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Home , Bag valve mask, Cardioversion, Cricothyrotomy, Defibrillation, Pocket mask

AARC GUIDELINE: AND

AARC Clinical Practice Guideline

Resuscitation and Defibrillation in the Health Care Setting— 2004 Revision & Update

RAD 1.0 PROCEDURE: signs, level of consciousness, and blood gas val- Recognition of signs suggesting the possibility ues—included in those conditions are or the presence of cardiopulmonary arrest, initia- 4.1 Airway obstruction—partial or complete tion of resuscitation, and therapeutic use of de- 4.2 Acute with cardio- in adults. dynamic instability 4.3 Life-threatening dysrhythmias RAD 2.0 DESCRIPTION/DEFINITION: 4.4 Hypovolemic shock Resuscitation in the health care setting for the 4.5 Severe infections purpose of this guideline encompasses all care 4.6 Spinal cord or head necessary to deal with sudden and often life- 4.7 Drug overdose threatening events affecting the cardiopul- 4.8 Pulmonary edema monary system, and involves the identification, 4.9 Anaphylaxis assessment, and treatment of patients in danger 4.10 Pulmonary embolus of or in frank arrest, including the high-risk de- 4.11 Smoke inhalation livery patient. This includes (1) alerting the re- 4.12 Defibrillation is indicated when cardiac suscitation team and the managing physician; (2) arrest results in or is due to ventricular fibril- using adjunctive equipment and special tech- lation.1-5 niques for establishing, maintaining, and moni- 4.13 Pulseless ventricular toring effective ventilation and circulation; (3) monitoring the electrocardiograph and recogniz- RAD 5.0 CONTRAINDICATIONS: ing dysrhythmias; (4) using defibrillators [This Resuscitation is contraindicated when includes the use of conventional defibrillators 5.1 The patient’s desire not to be resuscitated and automated (automatic or semi-automatic) has been clearly expressed and documented external defibrillators (AEDs).] and mechanical in the patient’s medical record6-9 ; (5) administering oxygen and drugs, 5.2 Resuscitation has been determined to be including instillation of drugs via the endotra- futile because of the patient’s underlying cheal tube; and (6) stabilizing RETIREDsuch patients in condition or disease9-18 the post-arrest period. 5.3 Defibrillation is also contraindicated when immediate danger to the rescuers is RAD 3.0 SETTING: present due to the environment, patient’s lo- This guideline applies to a variety of settings in- cation, or patient’s condition. cluding but not limited to , long-term facilities, outpatient clinics, rehabilitation cen- RAD 6.0 PRECAUTIONS/HAZARDS ters, skilled nursing facilities, and pre- and inter- AND/OR COMPLICATIONS: transport. The following represent possible hazards or complications related to the major facets of re- RAD 4.0 INDICATIONS: suscitation: , , or the presence 6.1 Airway management10,11 of conditions that may lead to cardiopulmonary 6.1.1 Failure to establish a patent air- arrest as indicated by rapid deterioration in vital way19-21

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6.1.2 Failure to intubate the trachea19,20 6.3.4.5 Acidosis 6.1.3 Failure to recognize intubation of 6.3.4.6 Hyperkalemia the esophagus19,22,23 6.3.4.7 Massive acute myocardial in- 6.1.4 Upper airway trauma, laryngeal farction63 and esophageal damage24-29 6.3.4.8 Aortic dissection63 6.1.4.1 Vocal cord paralysis28 6.3.4.9 Cardiac rupture59,65 6.1.5 Aspiration21,23,24,30 6.3.4.10 Air embolus, pulmonary 6.1.6 Cervical spine trauma24,31,32 embolism58,66 6.1.7 Unrecognized bronchial intuba- 6.3.5 Central nervous system impair- tion19,30,33 ment58 6.1.8 Eye injury21 6.4 Electrical therapy 6.1.9 Facial trauma30 6.4.1 AEDs may be hazardous in pa- 6.1.10 Problems with ETT cuff21,34-36 tients weighing < 25 kg67 6.1.11 Bronchospasm19,21,23 6.4.2 Failure of defibrillator68 6.1.12 Laryngospasm37 6.4.3 Shock to team members69 6.1.13 Dental accidents24,30 6.4.4 checking between sequen- 6.1.14 Dysrhythmias37,38 tial shocks of AEDs delays rapid identi- 6.1.15 Hypotension and bradycardia fication of persistent ventricular fibril- due to vagal stimulation37 lation, interferes with assessment capa- 6.1.16 Hypertension and tachycar- bilities of the devices, and increases the dia37,39 possibility of operator error.67 6.1.17 Inappropriate tube size30,34,40 6.4.5 The initial 3 shocks should be de- 6.1.18 livered in sequence, without delay, in- 6.1.19 Pneumonia41 terruption for CPR, medication admin- 6.2 Ventilation istration, or pulse checks for ventricu- 6.2.1 Inadequate oxygen delivery lar fibrillation and pulseless ventricular 42-45 2,4,70-72 (FDO2) tachycardia. 6.2.2 Hypo- and/or hyperventilation43-47 6.4.6 Induction of malignant dysrhyth- 6.2.3 Gastric insufflation and/or rup- mias73,74 ture45,48,49 6.4.7 Interference with implanted pace- 6.2.4 Barotrauma50,51 maker function75-77 6.2.5 Hypotension due to reduced ve- 6.4.8 Fire hazard nous return secondary to high mean in- 6.4.8.1 AEDs may be hazardous in trathoracic pressure52,53 an oxygen-enriched environment.78 6.2.6 Vomiting and aspiration21,54 6.4.8.2 Alcohol should never be used 6.2.7 Prolonged interruptionRETIRED of ventila- as conducting material for paddles tion for intubation55 because serious burns can result.79 6.3 Circulation/Compressions 6.4.8.3 Superficial arcing of the cur- 6.3.1 Ineffective chest compression56,57 rent along the chest wall can occur as 6.3.2 Fractured ribs and/or ster- a consequence of the presence of num24,54,58,59 conductive paste or gel between the 6.3.3 Laceration of spleen or paddles.80 liver24,54,58,60-62 6.4.8.4 The aluminized backing on 6.3.4 Failure to restore circulation de- some transdermal systems can cause spite functional rhythm electric arcing during defibrillation, 6.3.4.1 Severe hypovolemia63,64 with explosive noises, smoke, visible 6.3.4.2 Cardiac tamponade58,64 arcing, patient burns, and impaired 6.3.4.3 Hemo- or pneumothorax63,64 transmission of current;81-84 there- 6.3.4.4 Hypoxia fore, patches should be removed be-

