Automated external defibrillator

An automated external defibrillator or AED is a portable electronic device that automatically diagnoses the potentially life threatening cardiac arrhythmias of ventricular fibrillation and ventricular tachycardia in a patient,cite journal|url=http://circ.ahajournals.org/cgi/content/full/95/6/1677|title=Automatic External Defibrillators for Public Access Defibrillation|last=Kerber|first=Richard E|coauthors=Becker, Lance B; Bourland, Joseph D; Cummins, Richard O; Hallstrom, Alfred P; Michos, Mary B; Nichol, Graham; Ornato, Joseph P; Thies, William H; White, Roger D; Zuckerman, Bram D|date=1997|volume=95|issue=1677-1682|journal=Circulation|publisher=American Heart Association|accessdate=2007-06-28|pmid=9118556] and is able to treat them through defibrillation, the application of electrical therapy which stops the arrhythmia, allowing the heart to reestablish an effective rhythm.

AEDs are designed to be simple to use for the layman, and the use of AEDs is taught in many first aid, first responder and basic life support (BLS) level CPR classes. [cite web|publisher=American Red Cross|url=http://www.redcross.org/services/hss/courses/adultcpraed.html|accessdate=2007-06-28|title=CPR Adult Courses]

Usage

An automated external defibrillator is used in cases of life threatening cardiac arrhythmias which have led to cardiac arrest. The rhythms the device will treat are usually limited to:
* Ventricular fibrillation (shortened to VF or V-Fib)
* Pulseless Ventricular tachycardia (shortened to VT or V-Tach)

AEDs, as with all defibrillators, are not designed to shock asystole ('flat line' patterns) as this will not have a positive clinical outcome. The asystolic patient only has a chance of survival if, through a combination of CPR and cardiac stimulant drugs, one of the shockable rhythms can be established, which makes it imperative for CPR to be carried out by any lay rescuer prior to the arrival of a defibrillator.

In each of the two types of shockable cardiac arrhythmia, the heart is in activity, yet in an unusual pattern which can be life-threatening if left uncorrected. In ventricular fibrillation, the electrical activity of the heart becomes chaotic, preventing the ventricle from effectively pumping blood. In ventricular tachycardia, the heart beats too fast to effectively pump blood. Ultimately, ventricular tachycardia leads to ventricular fibrillation. The fibrillation in the heart decreases over time, and will eventually reach asystole.

Uncorrected, these cardiac conditions rapidly lead to irreversible brain damage and death. After approximately three minutes,Fact|date=December 2007 irreversible brain/tissue damage may begin to occur. For every minute that a person in cardiac arrest goes without being successfully treated (by defibrillation), the chance of survival decreases by 10 percent. [American Red Cross. "CPR/AED for the Professional Rescuer" (participant's manual). Yardley, PA: StayWell, 2006. (page 63).]

AEDs are designed to be used by laypersons who ideally should have received AED training. This is in contrast to more sophisticated manual and semi-automatic defibrillators used by health professionals, which can act as a pacemaker if the heart rate is too slow (bradycardia) and perform other functions which require a skilled operator able to read electrocardiograms.

Placement

Automated external defibrillators are generally either held by trained personnel who will attend events or are public access units which can be found in places including corporate and government offices, shopping centres, airports, restaurants, casinos, hotels, sports stadiums, schools and universities, community centers, fitness centers, health clubs and any other location where people may congregate.

The location of a public access AED should take in to account where large groups of people gather, regardless of age or activity. Children as well as adults may fall victim to sudden cardiac arrest (SCA)

In many areas, emergency vehicles are likely to carry AEDs, with some ambulances carrying an AED in addition to manual defibrillators. Police or fire vehicles often carry an AED for first responder use. Some areas have dedicated community first responders, who are volunteers tasked with keeping an AED and taking it to any victims in their area. AEDs are also increasingly common on commercial airlines, cruise ships, and other transportation facilities.

In order to make them highly visible, public access AEDs often are brightly colored, and are mounted in protective cases near the entrance of a building. When these protective cases are opened or the defibrillator is removed, some will sound a buzzer to alert nearby staff to their removal, though this does not necessarily summon emergency services; trained AED operators should know to phone for an ambulance when sending for or using an AED.

