Transcript
Do a little quick intro here.
And again, this is our last presentation for the for the symposium And, obviously, I think this is a you know, it leads into the really critical topics we've had today on shock and resuscitation.
Doctor Kuzil, I know that this topic is is really taken to heighten awareness in the last 8 to 10 months publicly.
With AED usage and special considerations, and just a pleasure to have you here today.
So as far as I'm gonna give I'm gonna give a quick background as for this last session.
So as you see on screen, Doctor Kuzl is a clinical instructor at University of Louisville, the Department of Emergency Medicine.
He's he's also currently the administrative the administration clinical operations fellow at University of Louisville School Medicine in the Department of Emergency Medicine.
He received his doctorate in business degree from Lincoln Royal University from osteopathic medicine.
He's also had a a residency trained emergency medicine.
As well and excuse me.
In in in 2022, He was also recognized by the National as an Emergency Medicine Residence Association of the National Chief Resident of the Year.
He's continued number of different trainings.
He's also currently serves as assistant medical director for Bullitt County EMS.
Medical director for the Florida volunteer fire department in Ferndale High School Fire And EMS Academy.
He's been active in many aspects of the emergency medicine, and also has been a resident representative of the Surgeon General's Listening Round Table on Physician Wellness on behalf of the American Board of Emergency Medicine.
As well as other accolades he's had there as well.
Also as an EMS physician, he works as a medical adviser for the Louisville Metro Police Department and has received the Louisville Metro Police Department of Physicians Award.
And with that, Doctor Kuzl, thank you again for being here excited to have you here on our present or our symposium this week.
That's all I'm gonna give over to you.
Well, thank you, Doctor Kessel, for that introduction.
Hello, everybody.
It's very nice to meet you.
Like I said, I'm Doctor Kuzelle.
I'm an emergency physician and EMS physician.
In at the University of Louisville in Louisville, Kentucky and in the Department of Emergency Medicine.
And today, we're gonna talk about automated external defibrillators their usage, as well as some special considerations when using automating external defibrillators or AEDs.
So first, we're gonna talk about our objectives.
What we're gonna accomplish today, we're gonna talk about the features, functions, precautions when using AEDs.
We're kind of briefly review the push hard, push fast approaches.
I know Doctor.
Slaven has gone into that in pretty significant detail.
When it comes to CPR and cardiac arrest.
We'll talk about some of the safety precautions associated with resuscitation situations as well as the use of AEDs kind of the importance of medical direction, training, and maintenance when it comes to the use of AEDs, and then also some special considerations when it comes to cardiac devices and automated chest compression devices.
Some disclosures, I have no financial disclosures, but, of course, I'm open to any kind of financial forms.
I don't work for Zol or for Lifepack who are kind of the big makers of the automatic external defibrillators, but I'm always open for that kind of stuff.
Just a couple things.
I am faculty, University, local, Lincoln Memorial University.
It's adjunct clinical.
Also, a board of director for the Emergency Medicine Residence Association, and then also medical director for Spencer County just sign the dotted line there, assistant medical director for Bullitt County in Kentucky, and also a TEI medical director for flirty fall into your fire department.
So I heard you all were talking about Demar Hamlin, and so I thought it would be very important to start with why this has become such an a a a national hot topic and talking about CPR and what this actually what this means for us.
And this was kind of the 1st national discussion about the on scene CPR and prolonged CPR on scene compared to the traditional of what we at least previously accepted as the load and go approach and putting patients into the ambulance and going as fast.
And as Doctor.
Hilton, Doctor.
Heath have kind of alluded to.
What we found when we move these patients into the ambulance, we really had that lack of quality of quality CPR and quality of compression death and good airway management.
And so what we found with Lamar Hamlin with his survival is what really proved what we've been doing in EMS over the last 10 to 15 years, which is kind of forcing our crews to stay on scene until we have a a defibrillable rhythm or getting some type of decision of whether or not to terminate resuscitative efforts in the then fortunately for Demar Hamlin, they were able to successfully get Ross and transport him, and he had a very successful outcome with neurological safe safety.
And so this has kinda brought that this this CPR cardiac arrest in the field and staying and and and actually running the arrest into field has become kind of a natural hot topic issue, but things that we've been doing for 10 to 15 years, it just now made it to the natural spotlight.
Now, you know, we now have seen this on national news.
A NFL player went down at cardiac arrest, but how common is cardiac arrest?
And, really, it's about 250,000 sudden cardiac arrest per year.
And to put that into perspective, we have naturally about 42,000 deaths from motor vehicle accidents, but we have about 5,000,000 motor vehicle accidents a year in Kentucky alone.
So that it it kind of varies.