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fore defibrillation. extremely low core temperatures, and 6.4.9 Muscle burn81,85 shocks should be limited to 3 until tem- 6.4.10 Muscle injury resulting in acute perature has risen above 86¡F (30¡C).91 renal failure86,87 Warming may improve success.91 6.4.11 If transthoracic impedance is 7.2.2 Subjects whose cardiac arrest oc- high, a low energy shock (< 100 J) may curs as a direct result of trauma may not fail to generate enough current to respond to defibrillation.91 achieve successful defibrillation.88-91 7.2.3 The patient must not move or be 6.4.12 Attention must be paid to factors moved while analysis is occurring influencing total and transthoracic when the automated or semi-automated impedance.67,79,88,90,91 defibrillator is used. (Compressions 6.4.12.1 Paddle electrode pressure must be stopped, and the patient should 6.4.12.2 The use of an appropriate not be moving.) conductive medium that can with- stand high current flow RAD 8.0 ASSESSMENT OF NEED: 6.4.12.3 Electrode/paddle size— 8.1 Assessment of patient condition should be 8.5 to 12 cm for adults 8.1.1 Pre-arrest—Identification of pa- 6.4.12.4 Electrode placement tients in danger of imminent arrest and 6.4.12.5 Time interval between in whom consequent early intervention shocks may prevent arrest and improve out- 6.4.12.6 Distance between electrodes come. These are patients with condi- (size of the chest) tions that may lead to cardiopulmonary 6.4.12.7 Energy selected arrest as indicated by rapid deteriora- 6.4.12.8 Paddle-skin electrode mate- tion in vital signs, level of conscious- rial ness, and blood gas values (see Section 6.4.12.9 Number of previous shocks 4.00). 6.4.12.10 Phase of ventilation 8.1.2 Arrest—absence of spontaneous 6.4.12.11 Diaphoretic patients breathing and/or circulation should be dried to prevent contact 8.1.3 Post-arrest—Once a patient has problems with adhesive defibrilla- sustained an arrest, the likelihood of tion pads and/or electrodes. additional life-threatening problems is 6.5 Drug administration high, and continued vigilance and ag- 6.5.1 Inappropriate drug or dose gressive action using this Guideline are 6.5.2 Idiosyncratic or allergic response indicated. Control of the airway and to drug cardiac monitoring must be continued 6.5.3 Endotracheal-tubeRETIRED drug-delivery and optimal oxygenation and ventila- failure91-94—The endotracheal tube tion assured. dose should be 2 to 2.5 times the nor- 8.1.3.1 After arrival of defibrillator: mal I.V. dose, diluted in 10 mL of nor- The patient should be evaluated im- mal saline (or distilled water). mediately for the presence of ven- tricular fibrillation or ventricular RAD 7.0 LIMITATIONS OF PROCEDURE: tachycardia by the operator (conven- 7.1 Despite adequate efforts, resuscitation tional) or the defibrillator (automat- may fail because of the patient’s underlying ed or semi-automated). Inappropriate disease. Institution of resuscitation may be defibrillation can cause harm. limited by patient or surrogate/guardian re- quest.6-9 RAD 9.0 ASSESSMENT OF PROCESS AND 7.2 Additional limitations to defibrillation OUTCOME: 7.2.1 Response is poor in subjects with 9.1 Timely, high-quality resuscitation im-

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proves patient outcome in terms of survival 10.2.1.1.4 Be transparent107-114 and level of function. Despite optimal resus- 10.2.1.1.5 Easily achieve an air- citation performance, outcomes are affected tight seal107-114 by patient-specific factors. Patient condition 10.2.1.1.6 Have extension tube to post-arrest should be evaluated from this facilitate visual monitoring and perspective. ventilation107-114 9.2 Documentation and evaluation of the re- 10.2.1.1.7 Have dead space as low suscitation process (eg, system activation, as practical107-114 team member performance, functioning of 10.2.1.2 Manual resuscitators must equipment, and adherence to guidelines and 10.2.1.2.1 Be capable of providing algorithms) should occur continuously and an FDO2 of 1.0 even when large improvements be made91,95-99 volumes are delivered42,91,115-118 9.3 Equipment management issues. Use of 10.2.1.2.2 Have no pressure-relief standard checklists can improve defibrillator valve for adults91 dependability.100 10.2.1.2.3 Have a bag volume of 9.4 Defibrillation process issues approximately 1,600 mL for 9.4.1System access101 adults91,103 9.4.2 Response time91,102,103 10.2.1.2.4 Have minimal forward 9.4.3 First-responder actions91,102-104 and back leak42,118 9.4.4 Adherence to established algo- 10.2.1.2.5 Have standard 15- and rithms105 22-mm fitting91,118,119 9.4.5 Patient selection and outcome 10.2.1.2.6 Be impossible to misas- 9.4.6 authorization to semble defibrillate91,103,106 10.2.1.2.7 Be easily sterilized or for single-patient use RAD 10.0 RESOURCES: 10.2.1.2.8 Provide for measure- 10.1 Emergency response system—A desig- ment of exhaled tidal volume95,96 nated resuscitation team should be continu- 10.2.1.2.9 Provide some indica- ously available (24 hours/day,7 days/week) tion that supplemental oxygen is to respond to emergencies.99 Specialty resus- being supplied (easily ascertained citation teams trained to meet the needs of with bag reservoir but difficult different hospital populations are desirable with tube-type reservoir) (eg, trauma, stroke). Team members should 10.2.1.2.10 Be capable of being be notified simultaneously. All hospital restored to proper function after workers must know how to activate the hos- being disabled with vomi- pital’s emergency response system.RETIREDtus42,120,121 10.2 Equipment should be rapidly available 10.2.1.2.11 Be able to be restored and functional. Durability, portability, relia- to proper function after being bility, and cost should be considered. dropped from a height of 1 meter 10.2.1 Ventilation devices onto concrete floor 10.2.1.1 Mouth-to-mask devices 10.2.1.2.12 Be designed so that must pressure generated at the patient 10.2.1.1.1 Provide a way to in- connection port is < 5 cm H2O 91,103,107-114 crease FDO2 during exhalation (at a flow of 5 10.2.1.1.2 Separate inhaled and L/min for patients weighing < 10 exhaled gas91,103,107-114 kg and 50 L/min for all oth- 10.2.1.1.3 Incorporate an effective ers)122,123 filter (one-way valve or bacteria 10.2.1.2.13 Be designed so that filter)107-114 pressure generated at the patient

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connection port does not exceed - with only brief interruption of manu- 5 cm H2O during inspiration (at a al CPR. The compressor head should flow of 5 L/ min for patients be designed to limit shift in position weighing < 10 kg and 50 L/min and stroke adjustment and should for all others)122,123 have a locking mechanism. The de- 10.2.1.2.14 Be capable of provid- vice must be portable, stored easily, ing a high FDO2 during sponta- and assembled quickly. neous breathing with low inspira- 10.2.2.2 Automatic mechanical chest tory and expiratory resistance (see compressors are appropriate for above)122,123 adults and should have the capabili- 10.2.1.3 Face-mask design should ties of the manual devices plus the allow a tight seal, provide minimal advantage of delivering optimal rate internal dead space, and have a clear and depth of compression by elimi- mask body. A variety of sizes should nating the variables of operator tech- be available.108-110,124 nique and fatigue. The device should 10.2.1.4 Non-self-inflating bags vary allow electrocardiogram (ECG) in size from 500-2,000 mL, are in- recording, and defibrillation should flated by a controlled gas source, not require that the device be have variable flow outlets, and con- stopped or removed.91 It is not rec- form to the same standards listed in ommended that these devices be 10.2.1.2 (where appropriate). used for ventilation unless a cuffed 10.2.1.5 Gas-powered resuscitators endotracheal tube is in place. (manually triggered, commonly 10.2.3 devices called demand valves) are not rec- 10.2.3.1 Oropharyngeal airways ommended.42,116,125-130 should be available in a variety of 10.2.1.6 Transport ventilators are sizes for adults. Design should incor- recommended for resuscitation if porate a flange, a short bite-block they provide control over tidal vol- segment, and a curved body contain- ume, inspiratory time, and inspirato- ing a channel for air movement and ry flow, and deliver FDO2 of suctioning. 1.0.131,132 10.2.3.2 Nasopharyngeal airways 10.2.1.7 The continued use of the should be available in a variety of mechanical is indicated sizes for adults. They consist of a when a patient already being me- soft rubber or plastic tube with a chanically ventilated is resuscitated beveled tip and a flange that prefer- if the ventilator providesRETIRED control ably is adjustable. over tidal volume, inspiratory time, 10.2.3.3 Endotracheal tubes should and flow; can be manually triggered; be available in a variety of sizes for and delivers an FDO2 of l .0. adults. Tubes should meet ASTM 10.2.2 Circulation devices standards.136 10.2.2.1 Manually operated mechan- 10.2.3.4 Intubation devices facilitate ical chest compressors are appropri- intubation and access to the difficult ate for adults and may be advanta- airway. Such devices may include geous during transport.91,133-135 They laryngoscope and blades (straight & must be capable of providing an ad- curved), wire guide/stylet, forceps, justable stroke of 1.5 to 2 in (3.9 to fiberoptic laryngoscope or broncho- 5.0 cm), deliver the compression for scope, “light wand,” or tube chang- 50% of the compression-relaxation ing stent. cycle, and should be placed in use 10.2.3.5 Tube stabilization should be

