Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Charging the Defibrillator While Continuing Chest Compressions – Part I

At EMS 12 Lead, Tom Bouthillet has a post that mentions a controversy in the safety of charging the defibrillator while continuing chest compressions.

This is where the “pit crew” concept or “choreographed model” comes into play. There is no reason to hesitate. The monitor should be charged immediately with the expectation that it’s a shockable rhythm so that the shock can be delivered as soon as possible.[1]

Is it safe to provide compressions while the defibrillator is charging?

Not while the patient is being shocked, but during the time that the defibrillator is charging.

Can the defibrillator even deliver a shock while charging?

The 2005 Guidelines state –

Delays to either start of CPR or defibrillation can reduce survival from SCA. In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs. Cobb6 noted, however, that as more Seattle first responders were equipped with AEDs, survival rates from SCA unexpectedly fell. He attributed this decline to reduced emphasis on CPR, and there is growing evidence to support this view. Part 4: “Adult Basic Life Support” summarizes the evidence on the importance of effective chest compressions and minimizing interruptions in providing compressions.[2]

The 2010 Guidelines change that last sentence to –

Part 5: “Adult Basic Life Support” summarizes the evidence on the importance of provision of high-quality CPR (including chest compressions of adequate rate and depth, allowing full chest recoil after each compression and minimizing interruptions in compressions).[3]

About compressions while charging the monitor, the 2005 Guidelines state –

When a rhythm check reveals VF/VT, rescuers should provide CPR while the defibrillator charges (when possible), until it is time to “clear” the victim for shock delivery. Give the shock as quickly as possible. Immediately after shock delivery, resume CPR (beginning with chest compressions) without delay[4]

They appear to have felt that the wording was not clear enough. So this is what it was changed to for the 2010 Guidelines –

When a rhythm check by a manual defibrillator reveals VF/VT, the first provider should resume CPR while the second provider charges the defibrillator. Once the defibrillator is charged, CPR is paused to “clear” the patient for shock delivery. After the patient is “clear,” the second provider gives a single shock as quickly as possible to minimize the interruption in chest compressions (“hands-off interval”). The first provider resumes CPR immediately after shock delivery (without a rhythm or pulse check and beginning with chest compressions) and continues for 2 minutes. After 2 minutes of CPR the sequence is repeated, beginning with a rhythm check.[5]

Is there any doubt that withholding compressions while charging the monitor is a violation of the 2005 and 2010 AHA (American Heart Association) Guidelines?

Why is any ACLS certified person not clear on that?

Probably due to misguided ACLS instructors.

There was a similarly confused approach to the possibility of fire from defibrillation. The real problem seems to have come from instructors who do not understand patient care and who never even read the guidelines they are supposed to be teaching. These instructors would stress turning off the oxygen to avoid starting a fire. This is not what the AHA recommended.

The thinking seems to have been limited to – Fire bad!

These instructors seem to be trying to push the lowest common denominator even farther below any level of competence.

These instructors seem to be more concerned with procedure than with competence.

To be continued in Part II.

Footnotes:

[1] 60 Year Old Male CC: Sudden Cardiac Arrest
EMS 12 Lead
Article

[2] Defibrillation Plus CPR: A Critical Combination
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 5: Electrical Therapies
Automated External Defibrillators, Defibrillation, Cardioversion, and Pacing
Free Full Text from Circulation with links to Free Full Text PDF

[3] Defibrillation Plus CPR: A Critical Combination
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 6: Electrical Therapies
Automated External Defibrillators, Defibrillation, Cardioversion, and Pacing
Free Full Text from Circulation with links to Free Full Text PDF

[4] Ventricular Fibrillation/Pulseless Ventricular Tachycardia
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.2: Management of Cardiac Arrest
Arrest Rhythms
Free Full Text from Circulation with links to Free Full Text PDF

[5] VF/Pulseless VT
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8: Adult Advanced Cardiovascular Life Support
Rhythm-Based Management of Cardiac Arrest
Free Full Text from Circulation with links to Free Full Text PDF

.

Comments

  1. Or, just leave your hands on the patient while shocking!

    http://circ.ahajournals.org/cgi/content/full/117/19/2510

  2. You do realize you’re making safety coordinators/officers/specialists/managers/etc nationwide have the need for a defibrillator right now right? They’re so convinced the employee will get killed/injured that way.

  3. Hmmmm slightly disappointing, all you’re doing (with regards to continuing CPR while the defib is charging) is parroting the guidelines. The 2010 ACLS guidelines (Part 8) do indeed have the paragraph you mention, but they fail to provide any references to support the approach they recommend. While many studies have demonstrated improved survival with reduced time off the chest during a cardiac arrest, these studies generally refer to continuous high-quality CPR of 30 beats or more when approaching the rhythm assessment. There is no study (that I can find) directly comparing the performance of 4-5 beats of CPR between a rhythm assessment and a shock to an immediate clearance and shock (our biphasic defibrillators only take approx 3 seconds to charge to their optimal energy of 150J). As an experienced ACLS instructor and a team leader at (far too many) in-house arrests, I know that arrest teams may not always function as efficiently as the AHA imagine, and may also be using paddles in some hospitals. As such I feel that some arrest teams may be at a significant risk of an inadvertent shock to a member of the resus team if they practice as the ACLS guidelines recommend, and I have yet to see the evidence to back it up, especially when dealing with a defib that charges quickly. So ultimately I feel that this issue deserves greater debate than a simple ‘read the guidelines’ approach. If you have more evidence, please present it.

Speak Your Mind