When to use AEDs in the outpatient setting?

[croaker3]

Family med resident here, and a little confused about when to use AEDs or standard monitors/defibrillators. For some reason, I've always had trouble understanding the details of this.

I know that indications for electric cardioversion include SVT, Vtach, Afib, Aflutter, & unstable tachycardia. However, I did not realize that usually when people are electrically cardioverted, that they have an IV and VS monitoring. In the outpatient clinic, when should we electrically cardiovert individuals ? Also, will a standard defibrillator be able to do this automatically, or will I have to recognize the rhythm and know the joules required to shock in the synchronized mode? I also don't think AEDs can electrically cardiovert, correct?

And just to make sure, Vfib, pulseless Vtach, cardiac arrest are indications for debrillation, but if a person is in PEA or asystole, then these are not shockable, correct?

And all this means is that for a stable individual w/ chest pain who is a&ox3, there only reason for placing pads is to assess rate and rhythm and just in case the person goes into cardiac arrest, pulseless Vtach, or Vfib?

Thanks!

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[VA Hopeful Dr]

As a family doctor, I would never cardiovert someone in the outpatient setting except in an emergency - ie. they pass out and the AED I put on them tells me to shock them.

Definitely don't shock PEA or asystole.

Cardiac arrest is loss of cardiac output for whatever reason - its that reason that determines what you do about it.

 

[Janders]

I gently suggest a review of your ACLS manual.

An AED will "shock" (Defib) any rhythm it believes is "shockable"
An AED cannot assess whether or not someone has a pulse.

As such, if you slap an AED on someone, it will look for (1) V Fib or (2) V Tach (wide complex tach...). If it finds either it will prompt to charge and deliver a "shock". It will not shock PEA or asystole, as these are not shockable rhythms. Theoretically, you could hook it up to someone with VTach and a pulse, and it would ask you to charge and defib them... typically you still need to hit the button to activate this step.

Now a real defibrillator (i.e. a Lifepack) has the ability to show you the rhythm and manually select the charge, set on synchronized for cardioversion, etc etc... Some AEDs DO have a screen that displays the rhythm, so you could place the pads on and get a snap-view of the rhythm...

 

[engineeredout]

Family med resident here, and a little confused about when to use AEDs or standard monitors/defibrillators. For some reason, I've always had trouble understanding the details of this.

I know that indications for electric cardioversion include SVT, Vtach, Afib, Aflutter, & unstable tachycardia. However, I did not realize that usually when people are electrically cardioverted, that they have an IV and VS monitoring. In the outpatient clinic, when should we electrically cardiovert individuals ? Also, will a standard defibrillator be able to do this automatically, or will I have to recognize the rhythm and know the joules required to shock in the synchronized mode? I also don't think AEDs can electrically cardiovert, correct?

And just to make sure, Vfib, pulseless Vtach, cardiac arrest are indications for debrillation, but if a person is in PEA or asystole, then these are not shockable, correct?

And all this means is that for a stable individual w/ chest pain who is a&ox3, there only reason for placing pads is to assess rate and rhythm and just in case the person goes into cardiac arrest, pulseless Vtach, or Vfib?

Thanks!

There's so much wrong with this post my head is going to explode.

 

[Birdstrike]

The AED will generally do the thinking for you. It will decide what's shockable or not. I personally have one of these. You put the pads on, you turn the machine on, and it either tells you, "Shock" or "Continue CPR."

That's it. They're dummy proof. If it tells you to shock, then you push the shock button. If it tells you to continue CPR, you do not push the shock button, but instead do CPR.

They're designed to be useable by completely untrained bystanders. So, yes, as a trained physician, you should use an AED if available.

Now a full blown life-pack unit/crash cart, with full synch/non-sync, pacing, rate, and energy output settings takes some training. Unless you have an EM, Cards, Critical Care, EMS background, know your ACLS inside/out or have another background training in resuscitation, you're going to have more difficulty knowing how to work such a machine in a crash setting, especially if it's your first rodeo. It can be intimidating when you're first starting out, though. I get that.