It varies to, like, death from motor vehicle is very low, but sudden cardiac arrest is pretty high.
But this sudden cardiac arrest is also including those that are in hospital cardiac arrest.
Now victims are typically gonna be greater than sixty five years of age.
And of that 250,000, 7000 of those are gonna be under the age of eighteen years.
It's going to be mostly those 7000 are going to be those that are out of hospital cardiac arrest each year in the United States.
Now Even though athletic cardiac arrest has become kind of a forefront and is very visible in the media, we all have an idea of a video that we've watched once or time where there's a basketball player who gets hit in the chest by an elbow and then collapses and goes into cardiac arrest in the field.
But there really is no evidence to suggest that cardiac arrest is more common in athletes than the general population of young people.
Although individuals with hypertrophic cardiomyopathy die at a young age, that is not those are supposed to be precluded by physical examination, and they do have a more higher likelihood of entering cardiac arrest from an arrhythmia But these are individuals that are a separate population that does not account for the entire young youth athletic population.
So one of the the most difficult things to determine when someone is in a cardiac arrest is how to determine someone is a cardiac arrest when you are a lay person, you don't have the training, you don't feel for pulses on a regular basis.
And so I kind of bring it back to how we determine dispatch.
Now when a call comes into 911, our emergency dispatch system will actually give pre arrival instructions to the person in the second party caller to determine a cardiac arrest.
And the things they look for are, is the patient unresponsive, if they're not breathing or they're what they're only gasping or having guppy breathing you might have heard of, or animal respiration is kind of the medical term of this.
And these are signs of cardiac arrest.
And so basically, my recommendation for those of you who may not have that experience is looking for those unresponsive patients who are not breathing vaginal respirations, and those are cardiac arrest until proven otherwise.
And that is why so many individuals who have opioid overdose get Victor or bystander CPR is because it's very hard to determine whether that's an overdose or whether that patient is a cardiac arrest or both.
Now often what we see in the pediatric athletic population is from cardiac rest, is usually from commercial quarters.
Now there could be some underlying arrhythmia such as hypertrophic cardiomyopathy, but most of the time it's from a commotional cortisone, that's a injury to the center of the chest.
This was what was suspected of what caused the cardiac arrest in Demar Hamlin, but it's also what we see a lot of times in our boards where we'll have a pediatric patient who was playing baseball and now found in cardiac arrest.
And most of the time, it's come from commercial cortis.
And what happens is you take an injury to the chest and that causes some increased rapid increase of intercavulatory pressure around the heart, and that causes if it hits it right on the right time, it's r on t phenomenon, which basically it hits at the at the heart's t wave where it's repolarizing to allow it to restart the cycle of beating, and it caused it to go into ventricular fibrillation, which then is Ergo into cardiac arrest because the heart is not perfusing the body, and that is a shockable rhythm with AED.
So that's a little bit of a review.
I know Doctor.
Slater probably went into a lot of details about cardiac arrest, but this allows to look at from the pediatric athletic side and and athletes in general side and kind of determine what what we're looking for.
And this is the chain of survival.
So basically, you have bystander 911 activation, but really where we can be involved in in the athletic situation is early CPR early detection of cardiac arrest, and early defibrillation.
Now the activation 911 in the chain will then activate advanced life support ambulance and EMS personnel and then we'll also activate transport, which then gets the patient to the hospital.
And then there's a whole link of chains to that survival.
But what we're focusing on here today in this presentation is early defibrillation.
Now before we talk about entering the scene and taking care of patients, it's very important to discuss scene safety.
One of the first things that EMTs learn when they go and take their national registry is they put their hands up and they say, BSI scene safe.
And we do this regimen because it's important for EMTs to always recognize not to enter a scene if it's unsafe.
I really preach this when it comes to domestic violence that individuals should always back out and wait for police to secure the scene and not putting yourself between 2 aggressors, whether that's the the the the one partner or the other.
In this case, this is probably more likely where we're seeing where the scene is unsafe.
We have individual who's found unresponsive, not moving, not breathing, and there's some down power lines there.
Putting yourself in trying to do CPR when there's down power lines, is not safe for any individual to get close to because that could create more victims.
So it's better to wait even though that individual may be in cardiac arrest, it's more important to make sure that nobody else joins this individual in that cardiac arrest.
Well, then athletics, most of the time, it seems safe, but if you look at the U University Louisville and Notre Dame game, which I had to work as a as a with my team and with our EMS team and with our other emergency positions.
You know, you have the storming in the field by the university Lowell fan.
So you could have a cardiac arrest, the game's over, and the t and you have individuals starting to move into the field.
That becomes kind of an untenable situation that you're gonna have to get this individual out of much quicker because the scene is no longer stable.
