AARC GUIDELINE: RESUSCITATION AND DEFIBRILLATION 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 myocardial infarction with cardio- fibrillation 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 injury 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 tachycardia 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 ventilators; (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 hospitals, long-term facilities, outpatient clinics, rehabilitation cen- RAD 6.0 PRECAUTIONS/HAZARDS ters, skilled nursing facilities, and pre- and inter- AND/OR COMPLICATIONS: hospital transport. The following represent possible hazards or complications related to the major facets of re- RAD 4.0 INDICATIONS: suscitation: Cardiac arrest, respiratory arrest, 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 RESPIRATORY CARE • SEPTEMBER 2004 VOL 49 NO 9 1085 AARC GUIDELINE: RESUSCITATION AND DEFIBRILLATION 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 Pulse 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 Bleeding 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- 1086 RESPIRATORY CARE • SEPTEMBER 2004 VOL 49 NO 9 AARC GUIDELINE: RESUSCITATION AND DEFIBRILLATION 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- RESPIRATORY CARE • SEPTEMBER 2004 VOL 49 NO 9 1087 AARC GUIDELINE: RESUSCITATION AND DEFIBRILLATION proves patient outcome in terms of survival 10.2.1.1.4 Be transparent107-114 and level of function.