuers

AHA Recommendations

Organizing, planning

Training of anticipated rescuers / frequent retraining/practice

Link with the local EMS system

Process of continuous quality improvement
대한심폐소생협회
AED (Automated External Defibrillator)
 Successful PAD Programs

Survival of OHCA ↑

Time from collapse to delivery of 1st shock (< 3~5min)

Airports, Casinos

1st responder programs with police officers

Targeted public area (recreation center, shopping mall, office
building, community center etc.)

General public area
대한심폐소생협회
Nationwide dissemination of AEDs
AEDs 9,906
AEDs 88,265
Kitamura T et al. N Eng J Med 2010;362:994-1004
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Community-based PAD programs
 Reasonable AED location

At least 1 OHCA every 2 yrs (Europe) or 5 yrs (USA)

At least 1 predicted OHCA during the study period
(>250 adults over 50 yrs, present for >16 hrs/day)
every 100m2
Folke F et al. Circulation 2009;120:510-7
대한심폐소생협회
PAD programs – 2010 AHA
 CPR & AED use by first responders (Class I, LOE B)
 Public location where SCA is likely to occur (Class I, LOE B)

Airports, casinos, sports facilities
 Plan to reduce time from collapse to shock (Class IIa, LOE B)

Establish response plan, train & retrain likely responders,
Maintain equipments, coordinate local EMS systems
 Continuous Quality Improvement (Class IIa, LOE C)

Performance of the emergency response plan

Responder performance, Patients outcome

AED function, Battery and Electrode pad status
 Home AED: no survival benefit (only one study)
대한심폐소생협회
Automated Rhythm Analysis
 Microprocessors
: Frequency, Amplitude, Slope or Wave morphology Integration
(Shock: VF, monomorphic VT, polymorphic VT)
 Other check
loose electrodes, poor electrode contact,
spontaneous movement of the patient, quality of CPR
대한심폐소생협회
AED Use in Children
 Ventricular fibrillation in children

Less common than adults (5 – 15 %)
 AED Use in children

Biphasic AED > Monophasic AED
2 - 4 J/kg (Class IIa, LOE C), initial 2 J/kg for easy teaching

4 J/kg or higher (<10 J/kg) for subsequent attempts (Class IIb, LOE C)
1 - 8 yrs: pediatric dose attenuation (Class IIa, LOE C)
(Use standard AED if not have this system)

< 1 yr: manual defibrillator > pediatric AED > standard AED
(Class IIb, LOE C)
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In-Hospital Use of AEDs
 No randomized trials, limited evidence
 In-hospital use of AED (Class IIb, LOE C)
Goal : early defibrillation ≤ 3 min. from collapse
In areas where staff have no rhythm recognition skills or
defibrillators are used infrequently
 Training & monitoring
First-responding personnel
Collapse-to-shock intervals and resuscitation outcomes
대한심폐소생협회
Fibrillation Waveform Analysis
 Aims
To predict success of defibrillation by analyzing VF waveform
 The value of VF wave form analysis
Uncertain to guide defibrillation management (Class IIb, LOE C)
 “defibrillate” asystole is beneficial ?
Not useful to shock asystole (Class III, LOE B)
대한심폐소생협회
Fire Hazard
 Several case reports

By sparks from poorly applied defibrillator paddles

O2-enriched atmosphere (disconnected ventilator)
Avoid defibrillation in an O2-enriched atmosphere (Class IIb, LOE C)
 Self-adhesive defibrillation pads with good contact

To minimize the risk of sparks during defibrillation
 Use gel pad for manual paddles

Risk for sparks with the pastes and gels (Class IIb, LOE C)
대한심폐소생협회
Synchronized Cardioversion
 Shock delivery timed with the QRS complex
 Indication

SVT - reentry, atrial fibrillation / flutter / tachycardia

Monomorphic VT
 Not effective : Automatic focus

Junctional tachycardia, multifocal atrial tachycaria
 Not used : only defibrillation

VF, pulseless VT, polymorphic (irregular) VT
대한심폐소생협회
Synchronized cardioversion - SVT
 Biphasic energy dose, adult (Class IIa, LOE A)

Atrial fibrillation: 120 to 200 J (increase stepwise fashion)

Atrial flutter & other SVT: 50 to 100 J (increase stepwise fashion)

 Monophasic energy dose, adult (Class IIa, LOE B)

Atrial fibrillation : begin 200 J (increase stepwise fashion)
 Cardioversion of SVT in children (Class IIb, LOE C)

Initial 0.5–1 J/kg, up to 2 J/kg (increase stepwise fashion)
대한심폐소생협회
Synchronized cardioversion - VT
 Adult monomorphic VT (Class IIb, LOE C)

Monophasic or biphasic 100 J (increase stepwise fashion)

 Child monophasic VT (Class I, LOE C)

Initial 0.5–1 J/kg, up to 2 J/kg (increase stepwise fashion)
 Any doubt: monomorphic or polymorphic VT
Do not shock delivery, perform unsynchronized defibrillation
대한심폐소생협회
Pacing – 2010 AHA
 Not recommended for asystole (Class III, LOE B)
 Symptomatic bradycardia

Prepare TCP (Transcutaneous pacing)


Immediate pacing


Not respond to atropine (Class IIa, LOE B)
Severely symptomatic bradycardia (Class IIb, LOE C)
Transvenous pacing

Not respond to drugs or TCP (Class IIa, LOE C)
대한심폐소생협회
Maintaining Devices
 Maintain devices in a state of readiness (Class I, LOE C)
 User checklists

To reduce equipment malfunction

To reduce operator errors

To properly maintain defibrillator or power supply
대한심폐소생협회
Summary – 2010 AHA
 The recommendations for electrical therapies

to improve survival from SCA / life-threatening arrhythmias
 Whenever defibrillation is attempted

High-quality CPR to minimize interruptions in chest compressions

Immediate resumption of chest compressions after shock delivery
 Single shock + immediate CPR for VF
 Use of biphasic waveforms

Further data is needed to refine recommendations for energy
levels
대한심폐소생협회