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Blind defibrillation
Blind Defibrillation WILLIAM RICHARD CARL New
J. GRACE,
MD,
J. KENNEDY,
T. NOLTE,
FACC MD,
FACC
MD
York, New York
“Blind defibrillation” is the immediate discharge of electrical current of 200 to 400 watt-seconds through the chest wall of a pulseless patient without foreknowledge of the type of arrhythmia present. The two key words are blind and immediate: (1) blind because the procedure is performed without determining the cardiac rhythm, and (2) immediate because as the time lag increases before application there is less likelihood of establishing an effective rhythm and preventing irreversible damage and death. Typically, the subject of blind defibrillation is a middle-aged or older man or woman in a hospital, at home or on the street. The patient is pulseless because of ventricular tachycardia, ventricular fibrillation or asystole, but the nature of the arrhythmia is not a determining factor in treatment. Defibrillation is called “blind” but is not truly so because of the high probability that ventricular fibrillation or tachycardia is the cause of the pulseless state. Ample documentation of this probability is available. Adgey and Pantridgel state that 10 percent of their patients had ventricular fibrillation. From the Coronary Care Unit at St. Vincent’s Hospital and Medical Center, Grace and Keyloun2 report that 75 percent of cardiac arrests were due to ventricular fibrillation and 20 percent to “straight line” asystole. Common&y medical examiners report coronary artery disease rather than massive myocardial infarction as a cause of sudden death. This implies that sudden death is due to arrhythmia, a presumably reversible condition. In the Baltimore study of Kuller3 66 percent of sudden deaths were associated with severe coronary disease. Because of these facts, treatment is blind and immediate with no time lost in obtaining an electrocardiogram or attempting to document a generally fatal arrhythmia. Critical seconds are not lost because the type of arrhythmia is of no practical importance. The determinant of success is the time
From the Departments of Medicine and Electrocardiography and Vectorcardiography. St. Vincent’s Hospital and Medical Center of New York, New York, N. Y. Address for reprints: William J. Grace, MD. Department of Medicine, St. Vincent’s Hospital and Medical Center of New York, 153 W. 11th St., New York, N. Y. 10011.
elapsed from onset to treatment.. Survival is directly related to the time interval between cardiac arrest and reestziblishment of circulation and ventilation. The combined data of Adgey and Pantridgel and Grace and Keyloun2 show that of 108 patients with cardiac arrest, 22 percent had long-term survival when a physician was immediately available to start treatment, compared with 1 percent when he was not. In 94 cases of documented ventricular fibrillation reported by Adgey and Pantridge,l 52 percent of patients survived when defibrillation and respiratory assistance were initiated within 4 minutes of arrest, but only 4.8 percent survived when resuscitation efforts were delayed beyond that time. There should be no hesitation about performing electrical cardioversion, for there is no evidence that the procedure is harmful. Should a normal sinus rhythm be inadvertently converted to ventricular fibrillation, reconversion can be readily accomplished electrically. At our institution four instances are recorded of electrical current having been delivered to patients who did not require this treatment. All four survived without harm. Blind defibrillation began at St. Vincent’s Hospital and Medical Center in 1968. The procedure does not lend itself to controlled study. Yet, interestingly, before the use of blind defibrillation, the survival rate of patients with cardiac arrest was 27 percent, but during 1972 it increased to 45 percent. This improvement is not entirely due to blind defibrillation, but the bias is strongly in favor of this method of treating the pulseless patient. In a nonmonitored hospital setting the success of cardiopulmonary resuscitation is proportional to the training and experience of the staff as well as the availability of the equipment. A plan of action must be designed which is meticulously detailed and regularly practiced. The first person to the scene assesses the situation and determines if cardiac arrest has taken place. If so, defibrillation is promptly initiated. The second person on the scene attends to the airway for ventillation while the third sets up the electrocardiograph and the intravenous infusion apparatus and prepares to administer medications that may be necessary. Hence, “blind defibrillation” is only a part of
July 1974
The American Journal of CARDIOLOGY
Volume 34
115
EDITORIALS
the scheme of resuscitation, but a most important part, and should be used when appropriate, as indicated. New equipment enables one to use the defibrillator paddles as electrodes for an electrocardiographic
monitor and obviates the need for “blind defibrillation.” Until such equipment is universally available, however, we advocate “blind defibrillation” of the pulseless patient as the initial definitive step in the resuscitation procedure.
