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March 29, 2010

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How to respond to a cardiac arrest

Seeing someone having a heart attack is a shock for anyone; seeing it happen to a work colleague makes it all the more dramatic. But is this really a workplace issue, or simply a 999 call and cross your fingers? Denny Beacham explores.

Heart disease is one of the UK’s biggest killers and the major cause of a cardiac arrest. Ultimately, cardiac arrest is unpredictable and can affect people of all ages, and at any time – during exercise, or at rest. It can be triggered by a heart attack, as well as severe blood loss, electick shock and drowning. Equally, it could happen in a sedate office to someone sitting quietly at their desk, or to someone visiting a workplace. Some people inherit genetic conditions that can lead to them experiencing an unnatural heart rhythm, which could also result in cardiac arrest.

Cardiac arrest or heart attack?
An easy way to think of a heart attack (myocardial infarction) is as a plumbing problem. It is caused when part of the heart suffers sudden blood loss, due to a coronary artery, which supplies oxygenated blood to the heart, becoming blocked. This results in a lack of oxygen reaching that part of the heart muscle. The heart doesn’t stop pumping blood unless the casualty slips into cardiac arrest. This can happen in the first few minutes or hours after a heart attack.

Cardiac arrest is caused by a disturbance to the electrical impulses in the heart. In effect, the heart’s ventricles hijack the heart’s rhythm by sending quicker impulses that overrule the sinus node (the heart’s natural pacemaker). These faster rhythms are called ventricular tachycardia (VT) and ventricular fibrillation (VF), under which the heart can’t pump blood properly, usually leading to cardiac arrest. To correct its rhythm, the heart needs a controlled electrical shock, which effectively stuns the heart, allowing it to return to its normal sinus rhythm.

So, given the differences between both scenarios, how should each case be treated, and how should a first-aider, or work colleague respond?

Heart attack – When a coronary artery breaks away from the artery wall, the resulting damaged area attracts platelets to its surface to repair it. This builds up to a blood clot. In terms of symptoms, a person may complain of ‘indigestion’, or may say they have a crushing central chest pain, or discomfort. They may feel sick, light-headed, and have difficulty breathing. The discomfort may spread to their jaw, neck, or back. They may feel tingling and numbness in their arm, usually the left one.

Look for signs like loss of normal skin colour, blueness around the lips, and breathlessness. Sit the casualty on the ground in the ‘W’ position, i.e. back supported and knees raised; loosen any tight clothing around the neck and waist; and keep the casualty calm. Phone for an ambulance as soon as you suspect a heart attack – the casualty needs the advanced cardiac care that only a hospital can provide. While waiting for the ambulance continue to monitor the casualty, and do not allow them to eat, drink, smoke, or move around. Be prepared to administer CPR (cardiopulmonary resuscitation) if trained to do so. If an automatic external defibrillator (AED) is available, have it ready.

Cardiac arrest – The casualty will have collapsed and be non-responsive, i.e. they do not respond to speech, or a gentle shake. Place the casualty on their back, open their airway (tilt their head back, holding the chin and forehead), and check their breathing. To do this, put your ear close to the casualty’s mouth, looking down their body to see if their chest or stomach is rising and falling. Listen and feel for ‘normal’ breathing, and check for 10 seconds.

If you spot anything other than normal rhythmic breathing, call for an ambulance. If at this point you are by yourself, leave the casualty and call for the emergency services, telling the operator you have a non-responsive, non-breathing casualty. If you have assistance, send them to call for an ambulance and ask that they return to let you know the ambulance is on its way.

‘Leave the casualty!’ I can hear people exclaim. Yes, if alone, then you have no alternative, as an ambulance must be called immediately. When you return to the casualty, if trained to do so, commence CPR immediately, so that oxygenated blood is circulated around the body.

