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Stephens AF, Šeman M, Nehme Z, Voskoboinik A, Smith K, Gregory SD, Stub D. Ex vivo evaluation of personal protective equipment in hands-on defibrillation. Resusc Plus 2022; 11:100284. [PMID: 35942482 PMCID: PMC9356271 DOI: 10.1016/j.resplu.2022.100284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 07/20/2022] [Accepted: 07/22/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Andrew F. Stephens
- Cardio-Respiratory Engineering and Technology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia
- Mechanical and Aerospace Engineering, Monash University, Melbourne, Australia
- Corresponding author at: Lab 2, Level 3, Baker Heart and Diabetes Institute, 75 Commercial Rd, 3004, Australia.
| | - Michael Šeman
- Cardio-Respiratory Engineering and Technology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Cardiology, Alfred Health, Melbourne, Australia
| | - Ziad Nehme
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, AU
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Melbourne, Australia
| | - Aleksandr Voskoboinik
- Department of Cardiology, Alfred Health, Melbourne, Australia
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Melbourne, Australia
- Electrophysiology Research, Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Karen Smith
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, AU
| | - Shaun D. Gregory
- Cardio-Respiratory Engineering and Technology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia
- Mechanical and Aerospace Engineering, Monash University, Melbourne, Australia
| | - Dion Stub
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Cardiology, Alfred Health, Melbourne, Australia
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, AU
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Wight JA, Bigham TE, Hanson PR, Zahid A, Iravanian S, Perkins PE, Lloyd MS. Hands-on defibrillation with safety drapes: Analysis of compressions and an alternate current pathway. Am J Emerg Med 2021; 52:132-136. [PMID: 34922232 DOI: 10.1016/j.ajem.2021.11.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 11/26/2021] [Accepted: 11/28/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Hands-on defibrillation (HOD) could theoretically improve the efficacy of cardiopulmonary resuscitation (CPR) though a few mechanisms. Polyethylene drapes could potentially facilitate safe HOD, but questions remain about the effects of CPR on polyethylene's conductance and the magnitude of current looping through rescuers' arms in contact with patients. METHODS This study measured the leakage current through 2 mil (0.002 in.) polyethylene through two different current pathways before and after 30 min of continuous compressions on a CPR mannequin. The two pathways analyzed were the standardized IEC (International Electrotechnical Commission) leakage current analysis and a setup analyzing a current pathway looping through a rescuer's arms and returning to the patient. First, ten measurements involving the two pathways were obtained on a single polyethylene drape. 30 min of continuous compressions were applied to the drape on a CPR mannequin after which the ten measurements were repeated. RESULTS Twenty patients undergoing elective cardioversion for atrial fibrillation (18/20) or atrial flutter (2/20) at Emory University Hospital underwent analysis all receiving 200 J shocks (age 38-101, 35% female). Through the IEC measurement method the peak leakage current mean was 0.70 +/- 0.02 mA before compressions and 0.59 +/- 0.19 mA after compressions. Only three of the ten measurements assessing current passing through a rescuer's arms had detectable current and each was of low magnitude. All measurements were well below the maximum IEC recommendations of 3.5 mA RMS and 5.0 mA peak. CONCLUSIONS Polyethylene may facilitate safe HOD even after long durations of compressions. Current looping through a rescuer's arms is likely of insignificant magnitude.
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Kwak J, Brady WJ. The safety and efficacy of hands-on defibrillation in the management of adult cardiac arrest: A systematic review. Am J Emerg Med 2020; 38:1233-1236. [DOI: 10.1016/j.ajem.2020.02.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/01/2020] [Accepted: 02/14/2020] [Indexed: 10/25/2022] Open
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Wight JA, Iravanian S, Haouzi AA, Lloyd MS. Hands-on defibrillation with a safety barrier: An analysis of potential risk to rescuers. Resuscitation 2019; 138:110-113. [PMID: 30862529 DOI: 10.1016/j.resuscitation.2019.02.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 02/17/2019] [Accepted: 02/27/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Interruptions in compressions reducethe efficacy of cardiopulmonary resuscitation (CPR) and are inevitable during hands-off periods for shocks. Clinical exam gloves were found to facilitate safe contact with patients during shock delivery but the safety of this practice has been questioned. Polyethylene is of interest because of its safety record in the medical arena and its electrical insulation properties. METHODS This study measured the current leak through 2 mil (0.002 inch) polyethylene drapes during shock delivery. The current leak was assessed by measurement of voltage changes in a circuit recommended by the International Electrotechnical Commission (IEC) for current leak safety testing. Current flowed off the drape, through the circuit and to electric ground in a manner consistent with standardized testing. Perceptibility was assessed in a subset with the investigator's bare hands pressed into the drape during shock delivery. RESULTS Thirty-three patients undergoing elective cardioversion at Emory University Hospital underwent analysis (age 23-90, 36% female). Biphasic energies were 200-360 J. The root mean square (RMS) current leak averaged 0.072 ± 0.022 mA and peak current leak averaged 0.67 ± 0.21 which is well below IEC recommendations of 3.5 mA RMS and 5.0 mA peak. Finally, no instances of dielectric breakdown occurred and no shocks were perceptible. CONCLUSIONS Polyethylene is a common medical material which may facilitate safe hands-on defibrillation. Our data illustrates that a thin, semitransparent layer of polyethylene is a safe and feasible adjunct to cardiac arrest kits to allow continued compressions and simplification of the CPR process.
