# BLS/ALS Defibrilation Question



## Mountain Res-Q (Apr 20, 2009)

So, I was watching a old episode of HOUSE at my parents house when my mom asked me a question HOUSE-related that I couldn't answer completely.

Pregnant woman (5 months) arrests.  V-Fib.  They "shock" her back to life.  "All hail House the Great!"

The question is:  What effect (if any) is ther to the fetus if a pregant woman is defibrilated?  We don't touch the patient becasue of the potential for us to be shocked (maybe into v-fib), so if we will not be attched for safety reasons, what happens to the "person" still attached via an umbical cord?

P.S. Obviously the alternative to not defibrilating the mom is not an optio  So I am not looking for a justification to shock / not to shock, just a response as to the effects on the fetus from a knowledgable source.  r/r911, you out there?


----------



## Melclin (Apr 20, 2009)

Seems to me that without the shock mum will die and so will baby. With the shock, mum might live = baby might live. So it's a no brainer from that perspective. 

Also, you try not to touch the patient because you might provide a more appealing route for the electricity to follow to ground. Seeing as though baby isn't grounded, it wouldn't be giving the electricity any options other than paddle to paddle. So I can't see how baby would cop any sparks. 

That being said, it couldn't possibly be good for baby to have mum defibed. Extreme muscle contractions, physiological changes from the electricity, the drugs involved -- This on top of the fact that mum is already sick enough to be getting defibed in the first place. I wouldn't wanna be the kid.

VF/VT aside, with other rhythms that leave more options open (SVT for eg.) I'd be interested to know if electrical of chemical cardioversion is best for pregnant women.


----------



## Ridryder911 (Apr 20, 2009)

Ditto to Melcin. Mother comes first as she is the "life support system" for the fetus. 

R/r 911


----------



## Scout (Apr 20, 2009)

Can anyone give exact detial on what the shock actually is. assume AED, if it varies between AED's will you provide detials of which AED the stats refer to.

Volts, AC/DC, lenght of pulse etc


Sorry about the hijack Mount.


----------



## Mountain Res-Q (Apr 20, 2009)

MY GOD, did no one read my _entire_ first post?

Obviously you are gonna shock!  As I SAID:  "Obviously the alternative to not defibrilating the mom is not an option.  So I am not looking for a justification to shock / not to shock, just a response as to the effects on the fetus from a knowledgable source."  

Because the baby is not grounded technically, will the baby be fine... or does the potential for killing the fetus exist?  Reseach, experience, atticles... Just looking to expand my education a little.  -_-


----------



## rmellish (Apr 20, 2009)

Mountain Res-Q said:


> MY GOD, did no one read my _entire_ first post?
> 
> Obviously you are gonna shock!  As I SAID:  "Obviously the alternative to not defibrilating the mom is not an option.  So I am not looking for a justification to shock / not to shock, just a response as to the effects on the fetus from a knowledgable source."
> 
> Because the baby is not grounded technically, will the baby be fine... or does the potential for killing the fetus exist?  Reseach, experience, atticles... Just looking to expand my education a little.  -_-



Relax...

I don't have anything to back this up, but think of the fetus as another internal structure. The intestines don't normally have defibrillation current passing through them...why? Because the shock would from the negative to the positive defib pad. (Monophasic) I can't speak intelligently on a biphasic defibrillation. If the pads were placed correctly, the heart would be in the path of this current, and if all goes as planned, it's effect would be isolated to this area. 

Or at least that's my best guess....


----------



## Mountain Res-Q (Apr 20, 2009)

rmellish said:


> Relax...QUOTE]
> 
> I am Relaxed...  I've spent my morning testing whether Ketamine provides the same level of analgesia as Morphine... http://www.emtlife.com/showthread.php?t=12330  :wacko:
> 
> Good susposition though, the differnece I see would be that your intestine doesn't have it's own independant electrical system with it's own developing circulatory pump.


----------



## rmellish (Apr 20, 2009)

Mountain Res-Q said:


> rmellish said:
> 
> 
> > Relax...QUOTE]
> ...


----------



## Mountain Res-Q (Apr 20, 2009)

rmellish said:


> Mountain Res-Q said:
> 
> 
> > That really wasn't what I was getting at. I'm supposing that the current is more or less linear, and passes through whatever structures are in its path.
> ...


----------



## exodus (Apr 20, 2009)

Well if the mom is going to die, the baby is going to die... Save the mom eff the baby.


----------



## Mountain Res-Q (Apr 20, 2009)

exodus said:


> Well if the mom is going to die, the baby is going to die... Save the mom eff the baby.



Once again, not the question!  It's not a "What would you do" but a "what will be the outcome when I do it" question.