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reliable and effective and allow for committee cannot recommend atraumatic extubation and reintuba- one type of defibrillator over tion when necessary. the other. 10.2.3.6 Suctioning devices should 10.2.4.1.2 Manual defibrillators be capable of subatmospheric pres- depend upon operator for analysis sure levels of > Ð120 cm H2O for of rhythm, charging, proper appli- pharyngeal suctioning and between cation of paddles to patient’s tho- Ð80 and Ð120 cm H2O for tracheo- rax, and delivery of countershock; bronchial suctioning in adults.91 A use of self-adhesive pads may in- portable system should be available crease efficacy and speed of coun- for transport. A variety of rigid pha- tershock.137,138 Using self-adhe- ryngeal tips and a variety of sizes of sive pads will also prevent the ap- sterile tracheal catheters should be plication of the wrong contact gel available. The tracheal suction during defibrillation. catheter selected should have an out- 10.2.4.1.3 Semiautomatic/auto- side diameter of < 1/2 the inside di- matic defibrillators utilize large, ameter of the endotracheal (or tra- self-adhesive pads to optimize cheostomy) tube and have a means of electrical contact with the pa- manual control (thumb port). tient’s thorax and allow delivery 10.2.4 Electrical therapy devices of countershock more rapidly than 10.2.4.1 Defibrillators manual defibrillators.68,138 Auto- 10.2.4.1.1 Monophasic or biphasic matic defibrillators, when at- defibrillator waveforms tached to patient, analyze rhythm 10.2.4.1.1.1 With monophasic and deliver countershock when devices the current is delivered appropriate without intervention in one direction. The recom- by operator; semiautomatic defib- mended first energy shock is rillators require pressing a button 200 J, the second is 200 or 300 to initiate rhythm analysis and ad- J, and the third is 360 J. This es- vise operator when delivery of calating energy level is used to countershock (by pressing a but- find the lowest level that termi- ton) is appropriate.139-142 nates 10.2.4.1.4 External pacemakers while minimizing injury from allow noninvasive cardiac pacing the shock.67 via large, self-adhesive pads, in 10.2.4.1.1.2 With biphasic de- cases of bradycardia with a pulse vices the currentRETIRED is delivered in or high-grade block when a con- 2 phases. In one phase it is de- ducted beat results in a pulse.142- livered in a positive direction, 145 and in the second it is delivered 10.2.5 Monitoring devices in the negative direction. Low 10.2.5.1 ECG monitors—Continuous energy (≤ 200 J) from biphasic electrocardiographic monitoring is devices can terminate ventricu- essential for detection of dysrhyth- lar fibrillation safely with as mias and for directing therapy. much or more efficacy com- 10.2.5.2 CO2 monitors—CO2 detec- pared to escalating energy from tors are useful for identification of monophasic devices. 67 correct endotracheal tube placement 10.2.4.1.1.3 Since randomized and for monitoring of cardiac func- prospective studies comparing tion during resuscitation.146-150 these devices are lacking, the 10.2.5.3 Ventilation monitors—Be-

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cause , either focus on identified deficiencies. manual or mechanical, is often in- 10.3.1.2 Responsibilities—Level I: consistent during resuscitation, mon- All health care providers who have itoring of exhaled volume is recom- direct patient care responsibilities mended.95,96 and may be the first responder to pa- 10.2.5.4 Pulse oximeters—Pulse tients in cardiac arrest are considered oximeters, if used in the pre- and Level I caregivers. No special pro- post-arrest situation, may provide fessional credential is necessary to useful information regarding oxy- qualify as Level I, by this definition. genation and cardiovascular perfor- Designated first responders must be mance. Those that display pulse able to recognize that the patient is waveform are preferred. unresponsive, apneic, and pulseless. 10.2.5.5 Invasive hemodynamic They should be able to attach auto- monitoring devices—Continuous mated defibrillator electrodes, oper- monitoring of intravascular wave- ate AEDs, and complete an AED forms and pressures provides useful checklist at least every shift.157 Level information for diagnosis and treat- I personnel also assist the primary ment of cardiovascular compromise. (Level II) members of the resuscita- 10.2.5.6 Airway pressure monitoring tion team. They should be capable of is useful in adults. assisting Level II personnel by (l) as- 10.3 Personnel: A high percentage of pa- sessing patients for respiratory tients in nontraumatic cardiac arrest are in and/or cardiac arrest, (2) activating ventricular fibrillation within the first few the resuscitation team, (3) adminis- minutes after their collapse. As time after ar- tering BLS, (4) providing mouth-to- rest increases, the likelihood of a successful mask ventilation, (5) attaching ECG outcome decreases rapidly.91,106,151 Early de- and automatic defibrillator elec- fibrillation as a standard has been expanded trodes, (6) assisting with tracheal in- to include the use of AEDs by first respon- tubation, (7) defibrillating with auto- ders trained in basic (BLS), for matic electronic defibrillators, (8) at- both prehospital and in-hospital cardiac ar- taching pulse oximeter and rest due to ventricular fibrillation. All health capnograph, (9) preparing a written care providers must recognize the need for record of resuscitation effort, (10) and know how to activate the facility’s emer- moving resuscitation equipment to gency response system. They should be the scene, and (11) collecting arterial trained, evaluated at frequent intervals by blood for analysis. monitoring performance, andRETIRED retrained as 10.3.1.3 Credentials—Level I health necessary in the skills of BLS. Health care care providers should have a current providers who are primary members of re- BLS health care provider course suscitation teams in acute care hospitals completion card from the American should be skilled in emergency cardiac care Association. Hospital person- (ECC) and advanced cardiac life support nel should at a minimum be capable (ACLS).152-156 of assessing the patient for respirato- 10.3.1 Level I152-156 ry and/or cardiac arrest, activating 10.3.1.1 Training—all Level I per- the resuscitation team, and adminis- sonnel should be trained, evaluated tering BLS until the team arrives. by performance, and retrained as 10.3.2 Level II152 necessary in BLS and the use of 10.3.2.1 Training—Level II person- AED at frequent intervals that do not nel should be trained, evaluated by exceed 2 years. Retraining should performance, and retrained as neces-

