# safe AED usage on a drowning victim?



## paramedichopeful (Nov 22, 2009)

Hey guys. This is the first time I've been on here in awhile (ok, months), and I need a bit of help. I am getting ready to go into the EMT-I phase of my class and we are starting with advanced AED tomorrow. Yesterday my instructor gave me a challenge: create detailed, illustrated flashcards for using and AED. It was very simple and easy, until I got to the section on using an AED on a pt. that has been pulled from the water. So, I have a few questions. What are some tips to keep from getting electrocuted? Is there any special placement of teh pads? Any other special procedures? I couldn't really find much online, but it has to be different procedure because common sense is telling me that h20 and 300 joules don't mix that well. I'd appreciate any help. Thanks!


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## Shishkabob (Nov 22, 2009)

Dry off the pt and don't touch water.



Nothing else to it.


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## MMiz (Nov 22, 2009)

I posted a thread about this a few years ago.  I learned that you pat the patient dry and stay clear of any standing water.


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## Lifeguards For Life (Nov 22, 2009)

just make sure you and your patient are not in a pool of water. 

Once you dry the patient off, they are no longer wet, so procceed as normal


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## Micro_87 (Nov 22, 2009)

+4 just make sure they're dry and your not around water.


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## foxfire (Nov 22, 2009)

Lifeguards For Life said:


> just make sure you and your patient are not in a pool of water.
> 
> Once you dry the patient off, they are no longer wet, so procceed as normal


agreed.
One way we were taught, is to make use of the back board that the pt is already on and move the them out of the puddle. because the pt is going to make one just coming out of the water. And have a few towels on hand to mop up any stray water. 
like from the lifeguard who is dripping wet while doing cpr.
sidenote: they are not actualy strapped to the board just on it.


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## medichopeful (Nov 23, 2009)

Dry the patient, and try not to have them lay in a pool of water.  The placement of the pads should be the same: lower left and upper right.

Also, make sure to remove any chains, necklaces, nicotine patches, etc.  Do it like you always would with an AED, just make sure to dry the patient and don't touch water.

Hope this helps!


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## Tyler Bruns (Nov 23, 2009)

Sounds like everyone else has your answer covered but I thought I would throw this out there. My teacher uses the mnemonic PANDA for AED indications. 
P- Pulse less
A- Apniec 
N- Non-traumatic 
D- Dry
A - All ages
Obviously the dry part pertains to this question.
Hope it helps.


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## trevor1189 (Nov 23, 2009)

medichopeful said:


> Also, make sure to remove any chains, necklaces, nicotine patches, etc.  Do it like you always would with an AED, just make sure to dry the patient and don't touch water.



I don't think I have ever been told to remove chains, necklaces, nicotine patches. Do you have a reason for doing this? I can understand if something is in the way where you need to place the pad, but otherwise what's the point?


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## medichopeful (Nov 23, 2009)

trevor1189 said:


> I don't think I have ever been told to remove chains, necklaces, nicotine patches. Do you have a reason for doing this? I can understand if something is in the way where you need to place the pad, but otherwise what's the point?



It's just to get rid of any possible interference.  If it's a metal necklace, you can see why (it's a good conductor).  If it's a different type of necklace, you may be able to leave it on, but I personally would cut it off.  Better to be safe than sorry.

As far as medication patches go, I should have been more clear.  You only need to take those off if they will interfere with the AED pads.

Hope that helps!


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## EMSLaw (Nov 23, 2009)

Yeah, ditto what everyone else said.  Dry them off, and don't stand in the puddle.  This time of year, you're probably going to want to get them out of those wet clothes anyway.

Actually, that's sort of an interesting scenario.  Victim in the water, in winter.  Obviously, you have to dry them off.  Would you move them to the rig for passive rewarming and start CPR in the back of the (non-moving) ambulance, or would you apply the AED and do some period of CPR on the cold, cold ground?


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## foxfire (Nov 23, 2009)

EMSLaw said:


> Yeah, ditto what everyone else said.  Dry them off, and don't stand in the puddle.  This time of year, you're probably going to want to get them out of those wet clothes anyway.
> 
> Actually, that's sort of an interesting scenario.  Victim in the water, in winter.  Obviously, you have to dry them off.  Would you move them to the rig for passive rewarming and start CPR in the back of the (non-moving) ambulance, or would you apply the AED and do some period of CPR on the cold, cold ground?


Hypothermia causes bradycardia, so I am thinking that staying out in the cold would not be a good idea. 
Staying in the cold would be counter productive to the efforts of restarting the heart.


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## paramedichopeful (Nov 23, 2009)

Thanks, guys. This should be the last piece of info I need to get these darn cards finished. Basic class was a cakewalk, but now things are getting a little harder. Just wish I could skip the rest of Intermediate and go right to IV's. Treatment of simple, almost nonexistent injuries is very much common sense, but still they feel the need to go over it 500 times. Should be very exciting when we get to doing airways and tubes. That's a long ways off though.


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## Shishkabob (Nov 23, 2009)

foxfire said:


> Hypothermia causes bradycardia, so I am thinking that staying out in the cold would not be a good idea.
> Staying in the cold would be counter productive to the efforts of restarting the heart.