----------



## gicts (Apr 20, 2009)

Mountain Res-Q said:


> Once again, not the question!  It's not a "What would you do" but a "what will be the outcome when I do it" question.



the baby would shoot out and disappear


----------



## Mountain Res-Q (Apr 20, 2009)

According to “Cardiac Arrhythmias” by Phillp J. Podrid and Peter R. Kowet (2001):
“Electrical cardioversion has been used in pregnancy and is well tolerated.  Fetal Monitoring is recommended immediately after cardioversion, although the risk of induction of fetal arrhythmias appears to be minimal, perhaps because of low electrical energy reaching the fetus or high defibrillation of the fetal heart.

Likewise, “Obstetric & Gynecological Emergencies” by Mark Pearlman, Judith E. Tintinalli, Pamela L. Dyne (2003) reads:
“Although special cardioresuscitative medications (i.e. epinephrine) have theoretical consequences, use of these medications is justified in the critically ill pregnant patient.  Likewise, defibrillation should be performed using the same indications as in nonpregnant patients.  Reports do exist of cardioresuscitative medications and electrical cardioversion being successfully used in pregnant patients with no discernable adverse effects on mother or fetus.”

The general thought from what I was reading, from other sources as well, is that “Defibrillation transfers no significant current to the fetus”.  While I am not ACLS certified, according to one site, ACLS textbooks mention using “a biphasic defibrillator (when you have the choice) because they achieve better results with a lower shock.  If you only had a monophasic defibrillator, they said they might try to start the first shock with a higher voltage (300J in stead of 200J) in the hopes that you get a desired result in one shock (verses the 3 stacked.... you would hopefully only have to shock once).”  They also suggested shocking anterior to posterior.  For those who use only AED’s, we can try anterior/posterior, but are unable to change the voltage.  The end result is, of course, that we will always shock a shockable rhythm.  Mom dies = Baby dies anyway.  Take the chance with the knowledge that complications to the fetus are unlikely if we shock, complications to the fetus are near 100% if we don’t.


----------



## Melclin (Apr 20, 2009)

Melclin said:


> Seems to me that without the shock mum will die and so will baby. With the shock, mum might live = baby might live. So it's a no brainer from that perspective.



I was agreeing with you, man. I was just going through the motions, thinking out loud.


----------



## Ridryder911 (Apr 21, 2009)

Mountain Res-Q said:


> MY GOD, did no one read my _entire_ first post?
> 
> Obviously you are gonna shock!  As I SAID:  "Obviously the alternative to not defibrilating the mom is not an option.  So I am not looking for a justification to shock / not to shock, just a response as to the effects on the fetus from a knowledgable source."
> 
> Because the baby is not grounded technically, will the baby be fine... or does the potential for killing the fetus exist?  Reseach, experience, atticles... Just looking to expand my education a little.  -_-



Okay..chill out. It does not really matter does it? Baby not grounded, what planet are you on? Hmm... let's see floating in aminotic fluid, connected by tissue. Yeah, I say it well grounded and yes will recieve the shock. So? 

Dead mom=dead baby. Yes there maybe effects and again there maybe none. Will not know until post delivery if that is possible. Then the differential of was it related to inneruterine hypoxia or r/t the defibrillation. Many have received being zapped and lived. I have by ignorant partners, nothing I would recommend but the circumstance leaves no other option. 

Clarrification on depending gestation age, if the fetus can be viable for an emergency induction or C-section or mother stable enough to leave alone. 

R/r 911


----------



## MSDeltaFlt (Apr 21, 2009)

Mountain Res-Q said:


> So, I was watching a old episode of HOUSE at my parents house when my mom asked me a question HOUSE-related that I couldn't answer completely.
> 
> Pregnant woman (5 months) arrests. V-Fib. They "shock" her back to life. "All hail House the Great!"
> 
> ...


 
I'm willing to bet noone knows for 100% sure.  I can only come up with about two ways anyone might find out just how much current a fetus will received or have received during countershock therapy.

1. Place an envitro electrode on the fetus and then shock the mother with everything you've got.  Yeah, not gonna happen.

2. Fetal autopsy after multiple attempts on defibrillating the mother.  Personally I just don't think it's been done yet.

That would be why those quotes you posted did not state for any certainty.  I'm with your posted authors.  The effects would probably be minimal.  Rid is also correct in my opinion, as is I believe is yours.  It's semmantics.  But good question though.


----------



## LAS46 (Apr 22, 2009)

My question is... would the AED pick up a pulse from the fetus and then if that is the case then the AED will not shock...

Is this the case?