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sary in ECC and ACLS as appropri- RAD 11.0 MONITORING: ate at intervals that should not ex- 11.1 Patient ceed 2 years. Retraining should 11.1.1 Clinical assessment—continuous focus on identified deficiencies. observation of the patient and repeated 10.3.2.2 Responsibilities—Level II clinical assessment by a trained observ- health professionals should be capa- er provide optimal monitoring of the re- ble of serving as primary members of suscitation process. Special considera- the resuscitation team and as team tion should be given to the following: leader when they are the best quali- 11.1.1.1 Level of consciousness fied respondent. They may respond 11.1.1.2 Adequacy of airway not only to resuscitation calls in their 11.1.1.3 Adequacy of ventilation work areas but also to other areas of 11.1.1.4 Peripheral/apical pulse and the hospital. They are skilled in the character use of all adjunctive equipment and 11.1.1.5 Evidence of chest and head special techniques for ECC/ACLS trauma (eg, establishing, maintaining, and 11.1.1.6 Pulmonary compliance and monitoring effective ventilation and airway resistance circulation). They have the skills of 11.1.1.7 Presence of seizure activity Level I personnel and the following 11.1.2 Assessment of physiologic pa- capabilities: (1) advanced ECG mon- rameters—Repeat assessment of physi- itoring and dysrhythmia recognition, ologic data by trained professionals (2) , (3) capability supplements clinical assessment in to deliver shocks with automated and managing patients throughout the re- conventional external defibrillators, suscitation process. Monitoring devices (4) use of continuous and transport should be available, accessible, func- mechanical ventilators, (5) use of tional, and periodically evaluated for manual or automatic external chest function. These data include but are not compressors, (6) preparation and ad- limited to95 ministration of cardiac drugs, (7) sta- 11.1.2.1 Arterial blood gas studies bilization of patients in the post-ar- (although investigators have sug- rest period, (8) provision of access gested that such values may have a for rapid administration of intra- limited role in decision-making dur- venous fluids, (9) managing ventila- ing CPR158 tion via transtracheal catheter and 11.1.2.2 Hemodynamic data152,158-160 cricothyrotomy, (10) emergency 11.1.2.3 Cardiac rhythm153,154 treatment of tensionRETIRED pneumo- or 11.1.2.4 Ventilatory frequency, tidal hemothorax with large bore needle, volume, and airway pressure95,96 146-150 (11) interpretation of hemodynamic 11.1.2.5 Exhaled CO2 data (12) preparing patients for 11.1.2.6 Neurologic status emergency transport, and (13) evalu- 11.2 Resuscitation process—properly per- ating oxygenation, ventilation and formed resuscitation should improve patient acid-base balance from blood gas re- outcome. Continuous monitoring of the pro- ports. cess will identify areas needing improve- 10.3.2.3 Credentials—Level II ment. Among these areas are response time, health professionals should have a equipment function, equipment availability, current BLS and ACLS certification team member performance, team perfor- from the American Heart Associa- mance, complication rate, and patient sur- tion. vival and functional status. 11.3 Equipment—All maintenance should be

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documented and records preserved. Included 13.2 Observe all infection control guidelines in documentation should be routine checks posted for patient. of energy output, condition of batteries, 13.3 Disinfect all equipment to be reused on proper functioning of monitor and recorder, other patients. and presence of disposables needed for func- Revised by David Vines MHS RRT, University of tion of defibrillator, including electrodes and Texas Health Science Center, San Antonio, Texas, defibrillation pads. Defibrillators should be and approved by the 2003 CPG Steering Committee checked and documented each shift for pres- ence, condition, and function of cables and This Clinical Practice Guideline combines 2 earlier guide- paddles; presence of defibrillating and moni- lines, Defibrillation During Resuscitation [Respir Care 1995;40(7):744-748] and Resuscitation in Acute Care Hos- toring electrodes, paper, and spare batteries pitals [Respir Care 1993;38(11):1179-1188] (as applicable); and charging, message/light indicators, monitors, and ECG recorder (as REFERENCES applicable).91 AEDs should be checked and documented each day for function and ap- 1. Atkins DL, Bossaert LL, Hazinski MF, Kerber propriate maintenance.67 RE, Mancini MB, Ornato JP, et al. Automated 11.4 Training—Records should be kept of external defibrillation/public access defibrilla- tion. Ann Emerg Med 2001;37(4 Suppl):S60- initial training and continuing education of S67. all personnel who perform defibrillation as 2. Kern KB, Halperin HR, Field J. New guidelines part of their professional activities. for cardiopulmonary resuscitation and emergen- cy cardiac care: changes in the management of RAD 12.0 FREQUENCY/AVAILABILITY/ cardiac arrest. JAMA 2001;285(10):1267-1269. DURATION: 3. Auble TE, Menegazzi JJ, Paris PM. Effect of out-of-hospital defibrillation by basic life sup- 12.1 Because the need for resuscitation oc- port providers on cardiac arrest mortality: a curs unpredictably, resources need to be metaanalysis. Ann Emerg Med 1995;25(5):642- available to respond to one or more locations 648. simultaneously 24 hours a day, 7 days a 4. Stults KR, Brown DD, Schug VL, Bean JA. Pre- week. BLS response should be immediate, hospital defibrillation performed by emergency and ACLS should be available as soon as medical technicians in rural communities. N Engl J Med 1984;310(4):219-223. feasible based upon the resources of the in- 5. Hargarten KM, Stueven HA, Waite EM, Olson stitution. Resuscitation continues until vital DW, Mateer JR, Aufderheide TP, Darin JC. Pre- signs are restored. If vital signs are not re- hospital experience with defibrillation of coarse stored, resuscitation efforts should continue ventricular fibrillation: a ten-year review. Ann until a physician decides further efforts are Emerg Med 1990;19(2):157-162. 6. Sachs GA, Miles SH, Levin RA. Limiting resus- futile. citation: emerging policy in the emergency med- 12.2 Personnel who respondRETIRED to cardiac ar- ical system. Ann Intern Med 1991;114(2):151- rests should be trained to operate, equipped 154. with, and permitted to operate a defibrilla- 7. Torian LV, Davidson EJ, Fillit HM, Fulop G, tor.67 No other therapeutic intervention, in- Sell LL. Decisions for and against resuscitation cluding setting up oxygen delivery systems, in an acute geriatric medicine unit serving the frail elderly. Arch Intern Med 1992;152(3):561- suction equipment, advanced airway proce- 565. Erratum in: Arch Intern Med dures, intravenous lines, or mechanical CPR 1992;152(8):1659. devices, should take precedence over or be 8. Stern SG, Orlowski JP. DNR or CPR—the routinely performed when a defibrillator is choice is ours. Crit Care Med 1992;20(9):1263- available and defibrillation is indicated.67 1272. 9. Abramson N, de Vos R, Fallat ME, Finucane T, Kettler D, Pepe P, et al; American Heart Associ- RAD 13.0 INFECTION CONTROL: ation; International Liaison Committee on Re- 13.1 Implement Standard Precautions,161 in- suscitation. Ethics in emergency cardiac care. cluding mouth-to-barrier devices. Ann Emerg Med 2001;37(4 Suppl):S196-S200.