Please Google "therapeutic hypothermia".   One of the 'new' protocols going around is to actively cool cardiac arrest pts because it provide a better survival rate.


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## Mountain Res-Q (Nov 23, 2009)

Come on people, you DO NOT use an AED on a drowning victim... haven't you ever read the label on the side of newer models?  "Not To Be Used As a Flotation Device!"  ^_^

Seriously, ditto all... and add to it that the same principles apply in Snow Conditions such as at a Ski/Snow Resort, in which scenerio the patient isn't just wet and moist, but actually lying in a field of water (frozen of course and with clothing already providing something of a barrier to the snow).  In this case, you do your best to remove them the water (snow) and then remove as much moisture from the patient as 3-5 seconds will allow.


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## foxfire (Nov 23, 2009)

Linuss said:


> Please Google "therapeutic hypothermia".   One of the 'new' protocols going around is to actively cool cardiac arrest pts because it provide a better survival rate.



I think I remember hearing about it. 
Is the "new" protocal for ALS or BLS?  
From what I read it is still undecided as to the survival rate being better.
They stated that PEA, astolye, and a few other rythms had a lower survival rate than the noncooled group. 
Please correct me if I am reading things wrong.


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## Shishkabob (Nov 23, 2009)

Many systems wont let you terminate care on a hypothermic pt, because they show a better survival rate.  As the old adage goes, "you're not dead until you're warm and dead".

Then there's Theraputic hypothermia, which tends to be after ROSC.



As far as ACLS, below a certain temp, you forgo normal ACLS algorithms, only do 1 shock, and don't do any drugs.  Just straight up CPR.


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## Scout (Nov 23, 2009)

I have a question, Will an AED shock you if your in a puddle with a Pt, assume pt chest has been dried and pads placed as per instruction.


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## medichopeful (Nov 23, 2009)

Scout said:


> I have a question, Will an AED shock you if your in a puddle with a Pt, assume pt chest has been dried and pads placed as per instruction.



I'm not sure, but why take the risk?


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## medichopeful (Nov 23, 2009)

*Read This*

Here's an informational article on AED usage.  It should answer any questions anybody has.

http://www.redcross.org/www-files/Documents/pdf/Preparedness/AED_FAQs.pdf


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## Scout (Nov 23, 2009)

medichopeful said:


> I'm not sure, but why take the risk?




Don't and you shouldn't, But whats the answer to the question? I'm not suggesting run out and try it.


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## medichopeful (Nov 24, 2009)

Scout said:


> Don't and you shouldn't, But whats the answer to the question? I'm not suggesting run out and try it.



I think under certain circumstances it could:

http://www.azshare.gov/documents/curriculum.pdf

Look at page 2.


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## Melclin (Nov 24, 2009)

Scout said:


> I have a question, Will an AED shock you if your in a puddle with a Pt, assume pt chest has been dried and pads placed as per instruction.



It's not going too most of the time. The electricity will always follow the path of least resistance, and the vast majority of the time, if you've done everything right, that's going to be from one pad to the other. But like medichopeful said, there's no point in taking the risk that the stars have aligned in just the right way to create a less resistant path to ground that happens to involve a quick trip through you. 

Wasn't there some talk a little while back about continuing compressions during defib? What was the deal with that?


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## Mountain Res-Q (Nov 24, 2009)

Scout said:


> I have a question, Will an AED shock you if your in a puddle with a Pt, assume pt chest has been dried and pads placed as per instruction.



True story (second hand)...  I know of some Firefighters that used an AED on a near drowning years ago, when AEDs were still novel locally.  The patient was removed from the water and placed on the dock, where the EMTs started working the code.  The dock was wooden and, of course, soaking wet after being used all day.  The patient was laying on the drenched dock and the Firefighters all standing of kneeling next to the patient.  They all felt the initial shock, but it was more of a tingling  little jolt.  In fact, a Firefighter that was standing ~20 feet away claimed to have felt a tingling running up his legs as well.  Obviously they did not get the full force of the shock, nor could they have as the shock wants to travel between the two pads; but remember that water is a great conductor of electricity, which is why (despite the low likelihood of problems) you quickly pat the patient dry and remove them from water...


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## mycrofft (Nov 24, 2009)

*Wayne Imahara could rig a remote trigger...*

Falling back on evidence- based chase-cutting, with as many AED's incuding old retired ones lying about as there must be, we are not reading about nor seeing people dead from it.


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## medichopeful (Nov 28, 2009)

medichopeful said:


> As far as medication patches go, I should have been more clear.  You only need to take those off if they will interfere with the AED pads.
> !



Turns out this was wrong.  Take patches off if they are anywhere on the chest.


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## Shishkabob (Nov 28, 2009)

Nope, only take off if they interfere with normal placement of the pads.  If the patch is on their left shoulder, there is no need to touch.


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## medichopeful (Nov 28, 2009)

Linuss said:


> Nope, only take off if they interfere with normal placement of the pads.  If the patch is on their left shoulder, there is no need to touch.



I left out a key work: nitroglycerin patches.  According to my book, these should be removed if they are on the chest.  Others, yes, if they interfere with the pads.