Dustin
MFR, EMT-Basic (+) Student


----------



## DV_EMT (Apr 22, 2009)

My fiancee (the RN) and I were discussing this the other day actually

we figured out a few things about the potential for death during delivery.

1. does natural selection (or God) choose who is to live and who is to die? after all, look at NICU babies. are we sure that they are going to be happy healthy people when they grow up... or are they going to have defects like cystic fibrosis, or down syndrome, or or or.

2. Who's life do we save (Playing God). there's 4 outcomes. both live, both die, mother lives/baby dies or vice versa. In my opinion. The mother is most likely healthy and to risk her death for an unknown baby's outcome is selfless. My opinion is that i'd put money on someone who i know is going to be ok as opposed to putting money on a baby that could potentially die. 

then again, there are people who like to gamble.


So it really depends...but in the end... mom makes the call (unless she can't due to complications)


----------



## rmellish (Apr 22, 2009)

LAS46 said:


> My question is... would the AED pick up a pulse from the fetus and then if that is the case then the AED will not shock...
> 
> Is this the case?
> 
> ...



Don't confuse electrical activity with a pulse. Remember the AED will evaluate the heart's electrical activity against the two rhythms it is programmed to shock. The AED cannot determine if the patient has a pulse.


----------



## LAS46 (Apr 22, 2009)

rmellish said:


> Don't confuse electrical activity with a pulse. Remember the AED will evaluate the heart's electrical activity against the two rhythms it is programmed to shock. The AED cannot determine if the patient has a pulse.



I understand that but if the AED detects PEA then it will not shock, so if you have a fetus who's heart is still beating then it may pick that up as PEA or even as a rhythm and will not let you shock....

Dustin
MFR, NREMT-B Student


----------



## rmellish (Apr 22, 2009)

LAS46 said:


> I understand that but if the AED detects PEA then it will not shock, so if you have a fetus who's heart is still beating then it may pick that up as PEA or even as a rhythm and will not let you shock....
> 
> Dustin
> MFR, NREMT-B Student



Fair enough, but your initial post was worded differently.


----------



## Mountain Res-Q (Apr 22, 2009)

DV_EMT said:


> My fiancee (the RN) and I were discussing this the other day actually
> 
> we figured out a few things about the potential for death during delivery.
> 
> ...



What does this have to do woth anything.  The question was what complications result from shocking a pregnant patient.  This has nothing to do with birth defects or a question of who do we save: mother or baby.  The answer isn't debatable, we shock the mother regardless of the outcome to the fetus.  The question wasn't what do you do but what results will our actions have.  "Mom makes the Call"?????  How does the mother tell us whether or not to defibrilate her?  If she is giving you advise on defibriallation A. Don't defibrilate her and B. Find a new Profession!

What's with the revival of dead threads by the newly certified?


----------



## LAS46 (Apr 22, 2009)

rmellish said:


> Fair enough, but your initial post was worded differently.



Sorry thats what I was meaning was the rhythm not the pulse.

Dustin
MFR, NREMT-B Student


----------



## Melbourne MICA (May 8, 2009)

Mountain Res-Q said:


> So, I was watching a old episode of HOUSE at my parents house when my mom asked me a question HOUSE-related that I couldn't answer completely.
> 
> Pregnant woman (5 months) arrests.  V-Fib.  They "shock" her back to life.  "All hail House the Great!"
> 
> ...



Electricity does not travel in a linear manner. It travels between poles of conductance via the shortest path with the least electrical resistance.

 As your AED pads are placed, axilla pad and sternum pad, it will find the fastest path of least resistance between them. If you touched *one* pole of a high voltage current to your arm you would not shocked - it needs the other (neg or post) for current to flow. This is called the potential difference.

I don't know a great deal about impedance but it is a take on electrical resistance and the calibration of the device relative to the resistance of tissues.

As the fetus is not between the poles it will not be electrocuted.

As regards picking up the baby's pulse does your AED do that or examine the electrical activity of the heart? If it does how is it picking it up by sound, vibration or electricity? And as your AED is a monitoring device how does it accomplish this?  - By measuring electrical impedance between the poles ie the electrodes (pads).

I can't speak to any great knowledge on the different brands of AED's and how they differ but the electrical principles are the same for all. And there must be an ex sparkie amongst the guys out there who can fill us all in.

One other thing - if you have to defib (sync) a guy in VT for example - with a pulse or where you can't pick one up - who has a pacemaker - where do you put the pads and why? What will happen (or not happen) to the pacemaker depending on where your pads are placed? 

If we had a pt in VT with a pulse and it was the case that defib/sync fries pacemakers irrespective of where you placed your pads  what would the pt be left with with after a successful sync out of VT? 