A trend that is developing is the purchase of AEDs to be used in the home, particularly by those with known existing heart conditions. [cite web|url=http://www.heartstarthome.com/content/why_defibrillators/why_defibs2_detail.asp|title=Heartstart Home Defibrillator|publisher=Philips Electronics|accessdate=2007-06-15] The number of devices in the community has grown as prices have fallen to affordable levels. There has been some concern among medical professionals that these home users do not necessarily have appropriate training, [cite news|url=http://www.nytimes.com/2005/05/03/business/03jolt.html?ei=5088&en=84d7afacd0fd7943&ex=1272772800&partner=rssnyt&emc=rss&pagewanted=all&position=|title=Do It Yourself: The Home Heart Defibrillator|last=Barnaby|First=Barnaby J|date=2005-05-03|accessdate=2007-06-15|publication=New York Times] and many advocate the more widespread use of community responders, who can be appropriately trained and managed.

Typically, an AED kit will contain a face shield for providing a barrier between patient and first aider during rescue breathing; a pair of nitrile rubber gloves; a pair of trauma shears for cutting through a patient's clothing to expose the chest; a small towel for wiping away any moisture on the chest, and a razor for shaving those with very hairy chests. ["CPR/AED for the Professional Rescuer", "supra", page 65 (" [a] safety surgical razor should be included in the AED kit.") The other items not directly mentioned in this text but are used in AED preparation, such as the gloves (used throughout patron assessment) and the towel, as the chest should be dried prior to AED pad attachment (id, at page 64).]

Preparation for operation

Most manufacturers recommend checking the AED before every period of duty or on a regular basis for fixed units. Some units need to be switched on in order to perform a self check; other models have a self check system built in with a visible indicator.Fact|date=December 2007

All manufacturers mark their pads with an expiry date, and it is important to ensure that the pads are in date. This is usually marked on the outside of the pads. Some models are designed to make this date visible through a 'window', although others will require the opening of the case to find the date stamp.Fact|date=December 2007

Mechanism of operation

An AED is "external" because the operator applies the electrode pads to the bare chest of the victim, as opposed to internal defibrillators, which have electrodes surgically implanted inside the body of a patient.

"Automatic" refers to the unit's ability to autonomously analyse the patient's condition, and to assist this, the vast majority of units have spoken prompts, and some may also have visual displays to instruct the user.

When turned on or opened, the AED will instruct the user to connect the electrodes (pads) to the patient. Once the pads are attached, everyone should avoid touching the patient so as to avoid false readings by the unit. The pads allow the AED to examine the electrical output from the heart and determine if the patient is in a shockable rhythm (either ventricular fibrillation or ventricular tachycardia). If the device determines that a shock is warranted, it will use the battery to charge its internal capacitor in preparation to deliver the shock. This system is not only safer (charging only when required), but also allows for a faster delivery of the electrical current.

When charged, the device instructs the user to ensure no one is touching the victim and then to press a button to deliver the shock; human intervention is usually required to deliver the shock to the patient in order to avoid the possibility of accidental injury to another person (which can result from a responder or bystander touching the patient at the time of ths shock). Depending on the manufacturer and particular model, after the shock is delivered most devices will analyze the victim and either instruct that CPR be given, or administer another shock.

Many AED units have an 'event memory' which store the ECG of the patient along with details of the time the unit was activated and the number and strength of any shocks delivered. Some units also have voice recording abilitiesFact|date=December 2007 to monitor the actions taken by the personnel in order to ascertain if these had any impact on the survival outcome. All this recorded data can be either downloaded to a computer or printed out so that the providing organisation or responsible body is able to see the effectiveness of both CPR and defibrillation.

AEDs available to the public may be semi-automatic or fully automatic. Fully automatic units are likely to have few buttons, often activating as soon as the case is opened, and possibly just one button to shock, or in some cases this will be performed automatically. The user has no input in the operation of the unit apart from attaching the pads and following the prompts. Health care professionals and other trained responders may use a semi-automatic defibrillator, which is likely to have an ECG readout display, and the possibility to override the rhythm analysis software. This allows trained personnel to provide a higher level of care.