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10. Bilsky GS, Banja JD. Outcomes following car- plications of cardiac resuscitation. Chest diopulmonary resuscitation in an acute rehabili- 1987;92(2):287-291. tation hospital: clinical and ethical implications. 25. Chen EH, Logman ZM, Glass PSA, Bilfinger Am J Phys Med Rehabil 1992;71(4):232-235. TV. A case of tracheal injury after emergent en- 11. Longstreth WT Jr, Cobb LA, Fahrenbruch CE, dotracheal intubation: a review of the literature Copass MK. Does age affect outcomes of out-of- and causalities. Anesth Analg 2001;93(5):1270- hospital cardiopulmonary resuscitation? JAMA 1271. 1990;264(16):2109-2110. 26. Jaeger K, Ruschulte H, Osthaus A, Scheinichen 12. Murphy DJ, Matchar DB. Life-sustaining thera- D, Heine J. Tracheal injury as a sequence of py: a model for appropriate use. JAMA multiple attempts of endotracheal intubation in 1990;264(16):2103-2108. the course of a preclinical cardiopulmonary re- 13. Tresch DD. CPR in the elderly: when should it suscitation. Resuscitation 2000;43(2):147-150. be performed? Geriatrics 1991;46(12):47-50,54- 27. Hofmann HS, Rettig G, Radke J, Neef H, Silber 56. RE. Iatrogenic ruptures of the tracheobronchial 14. Tomlinson T, Brody H. Futility and the ethics of tree. Eur J Cardiothorac Surg 2002; 21(4):649- resuscitation. JAMA 1990;264(10):1276-1280. 652. 15. Nelson LJ, Nelson RM. Ethics and the provision 28. Christopher K, Arbelaez C, Yodice PC. Bilateral of futile, harmful, or burdensome treatment to vocal cord dysfunction complicating short-term children. Crit Care Med 1992;20(3):427-433. intubation and the utility of . Respiration 16. Council on Ethical and Judicial Affairs, Ameri- 2002; 69(4):366-368. can Medical Association. Guidelines for the ap- 29. Naghibi K, Jalal HS. Esophageal perforation propriate use of do-not-resuscitate orders. after tracheal intubation, spontaneous or iatro- JAMA 1991:265(14):1868-1871. genic?—a case report. Acta Anaesthesiol Sin 17. Marik PE, Craft M. An outcomes analysis of in- 2003; 41(1):33-35. hospital cardiopulmonary resuscitation: the fu- 30. Stauffer JL, Olson DE, Petty TL. Complications tility rationale for do not resuscitate orders. J and consequences of endotracheal intubation and Crit Care 1997:12(3):142-146. : a prospective study of 150 critical- 18. Hopson LR, Hirsh E, Delgado J, Domeier RM, ly ill adult patients. Am J Med 1981;70(1):65- McSwain NE, Krohmer J. Guidelines for with- 76. holding or termination of resuscitation in pre- 31. Hastings RH, Marks JD. Airway management for hospital traumatic cardiopulmonary arrest: joint trauma patients with potential cervical spine in- position statement of the National Association juries. Anesth Analg 1991;73(4):471-482. of EMS Physicians and the American College of 32. Rhee KJ, Green W, Holcroft JW, Mangili JAA. Surgeons Committee on Trauma. J Am Coll Surg Oral intubation in the multiply injured patient: 2003;196(1):106-112. the risk of exacerbating spinal cord damage. Ann 19. Caplan RA, Posner KL, Ward RJ, Cheney FW. Emerg Med 1990;19(5):511-514. Adverse respiratory events in anesthesia: a 33. Owen RL, Cheney FW. Endobronchial intuba- closed claims analysis. Anesthesiology tion: a preventable complication. Anesthesiolo- 1990;72(5):828-833. gy 1987;67(2):255-257. 20. Schwartz DE, Matthay MA, Cohen NH. 34. Szekely SM, Webb RK, Williamson JA, Russell and other complications of emergency airway WJ. The Australian Incident Monitoring Study. management in critically ill adults: a prospective Problems related to the endotracheal tube: an investigation of 297 tracheal RETIREDintubations. Anes- analysis of 2000 incident reports. Anaesth Inten- thesiology 1995;82(2):367-376. sive Care 1993;21(5):611-616. 21. Cheney FW, Posner KL, Caplan RA. Adverse 35. Heusner JE, Viscomi CM. Endotracheal tube respiratory events infrequently leading to mal- cuff failure due to valve damage (letter). Anesth practice suits: a closed claims analysis. Anesthe- Analg 1991;72(2):270. siology 1991;75(6):932-939. 36. Siobal M, Kallet RH, Kraemer R, Jonson E, 22. Holland R, Webb RK, Runciman WB. The Aus- Lemons D, Young D, et al. Tracheal-innominate tralian Incident Monitoring Study. Oesophageal artery fistula caused by the endotracheal tube intubation: an analysis of 2000 incident reports. tip: case report and investigation of a fatal com- Anaesth Intensive Care 1993;21(5):608-610. plication of prolonged intubation. Respir Care 23. Williamson JA, Webb RK, Cockings J, Morgan 2001;46(10):1012-1018. C. The Australian Incident Monitoring Study. 37. Blanc VF, Tremblay NAG. The complications of The capnograph: applications and limitations-an tracheal intubation: a new classification with a analysis of 2000 incident reports. Anaesth Inten- review of the literature. Anesth Analg sive Care 1993;21(5):551-557. 1974;53(2):202-213. 24. Krischer JP, Fine EG, Davis JH, Nagel EL. Com- 38. MacKenzie RA, Gould AB Jr, Bardsley WT.

