Cardiac Arrest (Sudden Cardiac Death)

Definition

Cardiac arrest means the heart suddenly stops pumping. When the heart stops, the victim will also stop breathing resulting in sudden death.

Sudden cardiac arrest may occur as a complication of a heart attack, most commonly within 1 to 2 hours after the beginning of a heart attack. This may be the first sign of coronary artery disease without any other symptoms of heart attack.

Common causes of sudden death are listed below:

·                Ventricular Fibrillation

·                Stroke

·                Accidental electric shock

·                Drowning

·                Suffocation

·                Drug overdose

·                Trauma

·                Severe allergic reactions

Signs and Symptoms

·                Victim is unresponsive

·                Absence of breathing

·                Absence of circulation

Treatment

·                Begin CPR immediately.

·                Get first aid equipment e.g. Air-Viva resuscitator, oxygen cylinder and AED if available. Early CPR and early defibrillation increases the victim’s chance of survival.

HEART ATTACK

Definition

Heart attack or acute myocardial infarction occurs when a blood clot suddenly and completely blocks a diseased coronary artery. There is no blood supply resulting in the death of the heart muscle cells supplied by that artery.

Signs and Symptoms

The severity of a heart attack may include some, or all of the following signs and symptoms depend on the degree of damage to the heart muscle.

Severe chest pain or chest discomfort.

Ask these questions:

“What is the pain like?”

People describe the pain of a heart attack in many ways such as “pressure”, “fullness”,  “squeezing”, and “heaviness” or “chest tightness”.

“Where is the pain located?”

Location of pain is usually deep in the center of the chest, after a few moments the pain may spread to the shoulder, the neck or the lower jaw or down the arm.

“How long does the pain last?”

The discomfort of a heart attack usually lasts more than a few minutes and not relieved by rest.

·                Shortness of breath or suffocation

·                Giddiness and sweating

·                Pale face, skin cold and clammy

·                Nausea or vomiting

·                Pulse rapid, weak and irregular

·                Feeling apprehensive and fearful

·                Denial response – Do not admit that the symptoms may indicate a heart attack.

·                Collapse often without any warning

 Treatment

Early recognition of the signs and symptoms of a heart attack is important for successful treatment. The victim requires immediate attention.

Complete rest

Reassure victim.

·                Recline the seat (half-sitting position) and loosen tight clothing to ease breathing and allow comfort.

·                Administer high flow oxygen

·                Find out if victim has known history of heart disease and uses Nitroglycerin.

·                Monitor and record breathing and pulse every 10 – 15 minutes

Treat for victim shock and be prepared to resuscitate.

MEDICAL EMERGENCIES AND MINOR AILMENTS

Coronary Artery Disease

Introduction

Coronary Artery Disease affects the arteries that supply blood to the heart muscle. It is caused by gradual build-up of fatty deposits or cholesterol on the inner lining of the artery walls. As a result, the artery becomes thickened, narrowed and blood flow is decreased. This condition is known as atherosclerosis or commonly called hardening of the arteries.

Atherosclerosis

The disease may involve the arteries in many different areas of the body, including the heart (leading to a heart attack) and the brain (leading to a stroke).

Coronary artery disease may show up in three common ways:

•  Angina Pectoris
• Heart Attack
• Cardiac Arrest (Sudden cardiac death)

ANGINA PECTORIS

Definition

Angina Pectoris is a medical term for chest pain or chest discomfort due to insufficient blood supply to the heart muscle.

The pain is temporary brought on by exertion when narrowing of the coronary artery temporarily prevents and adequate supply of blood and oxygen to meet the demands of the working heart muscle. Once the demands of the heart muscle decrease, the pain disappears and there is usually no permanent damage to the heart muscle.

Signs and Symptoms

·                Chest pain

-         may radiates to one or both arms and throat.

-         pain will be relieved by rest – usually within 10 minutes.

-         pain will be relieved by Nitroglycerin prescribed by doctor.

Nitroglycerin works in most patients within 5 minutes to relieve the pain of angina. It comes in many forms: skin patches, ointment, spray and tablet (Glycerine Trinitrate or GTN). Spray and tablet are placed under the tongue (sublingually).