Guidelines for CPR from the Resuscitation Council (UK) advise 30 chest compressions followed by two inflations (mouth to mouth) at about 100 compressions a minute, a process that should be repeated until the paramedics arrive, or the casualty comes round. It is important to remember that CPR administered by a first-aider only buys time by keeping blood artificially circulating; it will not restart the heart once it has stopped without other interventions.

Unless immediate treatment is administered, the vast majority of cardiac-arrest victims outside of a hospital will die. It is therefore vital to shock the heart out of VF or VT, using a defibrillator, as soon as possible. If this is done within the first five minutes following arrest, the casualty has an 80-90 per-cent chance of recovery. For each minute that lapses, the casualty’s chances fall by 14 per cent.
More and more companies now recognise the risk from cardiac arrest, and are reviewing their current risk assessment for first-aid provision to include automatic external defibrillators (AEDs).

How does an AED work?
An AED gives the first-aider the opportunity to administer a controlled electric shock to the casualty’s heart. It is roughly about half the size of a briefcase. Once fitted with its battery, it will run through a self-testing phase to ensure that all circuitry is working correctly and the machine is ready for use. One AED model I am accustomed to features a ‘status indicator’. When this is indicating green, the unit is ready for use and the battery is charged. If, however, it goes red, the machine needs servicing.

The AED will then give the following sequence of instructions to the rescuer on the correct procedure for use:

  • ‘Tear open pad package and remove pads’;
  • ‘Peel one pad from plastic liner’;
  • ‘Place pad on bare upper chest as shown’;
  • ‘Place second pad on bare lower chest as shown’ (diagram on the back of each pad).

The AED then analyses the heart rhythm, and will give a clear instruction that the rescuer should ensure that no one is in contact with the casualty. If a shockable rhythm is detected the machine will instruct:

  • ‘Shock advised’;
  • ‘Stand clear! Push flashing button to deliver shock’;
  • ‘Shock delivered’;
  • ‘It is now safe to touch patient’.

Known as a ‘bi-phasic’ defibrillator, an AED I have experience with is designed to deliver two shocks to the heart from pad to pad, and then reversed. The aim of this is to stun the heart completely, stopping the fast VF and VT from acting as the heart’s rhythm. Once stopped, the heart will return to its natural sinus rhythm.

Who should use an AED?
This is an interesting question. Preferably, the user should be fully trained in the use of the machine and the delivery of CPR. However, what if a trained person is not around to use the defibrillator when a person arrests? The simple fact is that if a person’s heart goes into arrest, they will die unless they receive prompt defibrillation. Therefore, what damage could a trained, or untrained rescuer actually do? Indeed, the Resuscitation Council (UK) has itself gone on record to state that “the use of AEDs should NOT be restricted to trained personnel”.

A common reaction is: ‘what if it is misused?’, or ‘what if it is used on someone who isn’t in cardiac arrest?’. Put your mind at rest – unlike the manual defibrillators sometimes carried by paramedics, AEDs will not deliver a shock to a casualty unless their heart is in VF. As highlighted earlier, once the pads are placed on the casualty, as prompted by the machine, the AED will diagnose the condition of the heart. If it detects that the heart is in VF, it will give an instruction to the operator to deliver a shock. Some fully-automatic machines will deliver a shock without the responder even having to press a button, thereby further reducing the individual’s responsibility.

Helping the responder
The above being said, it is recognised and understandable that a person administering a shock using an AED could suffer from post-traumatic stress disorder (PTSD), especially if that incident has resulted in a fatality. Modern AEDs can help the responder cope with the aftermath of such an incident through their ability to record every stage of the casualty’s treatment. By using the incident log, the responder can be shown the actions they have taken – an ideal aid for post-event counselling.

Ongoing maintenance and user checks
Finally, it is important to note that AEDs, as with all technical equipment, must be well-maintained and regularly inspected. Monthly visual inspections should be carried out and recorded on each unit, and checks should include but not be limited to:

  • the ‘use by’ date on the pads (including any spares);
  • the ‘function-ready’ status indicator;
  • the battery-ready test, which initiates when the AED’s case is opened;
  • the visual condition of the unit; and
  • supplies, including gloves, scissors, razor, and hand towel, all of which should be present.