1094 RESPIRATORY CARE ¥ SEPTEMBER 2004 VOL 49 NO 9 AARC GUIDELINE: RESUSCITATION AND DEFIBRILLATION

Cardiac with endotracheal intuba- 221. tion (abstract). Anesthesiology 1980;53:S102. 52. Cournand A, Motley HL, Werko L, Richards 39. Kaplan JD, Schuster DP. Physiologic conse- DW. Physiological studies of the effects of in- quences of tracheal intubation. Clin Chest Med termittent positive pressure breathing on cardiac 1991;12(3):425-432. output in man. Am J Physiol 1948;15:162-174. 40. Stone DJ, Bogdonoff DL. Airway considerations 53. Venus B, Jacobs HK, Mathru M. Hemodynamic in the management of patients requiring long- responses to different modes of mechanical ven- term endotracheal intubation. Anesth Analg tilation in dogs with normal and acid aspirated 1992;74(2):276-287. . Crit Care Med 1980;8(11):620-627. 41. Rello J, Valles J, Jubert P, Ferrer A, Domingo C, 54. Nagel EL, Fine EG, Krischer JP, Davis JH. Com- Mariscal D, et al. Lower infec- plications of CPR. Crit Care Med 1981;9(5):424. tions following cardiac arrest and cardiopul- 55. Hee MK, Plevak DJ, Peters SG. Intubation of monary resuscitation. Clin Infect Dis critically ill patients. Mayo Clin Proc 1995;21(2):310-314. 1992;67(6):569-576. 42. Campbell TP, Stewart RD, Kaplan RM, 56. Maier GW, Tyson GS Jr, Olsen CO, Kernstein DeMichiei RV, Morton R. Oxygen enrichment of KH, Davis JW, Conn EH, et al. The physiology bag-valve-mask units during positive-pressure of external cardiac massage: high-impulse car- ventilation: a comparison of various techniques. diopulmonary resuscitation. Circulation Ann Emerg Med 1988;17(3):232-235. 1984;70(1):86-101. 43. Johannigman JA, Branson RD. Oxygen enrich- 57. Taylor GJ, Tucker WM, Greene HL, Rudikoff ment of expired gas for mouth-to-mask resusci- MT, Weisfeldt ML. Importance of prolonged tation. Respir Care 1991;36(5):99-103. compression during cardiopulmonary resuscita- 44. Stallinger A, Wenzel V, Oroszy S, Mayr VD, tion in man. N Engl J Med 1977;296(26):1515- Idris AH, Lindner KH, Hormann C. The effects 1517. of different mouth-to-mouth ventilation tidal 58. Schneider AP 2nd, Nelson DJ, Brown DD. In- volumes on gas exchange during simulated res- hospital cardiopulmonary resuscitation: a meta- cue breathing. Anesth Analg 2001;93(5):1265- analysis. ACP J Club 1994;120:21. 1269. 59. Machii M, Inaba H, Nakae H, Suzuki I, Tanaka 45. Wenzel V, Idris AH, Dorges V, Nolan JP, Parr H. Cardiac rupture by penetration of fractured MJ, Gabrielli A, et al. The sternum: a rare complication of cardiopulmonary during resuscitation: a review of the history, risk resuscitation. Resuscitation 2000;43(2):151-153. of infection during assisted ventilation, respira- 60. Pezzi A, Pasetti G, Lombardi F, Fiorentini C, tory mechanics, and ventilation strategies for pa- Iapichino G. Liver rupture after cardiopul- tients with an unprotected airway. Resuscitation monary resuscitation (CPR) and thrombolysis 2001;49(2):123-134. (letter). Intensive Care Med 1999;25(9):1032. 46. Hess D, Goff G, Johnson K. The effect of hand 61. Stallard N, Findlay G, Smithies M. Splenic rup- size, resuscitator brand, and use of two hands on ture following cardiopulmonary resuscitation. volumes delivered during adult bag-valve venti- Resuscitation 1997;35(2):171-173. lation. Respir Care 1989;34(9):805-810. 62. Fitchet A, Neal R, Bannister P. Splenic trauma 47. Fluck RR Jr, Sorbello JG. Comparison of tidal complicating cardiopulmonary resuscitation. volumes, minute ventilation, and respiratory fre- BMJ 2001;322(7284):480-481. quencies delivered by and respiratory 63. Vanags B, Thakur RK, Stueven HA, Aufderheide care students with pocket maskRETIRED versus demand T, Tresch DD. Interventions in the therapy of valve. Respir Care 1991;36(10):1105-1112. electromechanical dissociation. Resuscitation 48. Strear CM, Jarnagin WR, Schecter W, Mackersie 1989;17(2):163-171. RC, Hickey MS. Gastric rupture and tension 64. Pirolo JS, Hutchins GM, Moore GW. Electrome- pneumoperitoneum complicating cardiopul- chanical dissociation: pathologic explanations in monary resuscitation: case report. J Trauma 50 patients. Hum Pathol 1985;16(5):485-487. 1998;44(5):930-932. 65. Fosse E, Lindberg H. Left ventricular rupture 49. Offerman SR, Holmes JF, Wisner DH. Gastric following external chest compression. Acta rupture and massive pneumoperitoneum after by- Anaesthesiol Scand 1996;40(4):502-504. stander cardiopulmonary resuscitation. J Emerg 66. Hashimoto Y, Yamaki T, Sakakibara T, Matsui Med 2001;21(2):137-139. J, Matsui M. Cerebral air embolism caused by 50. Hillman K, Albin M. Pulmonary barotrauma dur- cardiopulmonary resuscitation after cardiopul- ing cardiopulmonary resuscitation. Crit Care monary arrest on arrival. J Trauma Med 1986;14(7):606-609. 2000;48(5):975-977. 51. Burdett-Smith P, Jaffey L. Tension pneumoperi- 67. Stapleton ER, Aufderheide TP, Hazinski MF, toneum. J Accid Emerg Med 1996;13(3):220- Cummins RO, editors. Textbook of basic life

RESPIRATORY CARE ¥ SEPTEMBER 2004 VOL 49 NO 9 1095 AARC GUIDELINE: RESUSCITATION AND DEFIBRILLATION

support for healthcare providers. Dallas: Ameri- ner SF. Report of nitropatch explosions compli- can Heart Association; 2001. cating defibrillation. Am J Emerg Med 68. Cummins RO, Chesemore K, White RD. Defib- 1992;10(2):128-129. rillator failures: causes of problems and recom- 84. Wrenn K. The hazards of defibrillation through mendations for improvement. Defibrillator nitroglycerin patches. Ann Emerg Med Working Group. JAMA 1990;264(8):1019-1025. 1990;19(11):1327-1328. 69. Gibbs W, Eisenberg M, Damon SK. Dangers of 85. Reisin L, Baruchin AM. Iatrogenic defibrillator defibrillation: to emergency personnel burns. Burns 1990;16(2):128. during patient resuscitation. Am J Emerg Med 86. Minor RL Jr, Chandran PKG, Williams CL. 1990;8(2):101-104. Rhabdomyolysis and myoglobinuric renal failure 70. Martin RG, Hawkins NS, Weigel JA, Rider DE, following and CPR for acute MI. Buckingham BD. Initial treatment of ventricular Chest 1990;97(2):485-486. fibrillation: defibrillation or drug therapy. Am J 87. Hojs R, Sinkovic A, Hojs-Fabjan T. Rhabdomy- Emerg Med 1988;6(2):113-119. olysis and acute renal failure following car- 71. Weaver WD, Fahrenbruch CE, Johnson DD, dioversion and cardiopulmonary resuscitation. Hallstrom AP, Cobb LA, Copass MK. Effect of Ren Fail 1995;17(6):765-768. epinephrine and therapy on outcome 88. Kerber RE, Kouba C, Martins J, Kelly K, Low R, after cardiac arrest due to ventricular fibrilla- Hoyt R, et al. Advance prediction of transtho- tion. Circulation 1990;82(6):2027-2034. racic impedance in human defibrillation and car- 72. Walters G, Glucksman E. Retention of skills by dioversion: importance of impedance in deter- advanced trained staff: implications mining the success of low-energy shocks. Circu- for monitoring and retraining. BMJ lation 1984;70(2):303-308. 1989;298(6674):649-650. 89. Kerber RE, Martins JB, Kienzle MG, Constantin 73. Geuze RH, de Vente J. Arrhythmias and left ven- L, Olsnansky B, Hopson R, Charbonnier F. Ener- tricular function after defibrillation during acute gy, current, and success in defibrillation and myocardial infarction in the intact dog. Am cardioversion: clinical studies using an automat- Heart J 1983;106(2):292-299. ed impedance-based method of energy adjust- 74. Leja FS, Euler DE, Scanlon PJ. Digoxin and the ment. Circulation 1988;77(5):1038-1046. susceptibility of the canine heart to counter- 90. Kerber RE, Kienzle MG, Olshansky B, Waldo shock-induced . Am J Cardiol AL, Wilber D, Carlson MD, et al. Ventricular 1985;55(8):1070-1075. tachycardia rate and morphology determine en- 75. Levine PA, Barold SS, Fletcher RD, Talbot P. ergy and current requirements for transthoracic Adverse acute and chronic effects of electrical cardioversion. Circulation 1992;85(1):158-163. defibrillation and cardioversion on implanted 91. Cummin RO, editor. Textbook of advanced car- unipolar cardiac pacing systems. J Am Coll Car- diac life support. Dallas: American Heart Asso- diol 1983;1(6):1413-1422. ciation; 1997. 76. Kerber RE. Electrical treatment of cardiac ar- 92. Mace SE. Effect of technique of administration rhythmias: defibrillation and cardioversion. Ann on plasma lidocaine levels. Ann Emerg Med Emerg Med 1993;22(2 Pt 2):296-301. 1986;15(5):552-556. 77. Zullo MA. Function of ventricular pacemakers 93. Orlowski JP, Gallagher JM, Porembka DT. En- during resuscitation. Pacing Clin Electrophysiol dotracheal epinephrine is unreliable. Resuscita- 1990;13(6):736-744. tion 1990;19(2):103-113. 78. ECRI. Health devices alert. DefibrillationRETIRED [11- 94. Aitkenhead AR. Drug administration during 132]. March 10, 1995. CPR: what route? Resuscitation 1991;22(2):191- 79. Sirna SJ, Ferguson DW, Charbonnier F, Kerber 195. RE. Factors affecting transthoracic impedance 95. Hess D, Eitel D. Monitoring during resuscita- during electrical cardioversion. Am J Cardiol tion. Respir Care 1992;37(7):739-765; discus- 1988;62(16):1048-1052. sion: 766-768. 80. Aufderheide TP. Pacemakers and electrical ther- 96. Ornato JP, Bryson BL, Donovan PJ, Farquharson apy during advanced cardiac life support. Respir RR, Jaegar C. Measurement of ventilation during Care 1995;40(4):364-376; discussion 376-379. cardiopulmonary resuscitation. Crit Care Med 81. Pride HB, Mckinley DF. Third-degree burns 1983;11(2):79-82. from the use of an external cardiac pacing de- 97. Elling R, Politis J. An evaluation of emergency vice. Crit Care Med 1990;18(5):572-573. medical technicians’ ability to use manual venti- 82. Wrenn K. The hazards of defibrillation through lation devices. Ann Emerg Med nitroglycerin patches. Ann Emerg Med 1983;12(12):765-768. 1990;19(11):1327-1328. 98. Anton WR, Gordon RW, Jordan TM, Posner KL, 83. Panacek EA, Munger MA, Rutherford WF, Gard- Cheney FW. A disposable end-tidal CO2 detector