·                Difficulty in breathing, shortness of breath

·                Face may be pale

·                Pulse rapid and weak

·                General body weakness

Treatment

¨              Have the victim rest completely. Put to half-sitting position to ease breathing and allow comfort. Loosen all tight clothing.

¨          Reassure the victim and administer oxygen high flow.

¨              Find out if victim has known history of heart disease and uses Nitroglycerin. Assist the victim in using it appropriately. Nitroglycerin dilates the coronary arteries and increase blood flow to the heart muscle.

¨              Monitor and record breathing and pulse every 10 – 15 minutes.

Foreign-Body Airway Obstruction (Choking)

Definition

Choking occurs when food especially a piece of meat or other foreign object such as a marble, a button gets lodged in the windpipe. When someone is choking, there is either a PARTIAL or a COMPLETE airway obstruction.

Causes

Large, poorly chewed pieces of food.

Loose dentures.

Playing, crying, laughing or talking while food or foreign bodies are in the mouth.

Elevated blood alcohol levels.

How to Recognize Choking

Foreign bodies may partially block the airway but still allow adequate air movement.

1)         Choking Victim with Partial Airway Obstruction

Signs and Symptoms

Victim remains conscious

Can cough forcefully and usually can speak

Breath sounds may be noisy

Management

Do not interfere with the victim’s attempts to cough, because a strong cough is the most effective way to expel a foreign body.

Stay with the victim and monitor his or her condition. Be prepared to act if the airway obstruction worsens.

2)         Choking Victim with Complete Airway Obstruction

Victim may die from lack of oxygen due to total blockage in the windpipe unless emergency action is taken. The rescuer has only 4 to 6 minutes to save victim’s life.

Recognizing and assisting the choking victim IMMEDIATELY is vital. Determine whether the victim is choking by asking. “Are you choking?”

Universal Choking Sign

Signs and Symptoms

• "Universal Choking Sign" or " Universal Distress Signal" - Victim is clutching the throat or neck with one or both hands. This indicates that victim is choking and needs help. 
• Victim cannot speak or cough forcefully.
• Victim cannot breathe
• Bluish skin colour (cyanosis)
• Loss of consciousness if not treated immediately

Relief of Complete Foreign-Body Airway Obstruction

1)         Choking Adult and Child – Victim is Conscious

Perform the abdominal thrusts or Heimlich maneuver to relieve severe airway obstruction caused by a foreign object while the victim is still conscious and standing. You must act quickly to relieve the obstruction.

Abdominal thrusts (Heimlich maneuver)

Stand behind the victim. Make a fist with one hand and place the thumb side of the fist on the Victim’s abdomen,  slightly above the navel and well below the xyphoid or breastbone. Grasp the fist with the other hand and deliver quick inward and upward thrusts into the victim’s abdomen. Repeat thrusts and continue until object is expelled or the victim becomes unconscious.

2)         Choking in Pregnant and Obese Victims – Conscious

Chest thrusts

If the choking victim is in the late stages of pregnancy or is obese, use Chest thrusts instead of abdominal thrusts. Stand behind victim and wrap your arms around her chest. Position your fist on the center of the chest or breastbone, between the nipples. Grab your fist with your other hand and deliver firm backward thrusts until the object is removed or the victim becomes unconscious.

3)         Choking Infant (less than 1 year)

It is important to determine the complete airway obstruction is caused by a foreign body. If obstruction is caused b swelling due to infection or other medical problem and the infant stops breathing, immediate basic and advanced life support is necessary.

Infant with severe or complete airway obstruction will not be able to move enough air to make much sound, may make very soft, high-pitched or wheezing sounds when the infant tires to breathe in, unable to cough or cry, and blueness of the lips and skin can be seen. You must act quickly to remove the object.

Infant is Conscious

To relief of choking in the conscious or responsive infant, perform 5 back blows and 5 chest thrusts.

Deliver 5 Back Blows

Support infant’s head and neck with one hand, straddle infant on your forearm with infant face down, head lower than body and supported on your thigh. Deliver 5 back blows forcefully between the shoulder blades with the heel of one hand.