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## reaper (Nov 28, 2009)

If the patch is not in the way, you can leave it alone. A NTG patch may be removed, but it has nothing to do with the AED.


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## MRE (Nov 29, 2009)

medichopeful said:


> I left out a key work: nitroglycerin patches.  According to my book, these should be removed if they are on the chest.  Others, yes, if they interfere with the pads.



I have always been told to remove all patches too.  Several reasons have been given, but in my engineering opinion; even if a patch is not under the defib pad, it could provide a lower resistance path across the surface of the chest than normal (especially foil backed patches), reducing the amount of current traveling through the chest where it should be.  This is probably more likely in a small person where the pads are already close together.

If it only takes an extra 0.5 seconds to remove the patch, I'll do it.


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## Brandon O (Nov 29, 2009)

I take off my patches when I shock so nobody can identify my service after I kill them <_<


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## medichopeful (Nov 29, 2009)

I think the key word here is "on the chest."  If they are anywhere on the chest, I would take them off.  If they are in the way of the pads, you MUST take them off.  This is especially true for Nitro patches.

The thing is, electricity can actually melt the plastic on the patches, and it could probably melt other materials as well.  I would say better safe than sorry.

But right, if it's on the arm or anything, I wouldn't really worry about it.  It's not like you're going to do a full sweep of the body and remove every single patch you see.  Instead, just remove the ones in the immediate area (in other words, the chest and possibly abdomen).


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## ruprgnant (Feb 6, 2011)

*abdomen patches?*

why remove patches on the abdomen?? i'm pretty sure no one is going to be putting the pads with a crosscurrent on the abdomen... and if they are... i'm less worried about the patches and more worried about the patients now fried stomach...



medichopeful said:


> I think the key word here is "on the chest."  If they are anywhere on the chest, I would take them off.  If they are in the way of the pads, you MUST take them off.  This is especially true for Nitro patches.
> 
> The thing is, electricity can actually melt the plastic on the patches, and it could probably melt other materials as well.  I would say better safe than sorry.
> 
> But right, if it's on the arm or anything, I wouldn't really worry about it.  It's not like you're going to do a full sweep of the body and remove every single patch you see.  Instead, just remove the ones in the immediate area (in other words, the chest and possibly abdomen).


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## MontanaEMT (Mar 28, 2011)

medichopeful said:


> It's just to get rid of any possible interference.  If it's a metal necklace, you can see why (it's a good conductor).  If it's a different type of necklace, you may be able to leave it on, but I personally would cut it off.  Better to be safe than sorry.
> 
> As far as medication patches go, I should have been more clear.  You only need to take those off if they will interfere with the AED pads.
> 
> Hope that helps!



Especially Nitro patches, make sure you clean the spot very well since they can be explosive.


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## Veneficus (Mar 28, 2011)

MontanaEMT said:


> Especially Nitro patches, make sure you clean the spot very well since they can be explosive.



Explosive huh?

I guess.

But having seen a first year EM resident about 10 years back mistakenly put Nitro paste on manual defib paddles thinking it a tube of defib jel and the rest of the people in the code not figuring it out until after the fact, let me describe what happens.

When the electricity was applied there was big blue and white flash of light.

No sound, no shock wave. When it was over the patient had 2 paddle shaped full thickness burn marks on his torso and his chest hair was still on fire in several places. (if he wasn't dead prior, I am sure that didn't help)

The resident was standing there with a look of utter shock on his face and the rest of us were encouraging him to sit down. It was about then one of the nurses noticed the open tube of nitro paste.

After a very thorough workup by 2 highly respected attendings, the only injury was to his pride. 

I wouldn't add his name here, but I will say at said facility, his story lives on eternally, retold to every incomming EM class even though the defib jel was replaced by orange defib pads.

But unlike so many stories of long ago, I actually witnessed this one first hand. I doubt I will ever forget his name.

Sorry to dissapoint, no "kaboom."


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## MontanaEMT (Mar 28, 2011)

Veneficus said:


> Explosive huh?
> 
> I guess.
> 
> ...



No disapointment. . but as you saw causes some serious burns.. I have heard other stories where the nitro burned into the skin when they did not clean it off.


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## TransportJockey (Mar 28, 2011)

Vene, it's from the same myth I think that NTG IV infusion bottles will explode if they are dropped.


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## Veneficus (Mar 28, 2011)

jtpaintball70 said:


> Vene, it's from the same myth I think that NTG IV infusion bottles will explode if they are dropped.



I've not heard that one before.

In order to have an explosion you need a rapid chemical reaction and containment. 

It always seems that at least one of those 2 critical pieces is always missing in peoples' theories.

If memory serves me right, it has been a long time since fire/arson investigation school, a low order explosive can be set off by an ignition source or expanding gas and travels at <4081 feet per second.

High order requires both a shockwave and nitrogen at >4081 feet per second. 

The practical difference being whether the shock wave pushes material or atomically disjoins it.

For the fire folk, a BLEVE is a low order explosion. 

The explosion of the Murrah federal building is actually now a textbook example low order explosion. Though as demonstrated, they can be quite devastating despite their name.


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