1096 RESPIRATORY CARE ¥ SEPTEMBER 2004 VOL 49 NO 9 AARC GUIDELINE: RESUSCITATION AND DEFIBRILLATION

to verify endotracheal intubation. Ann Emerg parison of six methods of emergency ventilation Med 1991;20(3):271-275. (letter). Lancet 1986;2(8518):1274-1275. 99. Thalman JJ, Rinaldo-Gallo S, Maclntyre NR. 114. Sainsbury DA, Davis R, Walker MC. Artificial Analysis of an endotracheal intubation service ventilation for cardiopulmonary resuscitation. provided by respiratory care practitioners. Med J Aust 1984;141(8):509-511. Respir Care 1993;38(5):469-473. 115. Pulmonary resuscitators. Health Devices 100. Brison RJ, Davidson JR, Dreyer JF, Jones G, 1989;18(10):333-352. Maloney J, Munkley DP, et al. Cardiac arrest in 116. Phillips GD, Skowronski GA. Manual resuscita- Ontario: circumstances, community response, tors and portable ventilators. Anaesth Intensive role of prehospital defibrillation and predictors Care 1986;14(3):306-313. of survival. CMAJ 1992;147(2):191-199. 117. ECRI. Manual resuscitators. Health Devices 101. White RD. Maintenance of defibrillators in a 1979;8:133-146. state of readiness. Ann Emerg Med 1993;22(2 Pt 118. American Society for Testing and Materials. 2):302-306. Standard specification for performance and safe- 102. Sedgwick ML, Dalziel K, Watson J, Carrington ty requirements for resuscitators intended for DJ, Cobbe SM. Performance of an established use with humans. Designation: F-920-Philadel- system of first responder out-of-hospital defib- phia: ASTM; 1985. rillation: the results of the second year of the 119. American National Standards Institute. ANSI Heartstart Scotland Project in the ‘Utstein Standard Z-79.2, 1976. Style’. Resuscitation 1993;26(1):75-88. 120. Barnes TA, Potash R. Evaluation of five adult 103. Cummin RO, editor. Textbook of advanced car- disposable operator-powered resuscitators. diac life support. Dallas: American Heart Asso- Respir Care 1989;34(4):254-261. ciation; 2001. 121. Fluck RR Jr, Sorbello JG. Comparison of tidal 104. Kellermann AL, Hackman BB, Dobyns R, Fra- volumes, minute ventilation, and respiratory fre- zier C, Nail L. Engineering excellence: options quencies delivered by paramedic and respiratory to enhance firefighter compliance with standing care students with versus demand orders for first responder defibrillation. Ann valve. Respir Care 1991;36(10): 1105-1112. Emerg Med 1993;22(8):1269-1275. 122. International Standards Organization (ISO). 105. Haynes BE, Mendoza A, McNeil M, Schroeder J, Draft International Standard ISO 8382: 1988 Smiley DR. A statewide early defibrillation ini- (E)-Resuscitators intended for use with humans. tiative including laypersons and outcome report- New York: American National Standards Insti- ing. JAMA 1991;266(4):545-547. tute; 1988. 106. Eisenberg MS. Who shall live? Who shall die? 123. Hess D, Simmons M. An evaluation of the resis- In: Eisenberg MS, Bergner L, Hallstrom AP, edi- tance to flow through the patient valves of tors. Sudden cardiac death in the community. twelve adult manual resuscitators. Respir Care Philadelphia: Praeger Scientific; 1984:44-58. 1992;37(5):432-438. 107. Giffen PR Jr, Hope CE. Preliminary evaluation 124. Hess D. Manual and gas powered resuscitators. of a prototype tube-valve-mask ventilator for In: Branson RD, Hess DR, Chatburn RL, editors. emergency artificial ventilation. Ann Emerg Respiratory care equipment, 2nd ed. Philadel- Med 1991;20(3):262-266. phia: Lippincott Williams & Wilkins; 1999:187- 108. Harrison RR, Maull KI, Keenan RL, Boyan CP. 204. Mouth-to-mask ventilation: a superior method of 125. ECRI. Evaluation: oxygen powered resuscita- rescue breathing. AnnRETIRED Emerg Med tors. Health Devices 1974;3:207-221. 1982;11(2):74-76. 126. ECRI. Hazard: demand valve resuscitators. 109. Hess D, Ness C, Oppel A, Rhoads K. Evaluation Health Devices 1976;5:145-146. of mouth-to-mask ventilation devices. Respir 127. ECRI. Gas powered resuscitators. Health De- Care 1989; 34(3):191-195. vices 1978; 8:24-38. 110. Hess D, Baran C. Ventilatory volumes using 128. Harber T, Lucas BG. An evaluation of some me- mouth-to-mouth, mouth-to-mask, and bag-valve- chanical resuscitators for use in the ambulance mask techniques. Am J Emerg Med service. Ann R Coll Surg Engl 1980;62(4):291- 1985;3(4):292-296. 293. 111. Lawrence PJ, Sivaneswaran N. Ventilation dur- 129. Osborn HH, Kayen D, Horne H, Bray W. Excess ing cardiopulmonary resuscitation: which ventilation with oxygen-powered resuscitators. method? Med J Aust 1985;143(10):443-446. Am J Emerg Med 1984;2(5):408-413. 112. Safar P. Pocket mask for emergency artificial 130. Paradis IL, Caldwell EJ. Traumatic pneumo- ventilation and oxygen inhalation. Crit Care cephalus: a hazard of resuscitators. J Trauma Med 1974;2(5):273-276. 1979;19(1):61-63. 113. Seidelin PH, Stolarek IH, Littlewood DG. Com- 131. Campbell RS, Branson RD, Davis K, Johnson