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Affiliation(s)
- John A Wight
- Emory University School of Medicine, United States
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Petley GW, Albon B, Banks P, Roberts PR, Deakin CD. Leakage current from transvenous and subcutaneous implantable cardioverter defibrillators (ICDs): A risk to the rescuer? Resuscitation 2019; 137:148-153. [PMID: 30794831 DOI: 10.1016/j.resuscitation.2019.02.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 01/23/2019] [Accepted: 02/12/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Implantable cardioverter-defibrillators (ICDs) are a well-established therapy for patients at risk of life-threatening ventricular arrhythmias. With rising implant rates, the risk of a rescuer performing chest compressions during discharge is increasing, leading to concerns over rescuer safety from the resultant leakage current. More recently, subcutaneous ICDs (S-ICD) have been developed, which utilise a higher energy and more superficial electrodes compared with transvenous ICDs (T-ICD), raising safety concerns further. OBJECTIVE We measured the current a rescuer would potentially receive from T-ICDs and S-ICDs if they were in contact with the patient at the time of ICD discharge to assess its magnitude in relation to international safety standards. METHODS Surface voltages adjacent to ICD electrodes were measured on patients undergoing defibrillation threshold checks. Rescuer current was then calculated assuming a total rescuer circuit impedance of 1696 Ω. RESULTS Twenty-five patients were recruited. Rescuer current from S-ICDs was significantly higher than those from T-ICDs (S-ICD: Median RMS 135 mA range 91 mA-164 mA, T-ICD: Median RMS 31 mA, range 9 mA-75 mA, P < 0.0001). Surface voltages (median RMS) to which the rescuer is likely to be exposed are higher when performing chest compressions from the patient's left side compared with the right (127 V vs 67 V respectively, 95% CI of difference -34 V to -67 V, P < 0.0001). CONCLUSIONS Rescuers performing chest compressions on ICD patients are at risk from leakage current, particularly from S-ICDs. Chest compressions should be performed from the opposite side to the ICD to reduce rescuer risk.
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Affiliation(s)
- Graham W Petley
- Faculty of Healthcare Sciences, University of Southampton, Southampton, UK.
| | - Beth Albon
- Medical School, University of Southampton, Southampton, UK.
| | - Phil Banks
- Cardiac Rhythm Management Unit, University Hospital Southampton, UK.
| | - Paul R Roberts
- Cardiac Rhythm Management Unit, University Hospital Southampton, UK.
| | - Charles D Deakin
- NIHR Respiratory BRU, University Hospital Southampton, Southampton SO16 6YD, UK.
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Vindigni SM, Lessing JN, Carlbom DJ. Hospital resuscitation teams: a review of the risks to the healthcare worker. J Intensive Care 2017; 5:59. [PMID: 29046809 PMCID: PMC5637256 DOI: 10.1186/s40560-017-0253-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/03/2017] [Indexed: 11/11/2022] Open
Abstract
Background “Code blue” events and related resuscitation efforts involve multidisciplinary bedside teams that implement specialized interventions aimed at patient revival. Activities include performing effective chest compressions, assessing and restoring a perfusing cardiac rhythm, stabilizing the airway, and treating the underlying cause of the arrest. While the existing critical care literature has appropriately focused on the patient, there has been a dearth of information discussing the various stresses to the healthcare team. This review summarizes the available literature regarding occupational risks to medical emergency teams, characterizes these risks, offers preventive strategies to healthcare workers, and highlights further research needs. Methods We performed a literature search of PubMed for English articles of all types (randomized controlled trials, case-control and cohort studies, case reports and series, editorials and commentaries) through September 22, 2016, discussing potential occupational hazards during resuscitation scenarios. Of the 6266 articles reviewed, 73 relevant articles were included. Results The literature search identified six potential occupational risk categories to members of the resuscitation team—infectious, electrical, musculoskeletal, chemical, irradiative, and psychological. Retrieved articles were reviewed in detail by the authors. Conclusion Overall, we found there is limited evidence detailing the risks to healthcare workers performing resuscitation. We identify these risks and offer potential solutions. There are clearly numerous opportunities for further study in this field.