Deliver 5 Chest Thrusts

If the foreign object is not expelled, continue to support the head, turn the infant on his back, head lower than body. Deliver 5 chest thrusts using 2 fingers positioned over the breastbone (sternum) in the same position used for chest compression during CPR.

·                Alternate the 5 back blows and 5 chest trusts until the object is dislodged or the infant becomes unconscious.

·                Relief of Complete Foreign-Body Airway Obstruction in an Unconscious Victim – For Adult, Child and Infant:

·                Place the unconscious victim on his or her back. Call for help and begin CPR. Follow the steps of ABCs:

·                Open the Airway and look for the choking object in the mouth. Perform a tongue-jaw lift and if you see an object, remove it using finger sweeps. However, do not perform blind finger sweeps.

·                Check for Breathing – if the victim is not breathing normally, give 2 slow rescue breaths. If you are unable to see the chest rise after the first breath, reposition the victim’s head and reattempt two rescue breaths.

·                Check for Circulation – After the 2 rescue breaths, look signs of circulation such as normal breathing, coughing or movement.

·                If the victim has no signs of circulation, begin CPR starting with chest compressions.

·                Each time you open the airway to provide rescue breathing after the chest compressions, look into the victim’s mouth for any object. If you see an object, remove it. Do not perform blind finger sweeps.

·                If the foreign object is removed, check for signs of circulation, if victim is breathing normally, turn into the recovery position.

·                Administer oxygen, monitor and record the vital signs. Seek urgent medical attention.

Automated External Defibrillator (AED) Model – Heartstream FR2

Introduction

The Heartstream FR2 defibrillator is a semi-Automated External Defibrillator (AED). It is compact, lightweight, portable and battery powered. It is designed for simple and reliable operation and is intended for use by personnel who have been trained in Basic Life Support (BLS) and in its operation.

Functions of AED

When connected to defibrillator pads that a property applied to the victim’s bare chest, an AED can:-

·                Analyze the heart rhythm of a victim in cardiac arrest.

·                Recognize a shock able rhythm called Ventricular Fibrillation (VF).

·                Advice the operator through voice prompts and visual indicators whether or not the rhythm is shock able.

The defibrillation pads sense the cardiac electric signal and send it to the computer and electrical shock is delivered through the defibrillation pads if a shock is indicated.

It delivers 150 joules each shock, non-escalating in a biphasic wave. Energy runs from left pad to right pad and again back to left pad.

Sudden Cardiac Arrest

Sudden Cardiac Arrest (SCA), also known as sudden cardiac death, is a major cause of death that claims many lives each year due to Ventricular Fibrillation (VF).

Ventricular Fibrillation (VF) is the most common abnormal heart rhythm that causes adult sudden cardiac arrest. VF is a type of uncoordinated, chaotic electrical activity that can occur within the heart  for reasons such as heart disease, drowning, asphyxiation, electrical shock, poisoning or drug overdose.

When the heart goes into VF, there is a rapid and unproductive quivering of the heart muscle that prevents blood from reaching the brain and other parts of the body. Death occurs within a few minutes unless VF is stopped by defibrillation, which is the only effective treatment.

Defibrillation means delivery of electrical currents to the heart muscle through defibrillation pads adhered to the patient’s chest and connected to a defibrillator. The therapeutic electrical shock stops the VF momentarily, allowing the heart to pause and enabling the heart to regain normal control of its rhythm to resume its normal function.

Ventricular Fibrillation rapidly deteriorates to an astolic rhythm (flat line on the heart monitor) typically in 5 – 6 minutes. The earlier the victim is defibrillated, the more likely the victim’s life can be saved. Survival rates after VF cardiac arrest decrease 7% to 10% with every minute that defibrillation is delayed. It is very important to understand the time factor – that seconds count for the victim of SCA. The AED must be made available at the victim’s side. If there is no VF present in the cardiac arrest victim, defibrillation will not be required; however victim must be given CPR to maintain blood circulation to the vital organs.

Maintaining The Chain of Survival

Activate the Chain of Survival immediately when a person collapses. CPR is a vital link in the chain of survival that must be initiated to support the victim until other, more advanced support is available.

