Response to Letter Regarding Article, “Hands-On Defibrillation: An Analysis of Electrical Current Flow Through Rescuers in Direct Contact With Patients During Biphasic External Defibrillation”

Abstract

We are grateful for J.L. Sullivan's interest in and comments regarding our article. 1 Clearly, the use of polyethylene gloves is an important constraint to our experiments (We mention this in the article more than once). However, such gloves are a part of standard precautions during resuscitation. Moreover, we clearly demonstrate the safety of hands-on defibrillation in humans despite a direct bare-skin-to-bare-skin return current pathway between the patient and rescuer.Should our findings be interpreted as the "go-ahead" to ignore guidelines and perform compressions while shocks are delivered? Obviously, they should not. As pointed out in the Discussion, we do not advocate that this maneuver be used clinically until proven safe by further testing. We must, however, address and clarify several points made by Mr Sullivan.Mr Sullivan points out that the dielectric integrity of the gloves may break down when exposed to electric fields in the kilovolt range. For gloves to be exposed to this type of voltage, the defibrillator pads would essentially have to be applied directly to either side of the glove. Defibrillating the gloves instead of the patient is beyond the range of foreseeable medical error. In reality, we have found that the measured voltage on the skin surface of patients 15 cm from the pads is less than 1/20th the voltages proposed by Mr Sullivan (unpublished experiments). This is likely the reason that none of our experiments have shown evidence of dielectric breakdown.There is no recommendation in resuscitation guidelines for the use of biphasic shock energies of Ͼ200 J. In 8 of our experiments, we included 360-J biphasic shocks to further test the safety margin of this maneuver. These measurements used energies beyond what would be used in cardiac arrest scenarios. Therefore, these measurements bolster, not hinder as Mr Sullivan would suggest, our conclusions.In our continuing research regarding hands-on defibrillation, we recognize that the safety of rescuers is an absolute requisite. We remain confident that future resuscitation protocols will include streamlined, efficient maneuvers such as ours. Until that time, in the care of our patients, we and the remainder of clinicians should stick to the guidelines. DisclosuresNone. Michael

Cardiac Arrest Resuscitation

“…A compelling study of patients undergoing elective cardioversion with a biphasic defibrillator demonstrated that rescuers, protected only by standard polyethylene gloves, could be in contact with the chest without exposure to dangerous levels of current. 61 Subsequent preclinical investigations have provided conflicting results about the amount of current the provider is exposed to, 62,63 and further study is necessary to determine the safety of this technique over the range of conditions encountered during resuscitation.…”

Advances in defibrillation

“…In an attempt to minimize hands-off time during CPR, it has been suggested that it is safe to remain in contact with the patient while defibrillation is performed [23]. Concern remains as to the safety of this approach and electrical risk needs to be better understood before this strategy is adopted.…”

Defibrillation safety: an examination of paramedic perceptions using eye-tracking technology

“…The importance of access to early defibrillation for patients in cardiac arrest has been emphasised as a critical part of the chain of survival by resuscitation bodies internationally,2–4 and as such has become a key procedure for many out-of-hospital emergency healthcare providers worldwide. Such procedures are, however, not without risk, with the potential for electrical current to inadvertently pass to rescuers 5. Healthcare providers are trained to perform a visual inspection prior to delivering a shock, to ensure no rescuers, bystanders or equipment is touching the patient 6.…”

“…Healthcare providers are trained to perform a visual inspection prior to delivering a shock, to ensure no rescuers, bystanders or equipment is touching the patient 6. While there is evidence to suggest the risk of accidental shock is in fact quite low,5 in the vast majority of documented accidental shock cases the shock could have been avoided with accurate visual inspections 7. Therefore the risk of accidental shock to rescuers can be mitigated by thorough visual inspections.…”