Won't will we really see unstable scenes in a athletic normal athletic day, probably not.
But it's always something to keep in the mindset when you're talking about and looking at cardiac arrest and also media we saw a Demar Hamlin cameras, every, you know, individuals who wanted to get involved, you know, you'll have doctors jumping off and the Raptors trying to get involved and adding to the scene that is gonna already be chaotic.
Now let's talk about the first two steps before we get into defibrillation.
So first, you're gonna call 911, and I love doing this to my residence and to my medical students that I teach ACLS for is I love them to just start CPR.
And if they never ask for 911, I don't dispatch resources.
So 10 minutes go by, they look at me and they're like, okay, ZMS here yet, and I said you never called them.
So it's very important to make sure you're calling for backup before you start the push hard, push fast, and center of the chest, and your typical CPR.
And you really wanna aim for a 100 and a 120 compressions per minute.
So always start getting those resources because it can take 10 to 20 minutes and by 3 rounds of CPR or 6 minutes, you're gonna be a little bit winded if you're doing it yourself.
Now your question is, how can I count a 100 to a 120 compressions per minute?
Well, the good news is you can really do it if you're a music lover like I am.
You can always find a list on Spotify where the American Heart Association actually has a playlist that they recommend.
So you can do hips don't lie by Shakira.
You can do work it by Missy Elliott.
You can do what the most typical that they teach is staying alive.
There's move along by all American rejects.
There are songs in all different 100 beats per minute to a 120 beats per minute as you can pick.
My personal favorite one doing CPR is Queen.
Another one bites the dust.
It's a little bit morbid, but I am a very dark humor individual.
So let's talk about now that we moved away from early CPR, let's talk about the early defibrillation.
Let's really get into the discussion about automated external defibrillators.
So here's the bad news.
With external defibrillation, you ventricular fibrillation and pulse and VTech are the only things that you can actually defibrillate.
There are several diff other different types of cardiac arrest rhythms that we see.
And unfortunately, 30% of those that we can actually make an impact on with defibrillation.
And that's ventricular fibrillation and pulseless ventricular tachycardia.
Other times, you can see pulseless electrical activity or PEA, or you may see asystole.
And those are not gonna be rhythms that an AED is gonna help you with.
And unfortunately, for defibrillation, even if we have the standard cardiac arrest survival, which is early defibrillation and early CPR, still the standard cardiac arrest arrest survival rate is only about 10%.
And each minute of delayed defibrillation in ventricular fibrillation and pulse's v tach arrest Even every minute of delayed deferralation, every delayed minute to CPR, we see a decrease of survival by 7th 10%.
So it's very important to make quick assessments of these individuals and start doing CPR very quickly.
Now the good news is we found is that if the patient enters ventricular fibrillation arrest.
If we can defibrillate within 3 minutes, that individual has a 75% chance of survival and a 40 45% to 50% chance of good neurological survival.
And then when we study those that had AEDs that were present on-site of the cardiac arrest, compared to those that did not have an AED on-site, survival chance doubled when the AED was present on-site in those research So that's the good news.
And that's also the the really the good sales tech for why we need to have an AED, especially when we're talking about athletic events.
And these are the different type of AEDs that you'll see you have the Philips.
It's probably the most common, the red, the life pack, which is back there in white, and then the lime green souls that are probably the most common, but there are other manufacturing.
It really depends on your program, your cost minimization, and what AEDs are going to be best for your for your practice and your use and what is most easy to mobilize, etcetera.
Now what are automatic external defibrillators and what do they do?
So we've determined that they're safe, and they do not deliver inappropriate shocks, and they only shock certain types of rhythms.
And that's gonna be ventricular fibrillation, which you have in front of you here or pulseless ventricular tachycardia.
These do not cardiovert.
So if you've taken an ACLS class, These are not what's used to cardiovert individuals who are unstable with the pulse.
This is only for pulseless or cardiac arrest patients that have ventricular fibrillation or pulseless ventricular tachycardia.
And this is how you can use an AD, and they all pretty much work in the same way.
The first thing that you do, and I always prefer this, a lot of people like to get ahead of themselves and plug in the electrodes, but it kinda sets off the machine.
So first, you turn on the power, It'll say connect electrodes and attach the pads to the patient.
So that's essentially which do you turn it on.
You attach the pads, one to the right of the chest, one to the lateral left of the chest as you see in our individual here.
And then it'll push they'll ask you to push analyze.
When you push analyze, that's the only time that you should not be doing compressions.
During that time before, you're setting up paths, you should still be delivering compressions.
It's only when the thing when the AED says that you should analyze, that you should it'll tell you to hold compression so it can analyze the heart rhythm.