References 1. Adgey AA, Pantridge JF: The prehospital phase treatment of myocardial infarction. Geriatrics 27: 102-l 10, 1972 2. Grace WJ, Keyloun VE. The Coronary Care Unit. New York, Appleton Century Crofts, 1970, p 4
116
July 1974
The American Journal of CARDIOLOGY
Volume 34
3. Kuller L, Lllienfeld A. Fisher R: Epidemological study of sudden and unexpected deaths due to arteriosclerotic heart disease. Circulation 34:1056-1068, 1966
J. GRACE,
MD,
J. KENNEDY,
T. NOLTE,
FACC MD,
FACC
MD
York, New York
“Blind defibrillation” is the immediate discharge of electrical current of 200 to 400 watt-seconds through the chest wall of a pulseless patient without foreknowledge of the type of arrhythmia present. The two key words are blind and immediate: (1) blind because the procedure is performed without determining the cardiac rhythm, and (2) immediate because as the time lag increases before application there is less likelihood of establishing an effective rhythm and preventing irreversible damage and death. Typically, the subject of blind defibrillation is a middle-aged or older man or woman in a hospital, at home or on the street. The patient is pulseless because of ventricular tachycardia, ventricular fibrillation or asystole, but the nature of the arrhythmia is not a determining factor in treatment. Defibrillation is called “blind” but is not truly so because of the high probability that ventricular fibrillation or tachycardia is the cause of the pulseless state. Ample documentation of this probability is available. Adgey and Pantridgel state that 10 percent of their patients had ventricular fibrillation. From the Coronary Care Unit at St. Vincent’s Hospital and Medical Center, Grace and Keyloun2 report that 75 percent of cardiac arrests were due to ventricular fibrillation and 20 percent to “straight line” asystole. Common&y medical examiners report coronary artery disease rather than massive myocardial infarction as a cause of sudden death. This implies that sudden death is due to arrhythmia, a presumably reversible condition. In the Baltimore study of Kuller3 66 percent of sudden deaths were associated with severe coronary disease. Because of these facts, treatment is blind and immediate with no time lost in obtaining an electrocardiogram or attempting to document a generally fatal arrhythmia. Critical seconds are not lost because the type of arrhythmia is of no practical importance. The determinant of success is the time
From the Departments of Medicine and Electrocardiography and Vectorcardiography. St. Vincent’s Hospital and Medical Center of New York, New York, N. Y. Address for reprints: William J. Grace, MD. Department of Medicine, St. Vincent’s Hospital and Medical Center of New York, 153 W. 11th St., New York, N. Y. 10011.
elapsed from onset to treatment.. Survival is directly related to the time interval between cardiac arrest and reestziblishment of circulation and ventilation. The combined data of Adgey and Pantridgel and Grace and Keyloun2 show that of 108 patients with cardiac arrest, 22 percent had long-term survival when a physician was immediately available to start treatment, compared with 1 percent when he was not. In 94 cases of documented ventricular fibrillation reported by Adgey and Pantridge,l 52 percent of patients survived when defibrillation and respiratory assistance were initiated within 4 minutes of arrest, but only 4.8 percent survived when resuscitation efforts were delayed beyond that time. There should be no hesitation about performing electrical cardioversion, for there is no evidence that the procedure is harmful. Should a normal sinus rhythm be inadvertently converted to ventricular fibrillation, reconversion can be readily accomplished electrically. At our institution four instances are recorded of electrical current having been delivered to patients who did not require this treatment. All four survived without harm. Blind defibrillation began at St. Vincent’s Hospital and Medical Center in 1968. The procedure does not lend itself to controlled study. Yet, interestingly, before the use of blind defibrillation, the survival rate of patients with cardiac arrest was 27 percent, but during 1972 it increased to 45 percent. This improvement is not entirely due to blind defibrillation, but the bias is strongly in favor of this method of treating the pulseless patient. In a nonmonitored hospital setting the success of cardiopulmonary resuscitation is proportional to the training and experience of the staff as well as the availability of the equipment. A plan of action must be designed which is meticulously detailed and regularly practiced. The first person to the scene assesses the situation and determines if cardiac arrest has taken place. If so, defibrillation is promptly initiated. The second person on the scene attends to the airway for ventillation while the third sets up the electrocardiograph and the intravenous infusion apparatus and prepares to administer medications that may be necessary. Hence, “blind defibrillation” is only a part of
July 1974
The American Journal of CARDIOLOGY
Volume 34
115
EDITORIALS
the scheme of resuscitation, but a most important part, and should be used when appropriate, as indicated. New equipment enables one to use the defibrillator paddles as electrodes for an electrocardiographic
monitor and obviates the need for “blind defibrillation.” Until such equipment is universally available, however, we advocate “blind defibrillation” of the pulseless patient as the initial definitive step in the resuscitation procedure.
References 1. Adgey AA, Pantridge JF: The prehospital phase treatment of myocardial infarction. Geriatrics 27: 102-l 10, 1972 2. Grace WJ, Keyloun VE. The Coronary Care Unit. New York, Appleton Century Crofts, 1970, p 4
116
July 1974
The American Journal of CARDIOLOGY
Volume 34
3. Kuller L, Lllienfeld A. Fisher R: Epidemological study of sudden and unexpected deaths due to arteriosclerotic heart disease. Circulation 34:1056-1068, 1966