The first commercially available AEDs were all of a monophasic type, which gave a high-energy shock, up to 360 to 400 joules depending on the model. This caused increased cardiac injury and in some cases second and third-degree burns around the shock pad sites. Newer AEDs (manufactured after late 2003) have tended to utilise biphasic algorithms which give two sequential lower-energy shocks of 120 - 200 joules, with each shock moving in an opposite polarity between the pads. This lower-energy waveform has proven more effective in clinical tests, as well as offering a reduced rate of complications and reduced recovery time.Fact|date=December 2007

implicity of use

Unlike regular defibrillators, an automated external defibrillator requires minimal training to use. It automatically diagnoses the heart rhythm and determines if a shock is needed. Automatic models will administer the shock without the user's command. Semi-automatic models will tell the user that a shock is needed, but the user must tell the machine to do so, usually by pressing a button. In most circumstances, the user cannot override a "no shock" advisory by an AED. Some AEDs may be used on children - those under 55 lbs (25 kg) in weight or under age 8. If a particular model of AED is approved for pediatric use, all that is required is the use of more appropriate pads. Some organizations, such as the American Heart Association, recommend that if pediatric AED pads are not available, adult pads should be used to determine if the child is in a shockable rhythm. There is insufficient evidence to suggest that a child, in a shockable cardiac arrest, can be "hurt" by an adult defibrillation energy setting.Fact|date=December 2007

All AEDs approved for use in the United States use an electronic voice to prompt users through each step. Because the user of an AED may be hearing impaired, many AEDs now include visual prompts as well. Most units are designed for use by non-medical operators. Their ease of use has given rise to the notion of public access defibrillation (PAD), which experts agree has the potential to be the single greatest advance in the treatment of out-of-hospital cardiac arrest since the invention of CPR. [ [http://circ.ahajournals.org/cgi/content/full/102/suppl_1/I-1?ijkey=0ea84b1fa73ef72b72aef923e0f1adc6d4fd6ba5&keytype2=tf_ipsecsha Introduction to the International Guidelines 2000 for CPR and ECC] ]

Liability

Most health professionalsWho|date=December 2007 agree that automated external defibrillators are so easy to use that most states in the United States now include the "good faith" use of an AED by any person under the Good Samaritan laws. [ [http://www.ncsl.org/programs/health/aed.htm Laws on Cardiac Arrest and Defibrillators, 2008 update.] National Conference of State Legislatures. Retrieved on 2008-03-23.] "Good faith" protection under a Good Samaritan law means that a volunteer responder (not acting as a part of one's occupation) cannot be held civilly liable for the harm or death of a victim by providing improper or inadequate care, given that the harm or death was not intentional and the responder was acting within the limits of their training and in good faith. In the United States, Good Samaritan laws provide some protection for the use of AEDs by trained and untrained responders. [ [http://www.ncsl.org/programs/health/aed.htm State Laws on Heart Attacks, Cardiac Arrest & Defibrillators] ] AEDs create little liability if used correctly;Fact|date=December 2007 NREMT-B and many state EMT training and many CPR classes incorporate or offer AED education as a part of their program. In addition to Good Samaritan laws, Ontario, Canada also has the "Chase McEachern Act (Heart Defibrillator Civil Liability), 2007 (Bill 171 – Subsection N)", passed in June, 2007, [ [http://www.e-laws.gov.on.ca/DBLaws/Source/Statutes/English/2007/S07010_e.htm Health System Improvement Act, 2007] Retrieved on 26 June 2007] which protects individuals from liability for damages that may occur from their use of an AED to save someone's life at the immediate scene of an emergency unless damages are caused by gross negligence.

References

External links

* [http://www.americanheart.org/presenter.jhtml?identifier=1200000 American Heart Association: Learn & Live]
* [http://www.redcross.org/services/hss/courses/aed.html American Red Cross: Saving a Life is as Easy as A-E-D]
* [http://www.fda.gov/hearthealth/treatments/medicaldevices/aed.html FDA Heart Health Online: Automated External Defibrillator (AED)]
* [http://www.resus.org.uk Resuscitation Council (UK)]