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Affiliation(s)
- Stephen M Vindigni
- Division of Gastroenterology, Department of Medicine, University of Washington, 1959 NE Pacific Street, Box 356424, Seattle, WA 98195-6424 USA
| | - Juan N Lessing
- Division of General Internal Medicine, Department of Medicine, University of Colorado, 13001 E 17th Place, Aurora, CO 80045 USA
| | - David J Carlbom
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195-6424 USA
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Perkins G, Handley A, Koster R, Castrén M, Smyth M, Olasveengen T, Monsieurs K, Raffay V, Gräsner JT, Wenzel V, Ristagno G, Soar J. [Adult basic life support and automated external defibrillation.]. Notf Rett Med 2017; 20:3-24. [PMID: 32214897 PMCID: PMC7087749 DOI: 10.1007/s10049-017-0328-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- G.D. Perkins
- Warwick Medical School, University of Warwick, Coventry, UK
- Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | | | - R.W. Koster
- Department of Cardiology, Academic Medical Center, Amsterdam, Niederlande
| | - M. Castrén
- Department of Emergency Medicine and Services, Helsinki University Hospital and Helsinki University, Helsinki, Finnland
| | - M.A. Smyth
- Warwick Medical School, University of Warwick, Coventry, UK
- West Midlands Ambulance Service NHS Foundation Trust, Dudley, UK
| | - T. Olasveengen
- Norwegian National Advisory Unit on Prehospital Emergency Medicine and Department of Anesthesiology, Oslo University Hospital, Oslo, Norwegen
| | - K.G. Monsieurs
- Emergency Medicine, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgien
- Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgien
| | - V. Raffay
- Municipal Institute for Emergency Medicine Novi Sad, Novi Sad, Serbien
| | - J.-T. Gräsner
- Department of Anaesthesia and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Kiel, Deutschland
| | - V. Wenzel
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Österreich
| | - G. Ristagno
- Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche „Mario Negri“, Milan, Italien
| | - J. Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
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Brady W, Berlat JA. Hands-on defibrillation during active chest compressions: eliminating another interruption. Am J Emerg Med 2016; 34:2172-2176. [PMID: 27645811 DOI: 10.1016/j.ajem.2016.08.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 08/04/2016] [Accepted: 08/08/2016] [Indexed: 10/21/2022] Open
Abstract
After decades of research, effective chest compressions have emerged as a key component of high-quality cardiopulmonary resuscitation (CPR) for cardiac arrest patients. Minimizing interruptions in chest compressions is garnering increasing attention as a method to improve CPR quality and outcomes. Hands-on defibrillation has been suggested as both a safe and effective means of reducing interruptions in chest compressions. This article discusses the safety and efficacy of a novel and controversial method to reduce interruptions: hands-on defibrillation.
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Affiliation(s)
- William Brady
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, Virginia 22908.
| | - Joshua A Berlat
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, Virginia 22908.
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Deakin CD, Petley GW. Re: Wampler D, Kharod C, Bolleter S, Burkett A, Gabehart C, Manifold C. A randomized control hands-on defibrillation study – Barrier use evaluation. Resuscitation. 2016. Resuscitation 2016; 105:e13. [DOI: 10.1016/j.resuscitation.2016.05.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 05/06/2016] [Indexed: 10/21/2022]
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Perkins G, Handley A, Koster R, Castrén M, Smyth M, Olasveengen T, Monsieurs K, Raffay V, Gräsner JT, Wenzel V, Ristagno G, Soar J. [Adult basic life support and automated external defibrillation.]. Notf Rett Med 2015; 18:748-769. [PMID: 32214896 PMCID: PMC7088113 DOI: 10.1007/s10049-015-0081-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- G.D. Perkins
- Warwick Medical School, University of Warwick, Coventry, UK
- Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | | | - R.W. Koster
- Department of Cardiology, Academic Medical Center, Amsterdam, Niederlande
| | - M. Castrén
- Department of Emergency Medicine and Services, Helsinki University Hospital and Helsinki University, Helsinki, Finnland
| | - M.A. Smyth
- Warwick Medical School, University of Warwick, Coventry, UK
- West Midlands Ambulance Service NHS Foundation Trust, Dudley, UK
| | - T. Olasveengen
- Norwegian National Advisory Unit on Prehospital Emergency Medicine and Department of Anesthesiology, Oslo University Hospital, Oslo, Norwegen
| | - K.G. Monsieurs
- Emergency Medicine, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgien
- Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgien
| | - V. Raffay
- Municipal Institute for Emergency Medicine Novi Sad, Novi Sad, Serbien
| | - J.-T. Gräsner
- Department of Anaesthesia and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Kiel, Deutschland
| | - V. Wenzel
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Österreich
| | - G. Ristagno
- Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche „Mario Negri“, Milan, Italien
| | - J. Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
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European Resuscitation Council Guidelines for Resuscitation 2015: Section 2. Adult basic life support and automated external defibrillation. Resuscitation 2015; 95:81-99. [PMID: 26477420 DOI: 10.1016/j.resuscitation.2015.07.015] [Citation(s) in RCA: 722] [Impact Index Per Article: 80.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Affiliation(s)
- Charles D Deakin
- NIHR Southampton Respiratory Biomedical Research Unit, University Hospital Southampton, Southampton, SO16 6YD, United Kingdom.