RESPIRATORY CARE ¥ SEPTEMBER 2004 VOL 49 NO 9 1097 AARC GUIDELINE: RESUSCITATION AND DEFIBRILLATION

DJ, Porembka D, Hurst JM. Laboratory and clin- 1983;11(10):779-782. ical evaluation of the Impact Uni-Vent 750 145. Bocka JJ. External transcutaneous pacemakers. portable ventilator. Respir Care 1992;37(1):29- Ann Emerg Med 1989;18(12):1280-1286. 36. 146. Murray IP, Modell JH. Early detection of endo- 132. McGough EK, Banner MJ, Melker RJ. Variations accidents by monitoring carbon in tidal volume with portable transport ventila- dioxide concentration in respiratory gas. Anes- tors. Respir Care 1992;37(3):233-239. thesiology 1983;59(4):344-346. 133. Kern KB, Carter AB, Showen RL, Vorhees WD 147. Sayah AJ, Peacock WF, Overton DT. End-tidal 3d, Babbs CF, Tacker WA, et al. Comparison of CO2 measurement in the detection of esophageal mechanical techniques of cardiopulmonary re- intubation during cardiac arrest. Ann Emerg suscitation: survival and neurologic outcome in Med 1990;19(8):857-860. dogs. Am J Emerg Med 1987;5(3):190-195. 148. Sanders AB, Kern KB, Otto CW, Milander MM, 134. Taylor GJ, Rubin R, Tucker M, Greene HL, Ewy GA. End-tidal carbon dioxide monitoring Rudikoff MT, Weisfeldt ML. External cardiac during cardiopulmonary resuscitation: a prog- compression: a randomized comparison of me- nostic indicator for survival. JAMA chanical and manual techniques. JAMA 1989;262(10):1347-1351. 1978;240(7):644-646. 149. Garnett AR, Ornato JP, Gonzalez ER, Johnson 135. McDonald JL. Systolic and mean arterial pres- EB. End-tidal carbon dioxide monitoring during sures during manual and mechanical CPR in hu- cardiopulmonary resuscitation. JAMA mans. Ann Emerg Med 1982;11(6):292-295. 1987;257(4):512-515. 136. American Society for Testing and Materials 150. Falk JL, Rackow EC, Weil MH. End-tidal carbon (ASTM). Standards for cuffed and uncuffed tra- dioxide concentration during cardiopulmonary cheal tubes (F290201). Philadelphia: ASTM; resuscitation. N Engl J Med 1988;318(10):607- 1989. 611. 137. American Society for Testing and Materials 151. Bayes de Luna A, Coumel P, Leclercq JF. Ambu- (ASTM). F 1254-90. Standard practice for per- latory sudden cardiac death: mechanism of pro- formance of prehospital manual defibrillation. duction of fatal dysrhythmia on the basis of data In: Annual book of ASTM standards, Vol from 157 cases. Am Heart J 1989;117(1):151- 13.01:661-662. Philadelphia: ASTM; 1990. 159. 138. Stults KR, Brown DD, Cooley F, Kerber RE. 152. Curry L, Gass D. Effects of training in car- Self-adhesive monitor/defibrillation pads im- diopulmonary resuscitation on competence and prove prehospital defibrillation success. Ann patient outcome. CMAJ 1987;137(6):491-496. Emerg Med 1987;16(8):872-877. 153. Heath ML, Brown RW. Quality of cardiopul- 139. American Society for Testing and Materials monary resuscitation (letter). Lancet (ASTM). F 1255-90. Standard practice for per- 1992;339(8808):1542. formance of prehospital automated defibrilla- 154. Kaye W, Mancini ME. Use of the Mega Code to tion. In: Annual book of ASTM standards. Vol evaluate team leader performance during ad- 13.01:663-664. Philadelphia: ASTM; 1990. vanced cardiac life support. Crit Care Med 140. Stults KR, Brown DD, Kerber RE. Efficacy of an 1986;14(2):99-104. automated external defibrillator in the manage- 155. Kaye W, Mancini ME. Retention of cardiopul- ment of out-of hospital cardiac arrest: validation monary resuscitation skills by physicians, regis- of the diagnostic algorithm and initial clinical tered nurses, and the general public. Crit Care experience in a rural environment.RETIRED Circulation Med 1986;14(7):620-622. 1986;73(4):701-709. 156. Lowenstein SR, Hansbrough JF, Libby LS, Hill 141. Weaver WD, Hill D, Fahrenbruch CE, Copass DM, Mountain RD, Scoggin CH. Cardiopul- MK, Martin JS, Cobb LA, et al. Use of the auto- monary resuscitation by medical and surgical matic external defibrillator in the management house-officers. Lancet 1981;2(8248):679-681. of out-of-hospital cardiac arrest. N Engl J Med 157. Weil MH, Rackow EC, Trevino R, Grundler W, 1988;319(11):661-666. Falk JL, Griffel MI. Difference in acid-base 142. Bocka JJ. Automatic external defibrillators. Ann state between venous and arterial blood during Emerg Med 1989:18(12):1264-1268. cardiopulmonary resuscitation. N Engl J Med 143. Zoll PM, Zoll RH, Falk RH, Clinton JE, Eitel 1986;315(3):153-156. DR, Antman EM. External noninvasive tempo- 158. Sanders AB, Ewy GA, Taft TV. Prognostic and rary cardiac pacing: clinical trials. Circulation therapeutic importance of the aortic diastolic 1985;71(5):937-944. pressure in resuscitation from cardiac arrest. 144. Falk RH, Jacobs L, Sinclair A, Madigan-McNeil Crit Care Med 1984;12(10):871-873. C. External noninvasive cardiac pacing in out- 159. Paradis NA, Martin GB, Rivers EP, Goetting of-hospital cardiac arrest. Crit Care Med MG, Appleton TJ, Feingold M, Nowak RM.

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Coronary pressure and the return of 161. Bolyard EA, Tablan OC, Williams WW, Pearson spontaneous circulation in human cardiopul- ML, Shapiro CN, Deitchmann SD. Guideline for monary resuscitation. JAMA 1990;263(8):1106- infection control in healthcare personnel, 1998. 1113. Hospital Infection Control Practices Advisory 160. Kannel WB, Doyle JT, McNamara PM, Quicken- Committee. Infect Control Hosp Epidemiol ton P, Gorton T. Precursors of sudden coronary 1998;18(6):4407-4462. Erratum in: Infection death: factors related to the incidence of sudden Control Hosp Epidemiol 1998;19(7):4493. death. Circulation 1975;51(4):606-613.

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