Then it'll say shock advice or no shock advice.
If no shock is advised, then you would immediately start compressions.
If a shock is advised, then you'll ask you to it'll start to say charging automatically.
While the AED is charging, there is no risks to the individual doing CPR.
So you should continue CPR while the AED is charging.
When it's ready to deliver a shock, it'll say it'll start blowing.
That little lightning bolt red light will start to flash and say ready to shock, it'll have a hold of the sound.
At that point, you wanna clear any individuals from touching the patient and then deliver the shot once everyone is clear and not touching the patient.
So that's as simple as using AED.
Now there are different positions of pad positioning.
Obviously, for the adult and child greater than 8 years, you can use the adult pads.
And place them on the right chest at kind of the center of the chest or just above the nipple line, and then the left just around the left lateral side or where the part would be around the left ribs and just underneath the the left breast.
For children, if they there can be pediatric pads associated with the AD.
It depends on the medical direction and also the manufacturer.
So some ADs will have pediatric paths and infant paths The ones that we have at our football stadium have all 3, but some places in the House of Worship may only have adult pads.
If you only have adult pads or alternate position for a child of less than 8, you can actually take the adult pads and put them on the front of the chest and then on the patient's back.
And that's the same thing for the infants as well.
You really want to use the manufacturer path for pediatrics.
But if you don't have that opportunity, you can always use the adult pads on front and back.
It's better to have some type of defibrillation for ventricular fibrillation arrest than to not do it at all based on survival.
And then pregnancy is a little bit different, especially when you're having pregnancy that's a little bit far along, but the position statement or the position statement.
The positioning of the pads is very, very similar.
So couple things as like a sobering moment, Every one minute without CPR has a 10% decrease in survivability.
And ideally, when you're doing chest compressions, you the idea of chest compressions is to perfuse and get oxygenated blood to the brain.
The reason is if we don't do this, if we don't provide oxygen to the brain, then the tissue in the brain dies.
And, yes, you might get the heart back, but you may not get the brain dead.
And a lot of these individuals who die from CPR or not that the heart stop, we were able to resuscitate the heart, is that their brain is no longer functioning, and then they are considered brain dead.
So ideally, every time you take the stop compressing the chest for more than 10 seconds, you have a chance of losing that brain function.
So you wanna make sure that you're keeping that coronary and that cerebral perfusion comp pressure up in getting that perfused blood full of oxygen to the brain tissues.
So next let's talk about public access to fibrillators.
So this is an example of a public access to fibrillator found in Annapolis.
Maryland is just kind of in a neighborhood.
But these are also things that you could see in the stadium around the area of the concession standard for some of the high school stadiums and and athletic events.
And so the question I want to ask and look for is public access to fibrillation worth the squeeze.
And really for the data that we've had from the early 2000 to the 2010 says yes.
And there were 3 major studies that kind of prove this to us.
There was the casino study which looked at defibrillation from public access defibrillators in ventricular fibrillation and VTAC, those of individuals who had early defibrillation, 53% survived.
And this is where we got the initial data that individuals who were defibrillated within 3 minutes had a 75% survivability.
Yeah.
American Airlines looked at AEDs on their planes, and they actually had 36 cardiac arrests in flight in 2009.
And they found that those individuals who had AEDs onboard and and delivered defibrillation on an American Airlines aircraft with the use of AED.
40% had complete neurologically intact and survived to hospital discharge.
And then finally, 2004, when they looked at public access to fibrillator's between public access defibrillators available and those not.
So late person CPR versus late person CPR and AED use.
The group that had AEDs with layperson CPR, their survival rates doubled.
So, yes, the juice is worth the squeeze.
But additionally to the juice being worth the squeeze, there's also a sense of liability.
In Kyiv versus Sports Fitness Clubs of America, they actually found for the plaintiffs 2,500,000 is awarded to the plaintiff because there was no AED available at the fitness club of America when they had this court place.
So is it there's a benefit and survivability, but there is also a liability if we do not have that public access to fibrillation.
Now where do we how do we build these programs, and where do we put them?
So really, it's targeting high risk, high traffic locations where we're gonna have that patient greater than 65 and where we're going to have a crowding of large individuals where the likelihood of a cardiac arrest is to occur.
So that includes convention centers, the Arris tour, Taylor Swift, for my Swifties out there, wherever that is, you probably wanna have a defibrillator close by because the shock of Taylor Swift coming on would probably put my wife into a cardiac arrest or at least meeting her, so definitely wanna have that defibrillator nearby.
Fitness centers, of course, when you're at when you're stressing the heart, hospitals clearly, and then, of course, athletic centers and airports were these high traffic areas.