Just know that AEDs are designed specifically not to shock rhythms that shouldn't be shocked. Just slap the pads on and do what the machine tells you to do. As far as a life pack unit, get some training please. Or, if you need the impossible task of boiling the defibrillatory part of acls into a one sentence nutshell, for those sphincter tightening crash situations where detailed recall tends to disappear, remember this:

In an unconscious patient, with a rhythm that looks like Vtach with identifiable qrs complexes, hit "synch" and shock, if no identifiable qrs complexes (vfib) then turn synch off and Defib.

(If unsure, safest to hit "synch" first. If VFib, it won't find any qrs complexes to synch with and will do nothing; quickly take synch off and shock un-synced/Defib.)

 

[The White Coat Investor]

There's so much wrong with this post my head is going to explode.

Be nice. Better to ask the question. The poster has up-front identified him/herself as #1 a trainee and #2 a trainee in another specialty. It's a perfectly reasonable question.

I agree that doing a cardioversion on a live person in a clinic is a mistake. Cardiologists don't do it, why would you?

If someone is dead, and you have an AED, turn it on and follow the directions. It'll do all the thinking for you.

Now, as far as your list of "indications":

SVT- Only if unstable, which it rarely is. 99% of the time a trip to the ER for some adenosine is indicated.
Vtach- Only if unstable. Otherwise, 911 and a trip to the ER.
A-fib- Could actually harm someone by stroking them out if they've been in it long enough to make a clot.
A-flutter- Same as a-fib for all intents and purposes.
Unstable tachycardia- If someone is unstable, shocking them is a great idea, especially if they're unconscious or dead. You really can't hurt dead people. So what if you shock PEA or asystole? Sure, it's not going to work very well, but you're probably not going to hurt em much.

Electricity is very safe most of the time, especially in dead people.

 

[rwmedic906]

Just for the sake of clarification, the AED will ONLY advise a shock if the patient is in V-fib, no other rhythm will prompt a shock. The unit does not know if the patient has a pulse or not (that's up to the caregiver) so it will not advise a shock if the patient is in v-tach. So if EMS brings you a patient and tells you the AED advised a shock, you know their presenting rhythm was V-fib.

 

[Oenak]

Just for the sake of clarification, the AED will ONLY advise a shock if the patient is in V-fib, no other rhythm will prompt a shock. The unit does not know if the patient has a pulse or not (that's up to the caregiver) so it will not advise a shock if the patient is in v-tach. So if EMS brings you a patient and tells you the AED advised a shock, you know their presenting rhythm was V-fib.

This is not correct. Many AEDs (if not all) detect both V-Fib and V-Tach. A quick search on Zoll's website for AED specifications showed that their AEDs detect both lethal dysrhythmias. Additionally, they have thresholds for the amplitude of V-Fib and the rate of V-Tach (over 150bpm for example).

 

[dchristismi]

And all this means is that for a stable individual w/ chest pain who is a&ox3, there only reason for placing pads is to assess rate and rhythm and just in case the person goes into cardiac arrest, pulseless Vtach, or Vfib?

Thanks!

I use the pads to ward off badness. If they're there, you probably won't need them. It's the patient who announces "I don't feel good" and collapses with a nasty fib on the monitor who doesn't have pads on, IME. All my STEMIs get 'em en route to the cath lab.

In an outpatient setting, an AED is the patient's best shot at recovery. Someone collapses, get the AED.

 

[Doctor Bob]

So if EMS brings you a patient and tells you the AED advised a shock, you know their presenting rhythm was V-fib.

Or it was asystole and the ride was a bit bumpy.
One of the guys I worked with way back when I was a medic would shake the stretcher if a patient was in asystole which caused enough artifact on the screen to resemble fine VF. Then he'd shock them. Never worked because dead is dead (and because the underlying rhythm was actually unshockable) but it made him feel better.

 

[rwmedic906]

This is not correct. Many AEDs (if not all) detect both V-Fib and V-Tach. A quick search on Zoll's website for AED specifications showed that their AEDs detect both lethal dysrhythmias. Additionally, they have thresholds for the amplitude of V-Fib and the rate of V-Tach (over 150bpm for example).

I stand corrected, there are newer AEDs that will provide a shock if the rate/R-wave and morphology exceed preset values. Thank you for the clarification!