Shocked? Hands On Defibrillation

In Medical Concepts by Sean McIntoshLeave a Comment

High quality chest compressions and defibrillation are two of the most meaningful interventions in a cardiac arrest1. If you have taken Advanced Cardiac Life Support (ACLS), you’ve heard the mantra “I’m clear, you’re clear, everybody’s clear.”1 During delivery of a shock, valuable seconds of chest compressions are lost. This pause in chest compression translates to a decrease in coronary perfusion pressure, one of the largest predictors of return of spontaneous circulation (ROSC).2 After chest compressions resume, it takes between 45 and 90 seconds for adequate coronary perfusion pressures to return, increasing ischemia of the myocardium.2

So, is there a way to minimize interruption to chest compressions, while still delivering defibrillating doses of electricity? Over the past decade, there has been an increasing interest in continuing chest compressions through shock delivering – also referred to as hands-on defibrillation. There has always been the theoretical concern of inducing ventricular fibrillation in the rescuer if they were in contact with the patient at the time of shock delivery. A systematic review conducted on adverse events with defibrillators found only 15 events affecting to the rescuer, all of which were minor tingling in arms or legs.3

While gloves add a layer of protection during hands-on defibrillation, there is some concern surrounding their durability in a resuscitation environment. Studies have shown that polyethylene gloves outperform both latex and nitrile gloves in terms of resistance to mechanical and electrical breakdown.4 Further, double gloving increases resistance, preventing electrical current from flowing through the rescuer.5

As hands-on defibrillation has not been implemented on a large scale yet, it is still unclear what impact this will have clinically. A study conducted on pigs compared hands-on defibrillation against traditional pauses in compression while delivering the shock. While it was not adequately powered to demonstrate a substantial difference in return of spontaneous circulation between the two groups, they did demonstrate a decrease in pauses of chest compression of 7.4%.6

The bottom line:

As this is still a fairly new concept, there is not enough high quality research to recommend this technique broadly. However, more and more research is being done in this field, and thus far there have been no major adverse events reported. The emphasis must continue to be on decreasing interruptions in chest compressions, which can include pre-charging the defibrillator to cut down time spent off the chest. If you do try hands-on defibrillation, the recommendation is to double glove and change gloves between shocks. This new technique shows great promise in minimizing interruptions to chest compressions.

This post was copyedited and uploaded by Sonja Wakeling (@SonjaWakeling)

References

1.
Kleinman M, Brennan E, Goldberger Z, et al. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(18 Suppl 2):S414-35. [PubMed]
2.
Andreka P, Frenneaux M. Haemodynamics of cardiac arrest and resuscitation. Curr Opin Crit Care. 2006;12(3):198-203. [PubMed]
3.
Hoke R, Heinroth K, Trappe H, Werdan K. Is external defibrillation an electric threat for bystanders? Resuscitation. 2009;80(4):395-401. [PubMed]
4.
Lloyd M, Heeke B, Walter P, Langberg J. Hands-on defibrillation: an analysis of electrical current flow through rescuers in direct contact with patients during biphasic external defibrillation. Circulation. 2008;117(19):2510-2514. [PubMed]
5.
Sullivan J, Chapman F. Will medical examination gloves protect rescuers from defibrillation voltages during hands-on defibrillation? Resuscitation. 2012;83(12):1467-1472. [PubMed]
6.
Neumann T, Gruenewald M, Lauenstein C, Drews T, Iden T, Meybohm P. Hands-on defibrillation has the potential to improve the quality of cardiopulmonary resuscitation and is safe for rescuers-a preclinical study. J Am Heart Assoc. 2012;1(5):e001313. [PubMed]

Reviewing with the Staff

It has been well documented that coronary perfusion pressure (CPP) decreases with interruptions in chest compressions. An increase in CPP directly correlates with a greater chance at ROSC. With this in mind, every attempt to decrease CPR interruptions is extremely important.

There have been substantial changes to external defibrillation technology in an attempt to increase the safety of the shock delivered. The few studies that have looked at continuous hands-on CPR during defibrillation however, have not shown sufficient evidence that it is safe to perform hands-on defibrillation with the current available personal protective equipment.

Decreasing interruptions in good quality CPR is of utmost importance, but further equipment and techniques must be developed to reduce the risk to the rescuer prior to attempting hands-on defibrillation.

Dr. Fareen Zaver
Fareen Zaver is an emergency medicine physician at the University of Calgary. She is the lead editor and co-founder of the ALiEM AIR Pro series as well as co-author of the 2016 edition of must read EM journal articles. She has also taken the lead on the CanadiEM Digital Scholarship Fellowship.
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Sean McIntosh

Sean McIntosh

Sean McIntosh is a second year medical student at the Niagara Regional Campus of McMaster University. His interests in emergency medicine include simulation and ultrasound.
Sean McIntosh

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Fareen Zaver MD

Fareen Zaver MD

Fareen Zaver is an Emergency Physician based in Calgary. She is the Co-Director for the CanadiEM Digital Scholars Fellowship and is the Lead Editor/Co-Founder of ALiEM Approved Instructional Resources - Professional (AIR-Pro) series
Fareen Zaver MD
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