I saw a comment from probably the chat about, I'm sure that got somebody with the t swift.
Now as of for response plans, you really need to have all these in place when you're developing this program.
There's a notification system to alert the site responders, whether that's a bell within the system or there's a computer algorithm software, which alerts security, to mobilize resources once the door is open.
Additionally, you wanna make sure that your your responders are trained in how to use the AED, whether that's people on staff or EMS that you have on staff.
Where to deploy the AD, maintenance of the AD, what are those requirements to make sure the AD is running when you need it, and then also QIs to make sure that we are shocking appropriately and that the the AD is functionally appropriately.
Now for training, There are 2 great courses that we use that most hospitals use as the American Red Cross, and then there's the American Heart Association Training Center.
Probably the one that I've trained most with is the American Heart Association.
But American Red Cross is also a good company as well.
There's other places.
These are just the ones that most hospitals recommend.
It's about a 4 to 8 hour course.
Sometimes they're 12 hours.
The recommendations from from my standpoint is you really wanna get the hands on, especially using mannequins that have that that audio feedback to tell you whether or not the compressions, it can be as easy as a click or as as easy as, like, the there's some that are high fidelity model that actually will tell you your end title CO2 that you're you're creating with every compression, just like you would in a hot but even the low fidelity, which just has a click for the correct depth, is appropriate.
And, of course, you definitely wanna be able to have that practice with an AED so that the first time you're using an AED is not when you're needing it.
Recertification every 2 years, every 1 hour refresher is what's recommended yearly, and, of course, the simulations as available.
Now AEDs are not cheap.
They are about 1500 to 2000 per unit, and that doesn't include the housing.
That is just the AED itself.
It's all dependent on the manufacturer just like the Honda Pilot or some Toyota Corolla has a maintenance requirement and oil change.
So do ADDs.
They are mechanical and computerized.
They will fail if they're not adequately checked.
So some places, like in the hospital, when we use eighties, we check that daily.
So we actually you'll see if you're ever in the emergency department at, like, 7 AM or 7 PM, The charge nurse will hit the AD, make sure it charges, and deliver a fake shock to make sure that the system is working and charging appropriately.
But I don't think that's necessary for your 80 recommendations every single day going out to the stadium and checking in.
Remember that pads expire and they are not lose their fidelity after 2 to 0.5 years, the battery can expire as well then also the internal monitor stuff need to be checked.
And usually, the battery will last about 2 to 5 years.
Another important part of this programs have some medical direction.
The medical director usually is a county or local EMS medical director, and it's an essential component for medical direction.
You wanna make sure you have an emergency response plan, having that physician consultation to make sure you have approval or training plan, which is required by most states.
And also determining where the AD placement is best for where EMS and the members of the public can find it.
And also to get an AED, you're gonna need a prescription to purchase an AED, and especially one that is new.
You might be able to get refurbished from the Facebook marketplace But to get a new AED with all the the manufacturing warranty, you're gonna have to get a prescription from a physician.
Now, lastly, in the last couple minutes that we have, I'm gonna talk a little bit about the special considerations that you have when it comes to AEDs.
There's pediatric cardiac devices What about the sports pads and equipment?
How can we do CPR over them or take them off?
And then, of course, automated CPR devices.
Pediatric AEDs, sometimes the ADs will not have pediatric pads.
So simply putting the adult pads over the patient's chest like seen here in the image, as well as behind the patient and using the AD just as recommended.
It's always preferable to have the pediatric pads and for that age group.
But if you are in a desperate situation, this is all you've got.
It's it it is what is recommended.
And the AED will typically this will separate the charge so it's not damaging to the patient.
Cardiac devices, one of the questions I get a lot is what about a, the automated internal defibrillators and pacemaker devices.
The good news is most of the time if there's an a if there's a internal defibrillator already, then Typically, it's gonna fire on its own, and you're never gonna have to use it, and you're just gonna call EMS.
But if it is, you can give it 30 seconds to actually you'll see the muscle spasming in the left chest, and you can actually give it 30 seconds.
If there's no return of cardiac function, then you can go ahead and deliver and use the a d as recommended.
You could still put the placement just as typical.
You put in the right chest and below the left chest.
The only thing that you wanna avoid is putting it over the actual device itself because you will then short circuit device.
So don't put the pads over the pacemaker or over the defibrillator itself.
Now let's talk about pads.
And when we're talking about, like, football pads, hockey pads, and lacrosse pads, So what we found from football pads is that we do have a decrease in depth compression.
So it is recommended to go ahead and start while you're cutting the pads off.
To get to start CPR.
But really, it's when the the trainer's angels kinda come into play and taking out taking off the pads and and getting CPR started.