The 4 crucial links in the chain of survival includes the following sequence:

1.         Early Access

2.         Early CPR

3.         Early Defibrillation

4.         Early Advanced Care

Begin the steps of DRABC as your priorities until the arrival of AED to initiate the third link: Early Defibrillation.

Danger           -         Rule out danger to yourself and victim. Ensure scene safety and personal 

                                  protection. Observe the Universal Precautions e.g. wear gloves, use the 

                                  Air-Viva resuscitator.

Response       -         Check responsiveness. If victim is unresponsive, call for help!
         Bring the AED and other first aid equipment.

Airway            -         Open the airway. Perform head tilt-chin lift or Jaw-thrust technique.

Breathing       -         Check for breathing. If victim is not breathing normally give 
              2 slow rescue breaths.

Circulation     -          Look for signs of circulation after the 2 rescue breaths. If no signs of 

                                  circulation,  begin CPR and AED use. When two or more rescuers are 

                                  present, integration of CPR and AED can be initiated simultaneously.

Defibrillation -          Use the AED immediately when it is available. Early defibrillation
          increases the victim’s chance of survival.

Patient Criteria

The AED is indicated or use on victim of sudden cardiac arrest with all the following signs:

·                Unresponsiveness

·                Absence of breathing

·                Absence of circulation

NOTE:   Victim must be 8 years old or older. This is in accordance with the recommendations
 of the FDA and American Heart Association.

Contraindications

The AED should not be used on victim who shows any of the following signs:

·                Responsiveness

·                Presence of breathing

·                Presence of circulation

Special Consideration:

The AED may be used on a conscious person for ECG monitoring upon request by trained medical personnel e.g. doctor, paramedic and emergency room personnel when a passenger is suspected of a serious heart condition.

Safety Considerations In AED Use

Before attaching the AED, determine whether special situations exist that contraindicate the use of AED or require additional actions before its use.

1.         Children

If the victim is younger than 8 years old, do not use the AED due to high electric energy setting. Standard operating procedures should be followed in treating children over eight years of age.

2.         Water

A good conductor of electricity and may provide a pathway for energy from the AED to rescuers and bystanders causing shock hazard.

·                Remove the victim from contact with water.

·                Dry the victim’s chest quickly before attaching the AED.

·                Do not immerse or wet any portion of the AED in water.

3.         Metal Surface

·                Do not allow the defibrillation pads to touch any metal surfaces to avoid possible shock hazard e.g. other ECG electrodes or lead wires.

4.         Transdermal Medications

·                Do not place defibrillation pads directly on top of medication patch as it  may block delivery  of shocks or cause small burns to the skin.

·                Remove the medication patches e.g. nitro-glycerine, hormone replacement, nicotine etc and wipes the area clean before attaching the AED pads.

5.         Implanted Pacemakers or Defibrillators

Placement of an AED defibrillation pad directly over an implanted medical device may reduce the effectiveness of defibrillation attempts.

·                Place the defibrillation pad at least 1 inch (2.5 cm) away from the implanted device.

Preparing The AED For Use

Installing the Battery

There are 2 battery packs supplied in the AED. One battery pack is ready installed for use at any time and the other one is for standby (spare). Before installing the battery, make sure the defibrillation pads are not connected to the AED. To install the battery:

1.      Hold the battery pack by the yellow latch end and slide it into the battery compartment at the top of the AED.

2.       Slide the battery all the way into the opening, until the yellow latch clicks into place. The latch will click into place only when the battery is inserted correctly.

3.      When the battery is installed, the AED automatically turns on. The Status Indicator displays a flashing black hourglass. The shock button light and the indicator light for the defibrillation pads connector port turn on briefly.

Running the Battery Insertion Selftest (BIT)

Except in an emergency. It is recommended that this selftest is carried out every time the battery is changed in order to make sure the display, buttons, lights, speaker and beeper of the Heartstream FR2 are working properly.

To run the Battery Insertion Selftest (BIT):

1.       Make sure that the defibrillation pads are not connected to the device. If the pads are connected, the selftest will stop immediately to allow the AED to be in the standby mode (ready for use).