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Deakin CD. Re: Editorial ‘Keep your hands on the chest’. Resuscitation 2015; 88:e11. [DOI: 10.1016/j.resuscitation.2014.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 09/07/2014] [Indexed: 10/24/2022]
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Achieving safe hands-on defibrillation using electrical safety gloves--a clinical evaluation. Resuscitation 2015; 90:163-7. [PMID: 25725295 DOI: 10.1016/j.resuscitation.2014.12.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 12/15/2014] [Accepted: 12/21/2014] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Safe hands-on defibrillation (HOD) will allow uninterrupted chest compression during defibrillation and may improve resuscitation success. We tested the ability of electrical insulating gloves to protect the rescuer during HOD using a 'worst case' electrical scenario. MATERIALS AND METHOD Leakage current flowing from the patient to the 'rescuer' during antero-lateral defibrillation of patients undergoing elective cardioversion was measured. The 'rescuer' maintained firm (20 kgf) contact with the patient during defibrillation, wearing Class 1 electrical insulating gloves while simulating an inadvertent contact with the patient, through an additional wired contact between 'rescuer' and patient. RESULTS Data from 61 shocks from 43 different patients were recorded. The median leakage current from all defibrillations was 20.0 μA, (range: 2.0-38.5). In total, 18 of the shocks were delivered at 360 J and had a median leakage current of 27.0 μA (range: 14.3-38.5). CONCLUSION When using Class 1 electrical insulating gloves for hands-on defibrillation, rescuer leakage current is significantly below the 1 mA safe threshold, allowing safe hands-on defibrillation if the rescuer makes only one other point of contact with the patient.
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Lemkin DL, Witting MD, Allison MG, Farzad A, Bond MC, Lemkin MA. Electrical exposure risk associated with hands-on defibrillation. Resuscitation 2014; 85:1330-6. [PMID: 24992873 DOI: 10.1016/j.resuscitation.2014.06.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 06/03/2014] [Accepted: 06/18/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND The use of hands-on defibrillation (HOD) to reduce interruption of chest compression after cardiac arrest has been suggested as a means of improving resuscitation outcomes. The potential dangers of this strategy in regard to exposing rescuers to electrical energy are still being debated. This study seeks to determine the plausible worst-case energy-transfer scenario that rescuers might encounter while performing routine resuscitative measures. METHODS Six cadavers were acquired and prepared for defibrillation. A custom instrumentation-amplifier circuit was built to measure differential voltages at various points on the bodies. Several skin preparations were used to determine the effects of contact resistance on our voltage measurements. Resistance and exposure voltage data were acquired for a representative number of anatomic landmarks and were used to map rescuers' voltage exposure. A formula for rescuer-received dose (RRD) was derived to represent the proportion of energy the rescuer could receive from a shock delivered to a patient. We used cadaver measurements to estimate a range of RRD. RESULTS Defibrillation resulted in rescuer exposure voltages ranging from 827V to ∼200V, depending on cadaver and anatomic location. The RRD under the test scenarios ranged from 1 to 8J, which is in excess of accepted energy exposure levels. CONCLUSIONS HOD using currently available personal protective equipment and resuscitative procedures poses a risk to rescuers. The process should be considered potentially dangerous until equipment and techniques that will protect rescuers are developed.
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Affiliation(s)
- Daniel L Lemkin
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States.
| | - Michael D Witting
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Michael G Allison
- Department of Emergency Medicine, University of Maryland Medical Center, Baltimore, MD, United States
| | - Ali Farzad
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Michael C Bond
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
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Thomsen JE, Petley GW, Deakin CD. Risk of injury to rescuers who use hands-on defibrillation. Resuscitation 2013; 84:e131-2. [DOI: 10.1016/j.resuscitation.2013.04.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Accepted: 04/29/2013] [Indexed: 11/27/2022]
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Kerber RE. Gloves to protect hands – and heart. Resuscitation 2013; 84:859-60. [DOI: 10.1016/j.resuscitation.2013.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 04/13/2013] [Indexed: 10/26/2022]
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