And so, recently, in the last 2018 to 23, we looked at this in the data and looked at this in the literature to see, can we do effective CPR over the paths?
And so this came from 2018 Journal of Athletic training, and it was the ability to provide quality compressions over lacrosse shoulder pads.
And what they found there was there was no change in compression depth or advocacy when it came to lacrosse shoulder pads.
Now that works for lacrosse, but what about football?
So what about under protect equipment or over protect equipment in this 2014 study in the clinical clinical journal of Sports Medicine and they found a 15% decrease in chest compression and death with football pads.
Now, whether that is clinically significant, it's hard to say, We do assume that if there's less chest compression, it's not as adequate CPR, but it doesn't necessarily say there wasn't a look they didn't look into the difference of survivability.
Now this study which was done 2016 did show the removal of chest compression and ventilation did improve with the removal of football equipment, including the helmet, and including removing the shoulder and chest pads.
But what about hockey shoulder pads?
And so we talked about shoulder pads when it comes to lacrosse.
What about when it comes to hockey?
Well, this journal out of the Ohio Athletic Trainers Association actually showed that we had decrease or we didn't poor chest compressions only fit half of the time, 51.82% of the time.
And the adequate ventilation was only 35.64% the in simulation.
And the overall CPR score when compared to pads off and pads in was was about 69% when performed with hockey pads.
And, of course, If you're gonna have to defibrillate, you're going to you could probably put it underneath the pads and defibrillate effectively, but you really want to get those pads off is what we're fine.
Now, finally, in the last couple minutes of the time that we have together, I'm gonna talk briefly about automated CPR, and these are 2 of the most common that we see.
We see the Lucas device, as well as the auto pulse.
The advantages of automated CPR is that you get some uniform, presumably high quality CPR, You don't have to interrupt between the two individuals that are switching off for CPR.
You're not having as many fire fighters and different members of the community switching around and being fatigued.
And then also you're pretty you're easier to transport this compared to the 6 firefighters that you have to put back in the ambulance.
Now some of the disadvantages of automated CPR is that this device takes a time to set up.
And incorrectly aligned devices can actually make it more difficult to get adequate CPR.
And there's even thoughts there could be more injuries.
In a study in 2022 that looked at automated CPR devices, they found more about doubled the chance of rib fractures when the use of automated CPR device and had a higher one third risk of pneumothorax compared to manual CPR.
And there really is no large body of evidence.
Now to push back a little bit on that research study with more a a third more of pneumothorizone rift factors.
The question is, are we doing poor CPR when it comes to manual CPR compared to automated CPR?
And that jury is still out.
There really is not a large body of evidence to support either or yet.
And so when we looked at this study in 2020 is the data's coming in.
They did look at 71,000 interventions, and they actually found they compared the 2 of automated compression devices had 63.5 percent of Ross and 49.8 percent of Ross can manually compress individuals.
But they're really well, they didn't have a discussion on 30 day mortality, which is really the tellers.
Did they survive the hospital discharge?
And, yes, we got Roche, but did it change the outcome of survival to hospital discharge or 30 day mortality?
So that is it for automated external devices.
I hope that's been helpful to learn kind of the data and learn why we need to have this in and also how to develop this program.
In summary, we have about 250,000 out of hospital cardiac arrest per year.
30% of those are ventricular fibrillation.
If you get 3 minutes of defibrillation within 3 minutes, you can have a 75% survival rate with ventricular fibrillation arrest.
The juice is worth the squeeze with public access defibrillation, but it's not as easy as buying a defibrillator from Facebook marketplace.
There is training you need, there is maintenance, and medical direction that that is a cost to building that program.
Special considerations with pediatrics front of the chest in in the back.
Cardiac devices don't put the pads over the cardiac device themselves.
It's better to remove the sports pad with the exception of maybe the cross, but still we need some more data to determine it.
When in doubt, remove the pads, and then automated CPR may be superior to manual CPR.
But it's a very expensive investment, and still there's not a large body of evidence to determine that.
But again, this I hope this has been helpful for you all.
My name is Doctor Kuzelle.
This is my email.
If you ever have any questions, and I'd be happy to answer any questions at this time.
Yes, Doctor Kuzelle.
Fantastic overview of AD, some very timely topic.
If anyone has any questions, please put them in the q and a, or if you'd like to raise your hand make sure your hands raised.
For that, we can answer questions.
So before we get started, I have a couple of questions.
If I just wanna go off on the on the songs you listed, you know, having that list.
So you gotta go into the country's countryside.
So I just did a quick search again.
I I knew I'd seen them before, but you know, a couple good ones that that fit in line with Queen would be a little too late by Toby Keith.