2.       Insert the battery into the battery port. The first screen displayed RUN SELFTEST highlighted.

3.       Press the upper option button to activate the test, or wait for 10 seconds and the selftest 
          will start automatically.

4.       When the interactive part of the battery insertion selftest is completed, the FR2 AED automatically turns off and returns to standby mode. The Status Indicator shows the flashing black hourglass. The AED is ready for use at any time simply by pressing the On/Off button to turn it on.

Periodic Selftests

In addition to the battery insertion selftest, the AED automatically performs periodic selftests (PSTs). These daily, weekly and extensive monthly selftests check many important functions of the AED, including battery capacity and internal circuitry. If a problem is detected, the Status Indicator will show a flashing red X or a solid red X and the AED will beep to alert you to the need for troubleshooting.

The 4 Universal Steps of AED Operation

When you arrive with the AED at the scene of a possible cardiac arrest, perform the following steps of AED operation after you have verified that the victim is 8 years of age or older, he or she is unresponsive, absence of breathing and circulation.

Step 1.  POWER ON the AED first (in order to get voice and visual guidance prompts).

·                   Open the carrying case of the AED.

·                Press the On/Off button to turn on the AED. Follow the voice and screen prompts in the order indicated.

·                Always turn the AED ON as the first step. DO NOT wait until you have opened the package of defibrillation pads or attached the pads to the patient’s chest.

Step 2.  APPLY defibrillation pads to the victim’s bare chest (stop chest compressions just before attaching the pads).

Preparing the Chest

·                Remove clothing and undergarments from the victim’s chest.

·                Wipe moisture from the victim’s chest.

·                Shave excessive chest hair if necessary. Be sure the chest is bare and dry so that the AED pads can stick firmly to give a good contact for defibrillation.

Pads Location.

·                Place each pad on the patient’s skin, one at a time.

·                Pull off the protective backing from the defibrillation pad and check that the gel has not dried out. If the pads are damaged or the gel has dried out, use a new set of pads.

·                It is important to refer to the drawing on the back of each pad for correct positioning.

·                One pad is attached just below the patient’s right collarbone, above the nipple.

·                Another pad is over the patient’s ribs in line with the armpit and below the left breast.

·               Plug pads connector firmly to the connector socket which is at the top left of the AED. A Flashing   light shows you where the socket is located.

SAFETY WARNING

·                Do not place the two pads on the patient’s chest and back.

·                Do not allow the defibrillation pads to touch each other or other ECG electrodes, lead wires, dressing, chest piercing etc to prevent skin burns and ineffective energy.

·                Air pocket between the skin and defibrillation pads can cause skin burns. To help prevent air pockets, make sure the pads completely adhere to the skin. Do not use dried-out defibrillation pads.

Step 3.  ANALYZE Heart Rhythm

Voice Prompt: ANALYZING! DO NOT TOUCH PATIENT!

As soon as the AED detects that the defibrillation pads are connected properly, it automatically begins analyzing the patient’s heart rhythm. To prevent incorrect heart rhythm analysis or delayed diagnosis caused by interference:

·                Clear the patient during analysis.

·                Check that no one is touching the patient, including the person doing the rescue breathing.

·                Avoid all movement affecting the patient during rhythm analysis.

Analyzing continues and AED displayed the patient’s ECG on the screen. Follow the instructions provided by the AED voice and screen prompts in the order indicated.

Step 4.  SHOCK DELIVERY

If a shock is advised: AED provides voice and screen prompts to tell you so.

The AED charges to prepare for shock delivery. While it is charging, it continues to analyze the patient’s heart rhythm. Make sure that no one is touching the patient. The shock button will be flushing orange when it is charged up.

AED prompts: “Press the SHOCK button now.”

The rescuer operating the AED should clear the patient before pushing the SHOCK button. You must check visually and verbally make sure that no one is touching the patient and refuse to push the SHOCK buttons until all contact with the patient stops.

 SHOUT: “I AM CLEAR, YOU’RE CLEAR, EVERYBODY’S CLEAR”

                 

          

·                It is important that you must press the button for a shock to be delivered. The AED will not automatically deliver a shock. After you have pressed the Shock button, a voice prompt tells you that the shock was delivered.

