Part 5: Electrical Therapies IV-39 the victims right superior-anterior(infraclavicular)chest and For children I to years of age the rescuer should use a the apical (left) pad is placed on the victims inferior-lateral pediatric dose-attenuator system if one is available. 78.83. 84If left chest, lateral to the left breast( Class Ila). Other accept the rescuer provides CPr to a child in cardiac arrest and does able pad positions are placement on the lateral chest wall not have an AED with a pediatric attenuator system, the the right and left sides(biaxillary)or the left pad in the rescuer should use a standard AED standard apical position and the other pad on the right or left There is insufficient data to make a recommendation for or upper back( Class Ila) against the use of AEDs for infants <I year of age(Class When an implantable medical device is located in an area Indeterminate). During infancy the risk of VF SCA is where a pad would normally be placed, position the pad at unknown, and most cardiac arrest is thought to be related to least I inch(2.5 cm) away from the device( Class Indetermi- progression of respiratory failure or shock. As a result there is nate). If the victim has an ICd that is delivering shocks(ie, concen that repeated interruption of CPR to try to detect and the patients muscles contract in a manner similar to that treat a rhythm uncommon in that age group may introduce observed during extermal defibrillation), allow 30 to 60 more risk than benefit 8 seconds for the ICD to complete the treatment cycle before If an AED program is established in systems or institutions attaching an AED. Occasionally the analysis and shock cycles that routinely provide care to children, the program should be of automatic ICDs and AEDs will conflict. 67 equipped with AEDs with a high specificity for pediatrie Do not place AED electrode pads directly on top of a shockable rhythms and with a pediatric attenuator system(eg, transdermal medication patch(eg, patch containing nitroglyc- pediatric pad-cable system or other method of attenuating the erin, nicotine, analgesics, hormone replacements, antihyper shock dose). This statement, however, should not be inter tensive)because the patch may block delivery of energy preted as a recommendation for or against AED placement in from the electrode pad to the heart and may cause small burns specific locations where children are present. Ideally health- to the skin. 6s Remove medication patches and wipe the area care systems that routinely provide care to children at risk for before attaching the electrode pad. cardiac arrest should have available manual defibrillators If an unresponsive victim is lying in water or if the victim's capable of dose adjustment. chest is covered with water or the victim is extremely diaphoretic, remove the victim from water and briskly wipe At the time of the 2005 Consensus Conference, there were no the chest before attaching electrode pads and attempting published in-hospital randomized trials of AEDs versus defibrillation. AEDs can be used when the victim is lying on manual defibrillators. Evidence from I study of fair qualit If the victim has a very hairy chest, it may be necessary to treat adult VF or pulseless VT in the hospita( were,er rates snow or ice. Most victims do not need any special preparation (OE 4)85 and a case series (LOE 5) indicated higl of the chest other than removal of the clothes from the chest. of survival to hospital discharge when AEDs were used to remove some hair so that the electrode pads will adhere to the Defibrillation may be delayed when patients develop SCA chest. This may be accomplished by briskly removing an in unmonitored hospital beds and in outpatient and diagnostic electrode pad (which will remove some hair), or it may be facilities. In such areas several minutes may elapse before necessary to shave the chest in that area centralized response teams arrive with the defibrillator, attach AED Use in children it, and deliver shocks. $7 Despite limited evidence, AEDs Cardiac arrest is less common in children than adults and its should be considered for the hospital setting as a way to causes are more diverse 69-71 Although vf is not a common facilitate early defibrillation(a goal of <3 minutes from arrhythmia in children, it is observed in 5% to 15% of collapse), especially in areas where staff have no rhythm pediatric and adolescent arrests. -75 In these patients rapid recognition skills or defibrillators are used infrequently. An defibrillation may improve outcomes. 75.76 effective system for training and retraining should be in plac The lowest energy dose for effective defibrillation in When hospitals deploy AEDs, first-responding personn fants and children is not known. The upper limit for safe should also receive authorization and training to use an AED. defibrillation is also not known, but doses >4 J/kg(as high as with the goal of providing the first shock for any SCA within 9 J/kg)have effectively defibrillated children, 78 and pediat- 3 minutes of collapse. The objective is to make goals for ric animal models 79 with no significant adverse effects. Based in-hospital use of AEDs consistent with goals established in on adult clinical data7.24 and pediatric animal models, 79-81 biphasic shocks appear to be at least as effective as monopl should be available in ambulatory care facilities as we sic shocks and less harmful Recommended manual defibril- throughout hospital inpatient areas. Hospitals should monitor lation(monophasic or biphasic) doses are 2 J/kg for the first collapse-to-first shock intervals and resuscitation outcomes attempt(Class Ila: LOE 582 and 67%)and 4 J/kg for subsequent (see Part 3: "Overview of CPR) tempts( Class Indeterminate) Many AEDs can accurately detect VF in children of all Manual defibrillation ages65,66 and differentiate shockable from nonshockable Shock Energies rhythms with a high degree of sensitivity and specificity. 