Uh-huh.
Done.
Done by the band Perry.
You know, another one by Randy Travis is too long, too long.
And then also, you may think about even more you can say, like, something more by Sugar Land.
So there's just a couple of ones there.
I like gone by Montgomery Gentry.
That's the one
I go for.
Yep.
That's a good one.
Well, I'm
like a freight train going like yesterday.
Oh, yeah.
He's going.
That's a a good way good way to however you learn it, get the beat, you know, you have have one for everybody in the in the least a 100 beats or close to it as well.
As we got some hopefully, get some questions coming in, audience.
Hope you if you wanna talk with Doctor Giselle or Doctor Heath, ask you questions.
Raise your hand.
I see one JD.
If you have a question, just let me know if you wanna go live, I'll I'll put you live on the audio.
The one question I have for you, and I think this comes up maybe come up is, like, for the automated defibrillators.
Mhmm.
Is there a situation where the patient or or the the late person who was applying it they apply it to a to a patient, and it would really read a shock, and the patient is still conscious.
And if so, but, you know, it comes up as I mean, I've I had that question before, and I had to think about it as well just because it's a like, someone who may have I did a case presentation on a case study about 2 months ago on Comenocortis, but the patient presented start presenting became really symptomatic about 8 hours after the fact, and they developed a trickier flutter, which then would have led in, they they they by the time that the the adolescent athlete was in the in worksheet when we presented with the flutter.
So just question, you know, because the high heart rate.
So, yeah, it it it is possible, and that's exactly what the AED is is you know, there's always the fear.
There's always the the the TikTok or the Instagram reels where the firefighters are joking about how it's charging on its own, and everyone's like, stop.
Stop.
Stop.
And they accidentally, you know, there's always a joke about that that goes.
But yes, could they potentially absolutely.
Now they are pretty safe and they when they're used for the appropriate for the appropriate setting, which is that unresponsive, not breathing cardiac arrest.
But sure, it is looking for a high heart rate couldn't potentially see SVT?
Probably not.
But in the case of when you have ventricular tachycardia with a pulse, So the same pulses VTech and then, you know, poll VTech with a pulse, those are the very same rhythms.
So it could be confused when you still have it on the patient that's conscious and they're in a ventricular tachycardia, it could recommend a shock at that point.
It's not what it's designed to do, so it has to be on the individual provider and layperson to actually, you know, shut off the device when the person is alert and talking to you and supposedly has a pulse.
And then if we get into BLS and and ALS, this is when you end up calling for ALS backup because the next thing you need to do with this conscious patient with a ventricular tachycardia with the pulse is start giving amiodarone and other medications.
Yeah.
Said to tighten medicines, they can actually then you can do the administration.
And I they're gonna And
they get it with a biphasic device where you need to synchronize cardioversion.
Yep.
So one question or is a comment that Eric Fuchs brought in the place was one resource is like the image.
It's the public point app or public point Okay.
Post point AED.
Where you can have one you can find an AED.
Now the the only thing with that is if it's registering someone has put that information in there, but I've seen that app before.
It's very it's a very useful app, and and they're just also knowing where those are within your locale.
And if they're Yes.
They're accessible, and they're operating.
One quick comment, and I'm gonna give it over to Doctor Heath to note, like, he's got some questions as well over the audience, is he brought up the point of checking the ADs, and I think that was an excellent point of if you have ADs on a regular if you're to school or whether you check that, whether it's you may do it every day, you may do it every week is have it written and stone or I've ever written in your policy procedure as to when you're going to do that, and then you need to follow make sure that it's followed through.
One of the biggest case if you think of cases that both people You mentioned some lawsuits as well.
You're gonna lose a lawsuit if you don't follow your procedure and whether and if you don't do it enough once a year, I'm not gonna I'm not the attorney on either side, but we'll probably think you wanna do it more than that.
If it's every day, just follow follow your plan you have, including protocols as well.
So
And that's the importance of having that medical direction.
It's having that physician to consult and say, Well, this is what the manufacturer recommends.
And a lot of times like Zol and Lifepack will have that recommendations and manufacturer recommendations as well.
And and, you know, you'll have you'll have some way some formalized way, but you have to have some written see in your in your manuals of when the time is to check these out.
Yeah.
I think I was gonna even with char like, I know that some there are some companies that offer that that physician direction with the guided service, so to speak.
But that may be helpful, like, for a church or someone who they would they don't have that specific direction, but they need they need to have that because it's a public access point NUD.
And having that also having bleeding control kits.
Those are having both the you may see those as a combination bleeding control and the CPR.
Yeah.