·                If the Shock button is not pressed within 30 seconds of being prompted, the AED will disarm the current itself and goes back to analyzing mode.

Following the first shock delivery, the AED continues to analyze the patient’s heart rhythm to see if the first shock was successful to treat the VF. The AED continues to provide voice and text prompts to guide you through additional shock if needed.

Pause for CPR. The AED is programmed to administer up to 3 shocks in a row if needed. If the victim requires 3 shocks in a row and VF rhythm is still present, you will hear the audio prompts: Pause! Check for signs of circulation, if needed begin CPR. The AED automatically pause for 1 minute to allow you to perform CPR to maintain blood circulation to the brain and heart.

During the pause, the AED screen shows a bar that fills in as the pause time is used up. It also shows how many shocks have been delivered and how much time has gone by since the AED was turned on. The AED will resume analyzing at the end of the pause period and advise to shock as needed.

If no shock is advised: AED provides voice and screen prompts to tell you so.

·                AED prompts: No shock advised. It is safe to touch the patient. Check for signs of circulation. If needed begin CPR.

·                Follow the AED prompts. Check for signs of circulation. Observe for Heart Rate (HR) on the display screen. If the victim is not breathing normally and has no signs of circulation, start CPR immediately.

·                The voice prompts are repeated at interval of 1 minute while the AED is monitoring the patient. If there is no VF present, the AED will not charge to shock.

·                If the AED detects a potentially shockable heart rhythm (VF), it automatically goes back to Step 3 (Analyze Heart Rhythm) to see if a shock is needed.

Care of Victim After Successful Defibrillation:

·                Do not switch of the AED or remove the pads. Leave AED turned “on” to monitor the victim.

·                If victim has a normal breathing and circulation, put into the recovery position.  Administer oxygen. Monitor victim closely and record the vital signs. Be prepared to shock again

·                Do not allow the AED to be removed during transfer of patient, instead unplug only the connector from the socket and leave the pads on the chest. Provide them a copy of your observation chart.

After  use, check the AED’s battery status and AED pad availability. Keep it ready for emergency use at all times.

Status Indicator Summary / Troubleshooting Guide

STATUS INDICATOR	RECOMMENDED ACTIONS DURING EMERGENCY
Flashing black hourglass	Ready for use. Follow the voice and screen prompts.
Flashing red X Other Signal: Audio signal: chirping Possible cause:- - Battery power is low. - An error has been detected as part of   the selftest.	Continue to use the AED in an emergency incident when there is no other  AED available. - Turn on the AED and follow the voice and screen   Prompts. Troubleshooting required: - Remove and reinstall the same battery and run a   Battery insertion selftest. - If it fails, install a new battery and repeat the     selftest. - Turn on AED and follow voice prompts.
Solid red X Possible cause:- The battery is completely depleted or missing.	Do not use the AED. Troubleshooting required: - Remove and reinstall the same battery. - Run the battery insertion selftest. If it fails, install    a new battery and repeat the selftest. Turn on     device and follow voice prompts. - If the solid red X is still not cleared, do not use     the AED.
None of the above	Check for visible damage. Do not use if is appears to be damaged. However, if voice and screen prompts are present, in an emergency incident, it is recommended that you continue to use the AED.

Defibrillation Pads / Troubleshooting Guide

Screen / Voice Prompts:	Possible Cause	Recommended Action
Voice prompts: Press pads firmly to patient’s bare chest or Poor pads contact	Pads are not making good contact with the chest	- Make sure that the pads are   sticking completely to the    patient’s skin. - Dry the chest or shave off   excessive chest hair if this   is the caused. - If the prompts continues   after  attempting the above,   replace the pads.
Replace Pads	The pads, cable or connector may be damaged or defect	- Replace the defibrillation     pads with new one.
Plug in connector              or              Insert connector firmly	The pads connector is not firmly inserted in the connector port	- Make sure the pads      connector is completely        inserted in the   connector port. - If the prompts continues   after trying, replace the   defibrillation pads.