6 At present it is clear that both low-energy and high-energy Some are equipped with pediatric attenuator systems(eg, biphasic waveform shocks are effective, but definitive rec- pad-cable systems or a key), to reduce the delivered energy to ommendations for the first and subsequent energy levels for a dose suitable for children all devices cannot be made because devices vary in waveformthe victim’s right superior-anterior (infraclavicular) chest and the apical (left) pad is placed on the victim’s inferior-lateral left chest, lateral to the left breast (Class IIa). Other accept￾able pad positions are placement on the lateral chest wall on the right and left sides (biaxillary) or the left pad in the standard apical position and the other pad on the right or left upper back (Class IIa). When an implantable medical device is located in an area where a pad would normally be placed, position the pad at least 1 inch (2.5 cm) away from the device (Class Indetermi￾nate). If the victim has an ICD that is delivering shocks (ie, the patient’s muscles contract in a manner similar to that observed during external defibrillation), allow 30 to 60 seconds for the ICD to complete the treatment cycle before attaching an AED. Occasionally the analysis and shock cycles of automatic ICDs and AEDs will conflict.67 Do not place AED electrode pads directly on top of a transdermal medication patch (eg, patch containing nitroglyc￾erin, nicotine, analgesics, hormone replacements, antihyper￾tensives) because the patch may block delivery of energy from the electrode pad to the heart and may cause small burns to the skin.68 Remove medication patches and wipe the area before attaching the electrode pad. If an unresponsive victim is lying in water or if the victim’s chest is covered with water or the victim is extremely diaphoretic, remove the victim from water and briskly wipe the chest before attaching electrode pads and attempting defibrillation. AEDs can be used when the victim is lying on snow or ice. Most victims do not need any special preparation of the chest other than removal of the clothes from the chest. If the victim has a very hairy chest, it may be necessary to remove some hair so that the electrode pads will adhere to the chest. This may be accomplished by briskly removing an electrode pad (which will remove some hair), or it may be necessary to shave the chest in that area. AED Use in Children Cardiac arrest is less common in children than adults, and its causes are more diverse.69–71 Although VF is not a common arrhythmia in children, it is observed in 5% to 15% of pediatric and adolescent arrests.71–75 In these patients rapid defibrillation may improve outcomes.75,76 The lowest energy dose for effective defibrillation in infants and children is not known. The upper limit for safe defibrillation is also not known, but doses
4 J/kg (as high as 9 J/kg) have effectively defibrillated children77,78 and pediat￾ric animal models79 with no significant adverse effects. Based on adult clinical data17,24 and pediatric animal models,79–81 biphasic shocks appear to be at least as effective as monopha￾sic shocks and less harmful. Recommended manual defibril￾lation (monophasic or biphasic) doses are 2 J/kg for the first attempt (Class IIa; LOE 582 and 679) and 4 J/kg for subsequent attempts (Class Indeterminate). Many AEDs can accurately detect VF in children of all ages65,66 and differentiate shockable from nonshockable rhythms with a high degree of sensitivity and specificity.65,66 Some are equipped with pediatric attenuator systems (eg, pad-cable systems or a key), to reduce the delivered energy to a dose suitable for children. For children 1 to 8 years of age the rescuer should use a pediatric dose-attenuator system if one is available.78,83,84 If the rescuer provides CPR to a child in cardiac arrest and does not have an AED with a pediatric attenuator system, the rescuer should use a standard AED. There is insufficient data to make a recommendation for or against the use of AEDs for infants 1 year of age (Class Indeterminate). During infancy the risk of VF SCA is unknown, and most cardiac arrest is thought to be related to progression of respiratory failure or shock. As a result there is concern that repeated interruption of CPR to try to detect and treat a rhythm uncommon in that age group may introduce more risk than benefit.83 If an AED program is established in systems or institutions that routinely provide care to children, the program should be equipped with AEDs with a high specificity for pediatric shockable rhythms and with a pediatric attenuator system (eg, pediatric pad-cable system or other method of attenuating the shock dose). This statement, however, should not be inter￾preted as a recommendation for or against AED placement in specific locations where children are present. Ideally health￾care systems that routinely provide care to children at risk for cardiac arrest should have available manual defibrillators capable of dose adjustment.83 In-Hospital Use of AEDs At the time of the 2005 Consensus Conference, there were no published in-hospital randomized trials of AEDs versus manual defibrillators. Evidence from 1 study of fair quality (LOE 4)85 and a case series (LOE 5)86 indicated higher rates of survival to hospital discharge when AEDs were used to treat adult VF or pulseless VT in the hospital. Defibrillation may be delayed when patients develop SCA in unmonitored hospital beds and in outpatient and diagnostic facilities. In such areas several minutes may elapse before centralized response teams arrive with the defibrillator, attach it, and deliver shocks.87 Despite limited evidence, AEDs should be considered for the hospital setting as a way to facilitate early defibrillation (a goal of
3 minutes from collapse), especially in areas where staff have no rhythm recognition skills or defibrillators are used infrequently. An effective system for training and retraining should be in place. When hospitals deploy AEDs, first-responding personnel should also receive authorization and training to use an AED, with the goal of providing the first shock for any SCA within 3 minutes of collapse. The objective is to make goals for in-hospital use of AEDs consistent with goals established in the out-of-hospital setting.88 Early defibrillation capability should be available in ambulatory care facilities as well as throughout hospital inpatient areas. Hospitals should monitor collapse-to–first shock intervals and resuscitation outcomes (see Part 3: “Overview of CPR”). Manual Defibrillation Shock Energies At present it is clear that both low-energy and high-energy biphasic waveform shocks are effective, but definitive rec￾ommendations for the first and subsequent energy levels for all devices cannot be made because devices vary in waveform Part 5: Electrical Therapies IV-39