If you don't know where to start, your county medical director if you have a county medical director, you have a a public health director or your EMS medical director as gonna the EMS medical director is gonna be most likely the one who's covering it for the county.
Yep.
And we and we were talking about earlier in the previous presentation, most Aflac the Aflac trends are good.
They will all all of them will have physician direction by state law.
So go if you're uncertain of where to get some of the you're gonna have to order depending on the device, you have to have a physician sign off in order to make that in order to complete an order for an AAV, And again, it's just, you know, as a license provider, you just gotta go back.
It doesn't same same things don't apply.
To the layperson as you have different things that come into play, whether it's medication administration, like, NARCAN or something that is not the topic here.
But because you have access to it, doesn't mean you can do it necessarily.
It goes under different the whole different it it goes off the window, bits of meriden, those things you need to make sure those are checked on as well.
So doctor Heath, doctor Gazelle, you wanna I guess, any other comments on that?
I will just maybe add one more thing.
So last time I checked, the American Heart Association guideline, had a class 2b recommendation for the mechanical CPR devices.
So it's still recommended that you do hands on CPR, but if the situation warrants, like, the risks, the benefits outweigh the risks.
Like, in our in our place in Guernsey County in Ohio, it's pretty rural.
So sometimes, we only have 2 medics on a truck, 1 to drive, and 1 to do care.
So our decision was to get the pneumatic piston device So the Lucas.
So there are 2 types of devices out there for folks that are listening.
You got the pneumatic piston devices.
And you have a low distributing band devices.
So the piston is basically a plumper, and then you have a Lucas and you have a Michigan instrument.
Those are the 2 type those are the 2 brands for the pistons.
And then you have the low distributing Vazole, the auto pulse.
It it actually takes the the thorax and squeezes it.
So since we get a lot of blunt trauma in our area, our decision was to get the piston device rather than the compression because we didn't wanna cause trauma, you know, unlike those Amish people and things falling, that type of thing.
So I just wanted to add a little bit about the mechanical CPR devices.
So as we're I guess to add for Doctor Heath, you mentioned, like, Forest Rural Areas.
Just something to be in consideration, I'm assuming that you may you have a BLS unit who's out in that area.
Correct?
Or maybe rule.
But you're doing they are they're doing initial care, but you're doing some form of communication to intercept with an ALS unit if if the basically, the the distance.
Is that that would be the case, I guess, if it's a 30 minute drive from where the closest to the to the emergency facility, accepting facility, they may have a ALS unit go and transport, and their product care, and they may meet them at a certain point on the road.
Or at a intersection to assist in delivery of care, and then they move along with having more advanced resources.
Correct?
Correct.
And as doctor Kuzelle will attest to with his multiple EMS direction responsibilities, you can only have so many of your trucks out of the county at any given time legally.
So you have to really really watch on where you send your trucks and who's available at any given time.
Yeah.
And we, you know, we have that In Spencer County, we have 2 trucks for the entire county of Spencer.
We're building more, but we're in a in a building posture at this time, and it's a pretty big county.
And so our response times are usually on average 15 to 20 minutes anywhere in the county.
And so, yeah, you may only have one paramedic on for that time, you had to be very judicious on where you're saying that paramedic.
So in that, you know, if we're if we're talking about Metro Louisville, Sure.
We have paramedics.
We can spare.
We can do ALS intercept.
But it's gonna be the decision of, do we take the paramedic county, or do we go are we 10 minutes waiting to go to the hospital and distance, or are we 20 minutes waiting for the ALS intercepts then takes that paramedic out into Shelby County.
We're our hospital that there's no hospital expense accounting.
We have to go to Shelby County, which about 20 minutes away.
Do we take that paramedic out of service?
For 45 minutes, or do we just go to the hospital with the BLS group?
So it's the difficult decision that you have to make in in when you're trying to determine resources for the county and with with your in relation to what medical calls and what trauma calls are coming in.
Great.
Thank you.
I think we are we are now at the last minute of the Sports And Emergency Care Symposium 2.0.
Uh-huh.
It's been a pleasure having doctor Gazelle.
Thank you for wrapping things up today.
Doctor Heath, thank you so much for lining up a fantastic topics and the flow of the topics through today on shock and resuscitation came in to thank you enough.
Audience.
Thank you so much for participating throughout the symposium.
We will send information about how to access the courses on demand in the next day or so.
And with that, I just wanna thank, actually, one of you again.
For your time and effort put into these presentations.
Thank you all so much, and thank you for the opportunity to come hang out with you.
Great.
Great.
Look forward to having you on lunch.
Yeah.
Definitely.
For both of you all.
Excited sorry to have you all here, and great to work with you all during the symposium.
You all have a good day.
Thank you.
AED Usage and Special Considerations
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