I guess we have to be careful about how we setup for defib/sync with AED or manual mode monitor defibrillator - especially where you put the two Pads (poles) for the zap to go between.

As the old saying goes - never come between moving electricity and its  destination!!!

MM


----------



## Melclin (May 9, 2009)

Ridryder911 said:


> Baby not grounded, what planet are you on? Hmm... let's see floating in aminotic fluid, connected by tissue. Yeah, I say it well grounded and yes will recieve the shock. So?
> 
> R/r 911



It's not separately grounded as opposed to the mother (such as say a person touching the mother's body would be). Its no providing any more appealing a path for the electricity to follow to ground than the mother is. That's what I was getting at anyway, but I'm not even sure if u were aiming your comment at me.  

As far as the electricity traveling from pol to pol (MelbMic), electricity will travel to wherever the greatest potential difference lays (as I understand it from highschool physics). The defib creates a greater difference across the two pols, relative to the resistance encountered, than the difference between the defib and the earth or anything else(hence why the shock doesn't just go straight to the ground, I assume). However, if the resistance is changed in a specific spot, it changes the equation, and the electricity will travel that way instead (arching over wet skin, bubles under defib pads, OR TOUCHING A PERSON WHILE DEFIBING). I have bugger all to base this on, but it seems like the presences of a pocket of fluid full of charged molecules, like amniotic fluid, near the pads might provide a more appealing path to ground, or the other pole. Perhaps lessening the effectiveness of the defib and maybe harming baby?

Its all purely academic, obviously, as I said, if mum needs some sparks, she ganna get them, but its got me interested.

*MelbMica*: if someone was using an AED, I don't know that they would be treating more complex rhythms than VF/VT, unless my understanding of AEDs is off. When I did my semi auto training last year on the old Zolls, the only rhythms were VF and pulseless VT (if they have a pulse/conscious, its MICA's business, as is my understanding from the CPGs). 
*You other blokes who use AEDs*: are there new fangled ones that do more than pulseless VT/VF? I thought that if u were using an AED and not a manual defib, your scope of practice wouldn't include dysrhythmias with a pulse/concious. My experience of AEDs is those used by people with very little medical training (firefighters, lifesavers, security guards). Is this not always the case?


----------



## Melbourne MICA (May 9, 2009)

Melclin said:


> *MelbMica*: if someone was using an AED, I don't know that they would be treating more complex rhythms than VF/VT, unless my understanding of AEDs is off. When I did my semi auto training last year on the old Zolls, the only rhythms were VF and pulseless VT (if they have a pulse/conscious, its MICA's business, as is my understanding from the CPGs).



Absolutely. I was just trying to get across the idea about electricity going along a set pathway determined by electrical conductance between poles. If you placed the pads on top of a pacemaker you would fry it because it is now inside the elctrical pathway when discharged. 

If the pt was in say VT and needed to be synced by an ALS crew you can do it without frying the pacemaker provided you place the pads correctly. I'm aware an AED can't be used for this. I was following on from the original enquiry about the safety of an unborn when defib is happening by using a couple of examples to demonstarte the point. Sorry for any confusion.

I guess the overall point when using the juice is to handle with care. Done correctly and safely no worries. 

MM


----------



## Melclin (May 9, 2009)

Melbourne MICA said:


> Absolutely. I was just trying to get across the idea about electricity going along a set pathway determined by electrical conductance between poles. If you placed the pads on top of a pacemaker you would fry it because it is now inside the elctrical pathway when discharged.
> 
> If the pt was in say VT and needed to be synced by an ALS crew you can do it without frying the pacemaker provided you place the pads correctly. I'm aware an AED can't be used for this. I was following on from the original enquiry about the safety of an unborn when defib is happening by using a couple of examples to demonstarte the point. Sorry for any confusion.
> 
> ...



Oh my bad. I just read through it quickly and thought you just had a decidedly odd way of talking about the organic pacemaking sites in the heart->> more complex dysrythmia analysis. Yeah I missed the point completely. 

But the argument about the path of conduction offering less resistance through amniotic fluid still stands. And the grounding issue, for whoever was having a go at that. 

_And on a side note, am I right in thinking VTs with a pulse are not an ALS issue (other than calling MICA). Seems like it would be frustrating being a QAP and sitting on my hands while a person sat there in a wide complex VT or VT with a pulse. Seems to me with my limited education that a serious VT with a pulse will probably soon degenerate into a non perfusing VT and then VF. Do us ALS guys have to sit on our hands (while transporting/waiting for MICA) until we loose a pulse? Sorry guys, don't mean to hijack the thread with our Victoria talk._


----------