User checks should be carried out by a competent person, i.e. a first-aider, and all checks should be recorded. Self-checks on all circuitry and battery status should not be relied on alone.

Panel – Training still relevant

The Resuscitation Council (UK) makes a point that defibrillators should be able to be used by members of the public without any formal training. Indeed, the growth of community-based public-access defibrillation (cPAD) in the past year has necessitated this. Defibrillators for public use are now very intuitive and the manufacturers have gone to great lengths to make them very easy, and safe, for anyone to use. They ‘talk’ you through the process and will even count, metronome style, the rate at which chest compressions (CPR) should be undertaken.

From the point of view of the health and safety officer, this is reassuring. However should training still be undertaken? Of course, training of any sort is good, but the training should not focus on how to use the defibrillator, as AEDs are easy and safe to use.
Instead, the training should focus on two areas: firstly, how to recognise a cardiac arrest; and secondly, how to carry out chest compressions effectively. Good chest compressions can increase the possibility of the defibrillator working to its maximum effect and result in a better outcome for the patient. There are many schemes to help communities undertake correct chest compressions, including the British Heart Foundation’s Heartstart scheme.

The use of defibrillators in businesses is, without doubt, a good move to help protect staff. However, we would also encourage local organisations to locate them in cabinets, and fix them to walls outside their businesses. Not only would this increase the availability of these life-saving devices, and make good use of resources, but it would also allow the local business to show it is community-centric. Local businesses could also sponsor the training in the community.

By Martin Fagan, secretary, The Community HeartBeat Trust

Case study: Wirral Partnership Homes

Wirral Partnership Homes, a social landlord on the Wirral, has decided to equip ten key sites with AEDs – six in staff locations and four in sheltered accommodation schemes.

Full guidance and support was given by the North West Ambulance Service (NWAS), which will also provide expert training for all staff who have access to the units, with supplementary funding in the shape of a grant from the British Heart Foundation. In return, WPH has agreed to act as a first responder for the Ambulance Service. This means that if an emergency call is logged in the immediate area, an ambulance will be despatched and a call will go out to the WPH site nearest to the incident. The aim is to get a defibrillator to the casualty as soon as possible, thus raising their chances of survival.

Once the request has been received from the emergency operator, the responder will be covered by the Ambulance Service’s insurance. However, as a general point, it should be noted that any extension to an organisation’s provision for first aid that includes any specialised equipment, i.e. AEDs, should only be undertaken following full consultation with its insurance provider.

AED supplier Cardiac Science advises that there should be no concerns raised by insurers provided that the units are installed on a risk-based need, and that suitable training is given to individuals expected to use them. The company indemnifies its AEDs and users against any claims, damages, liabilities, or actions instigated by a third party, provided that the machine has been correctly used, and inspected and maintained in accordance with the unit’s user manual. The incident log created when the AED is deployed should also be downloaded from the device and retained for record purposes.

Commenting on the scheme with the NWAS, Brian Simpson, chief executive of WPH, said: “The welfare of our tenants and staff is extremely important to WPH. We know that both staff and tenants have a history of heart problems. By providing AEDs, it is our aim, wherever possible, to prevent friends and families suffering the tragic loss of a loved one.”

Useful links

About the author
Denny Beacham is safety health & environmental manager for Wirral Partnership Homes.


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14 years ago

I don’t think the term ‘or the casualty comes round’ is really the right way to convey CPR. When CPR is being administerer the casualty is clinicaly dead. Defib is often the only answer to possibly saving the person. CPR aims to keep oxygen levels high enough to keep the intenal organs, spine and of course the brain alive. We shouldn’t be afraid of saying the person may remain dead. People often think they have done something wrong if the person doesn’t Come Round. They just stay dead.