PURPOSE: To provide guidelines For using the LifePak 20 Defibrillator/Monitor with ADAPITIV Biphasic technology. This device may be used for AED defibrillation, manual defibrillation, synchronized cardioversion, noninvasive pacing and Sp0 2 monitoring. Policy: Only Physician s, PA s, RN s & ARNP s who have been trained and who have demonstrated competency in the operation of the LifePak 20 Defibrillator/Monitor/Pacemaker will be allowed to use the equipment. PROCEDURE: A. Automated External Defibrillator (AED) function 1. Assess patient for unresponsiveness, lack of pulse and respirations. 2. Call for help. 3. Start all necessary BLS/CPR steps following current guidelines. 4. Place LifePak 20 near patient. 5. Turn on LifePak 20, by pressing "Green On" button, keep AED door closed at this time. 6. Remove all clothing from the patient s chest. Remove excessive hair, or medication patch if necessary, ensure that chest is clean and dry. 7. Remove Quick-Combo electrodes from package. 8. Attach Quick-Combo electrodes to patient defibrillation cable on LifePak 20. 9. Place Quick-Combo electrodes on patient s chest, ensuring electrodes are placed correctly. Anterior-Lateral "Quik-Combo" Electrode Placement allows for ECG monitoring, Defibrillation, Synchronized Cardioversion and Noninvasive Pacing. A. Place the heart electrode lateral to patient s left nipple in the midaxillary line, with the center of the electrode in the midaxillary line, if possible. B. Place anterior electrode on the patient s right upper torso, lateral to the sternum and below the clavicle. SUPERCEDES: 4/96, 6/99, 6/01, 4/06, 12/07 Page 1 of 8
Note: Follow diagrams on "Quik-Combo" electrode pads. Anterior-Posterior Electrode Placement: Is an alternative position for Noninvasive Pacing, Manual Defibrillation and Cardioversion, but NOT for ECG monitoring or Automated Defibrillation. The ECG signal obtained through electrodes in this position is not a standard lead. Use this configuration if Anterior-Lateral placement is not possible. A. Place the heart electrode over the patient s left precardium. The upper edge of the electrode should be just below the nipple. Avoid placement over the nipple, the diaphragm, or the bony prominence of the sternum if possible. B. Place the posterior electrode behind the heart in the infrascapular area. Note: For patient comfort, place the cable away from the spine. Do not place the electrode over the bony prominences of the spine or scapula. Note: Be sure to place 3 lead ECG electrodes on patient ASAP After "Quik-Combo" pads have been placed. 10. When electrodes have been properly placed, press "Yellow Analyze" button. Ensure no one is touching the patient or bed while AED analyzes the rhythm. 11. If a shock is advised, AED will automatically charge to 200 joules and a voice prompt to clear the patient and push the shock button will be stated. 12. Prior to pushing the "RED Shock" button repeat mnemonic: "Oxygen clear, I'm Clear, You're Clear, Every Body Clear" visually check that no one is touching the patient or the bed and the 0 2 is clear. Call out "Shocking" and press the "RED Shock" button. 13. Immediately following the shock the AED will prompt you to Start CPR. DO NOT push analyze at this time as 2005 ACLS/BLS guidelines require 2 minutes of CPR prior to next defibrillation attempt. Perform 2 minutes of CPR the AED will countdown from 2 minutes and will prompt you to push analyze at the end of 2 minutes of CPR. SUPERCEDES: 4/96, 6/99, 6/01, 4/06, 12/07 Page 2 of 8
14. After 2 minutes of chest compressions and ventilations STOP CPR If physician/pa/nurse practitioner not present to interpret ECG rhythm, press the yellow analyze button clear the patient while AED analyzes the rhythm. AED will prompt for defibrillation or state "No Shock Advised". If shock is advised AED will automatically charge to 300 joules. Repeat steps 12 & 13 above. 15. Continue with Automated External Defibrillation as described above until a physician/pa/nurse practitioner arrives and assumes control of the code. When physician/pa/nurse practitioner assumes command then take Lifepak 20 out of AED mode by opening the AED door = push the Grey manual door latch located at the bottom left of the door with your thumb and pull door open, or by pressing the "Energy Select" button if the door had already been opened. Defibrillator may now be used in manual (ACLS) mode and manual defibrillation may be performed on physician/pa/nurse practitioners order. 16. For manual defibrillation in ACLS (manual) mode, press "Energy Select" button to activate ability to select joules for defibrillation. Rotate the speed dial button to highlight desired joules, press speed dial button to select desired joules, press "Yellow Charge" button to charge LifePak 20. Follow step 12 above to defibrillate. 17. Repeat steps 14-16, above if further defibrillation is ordered by physician/pa/nurse practitioner. 18. Press CODE SUMMARY button at the end of code to print summary of events. Note: Immediately after the patient is taken off our LifePak 20 (when Patient transferred out of the area), Be sure to print 2 full code summary strips and staple one strip to the CPR record placed in patient's chart. Staple the second strip to the photocopy of the CPR record that is sent to Sylvester Performance Improvement Office. See code Blue policy & Procedure Code # 166 for details on paperwork distribution. NOTE: Be sure to turn the LifePak 20 OFF immediately after final Code Summary strip has completed printing. DO NOT leave the machine ON as it continues to record the event and will show on the patient s medical record. SPECIAL NOTE: After All Code Blue Tasks Are Complete And Patient Is Transferred, The CHARGE NURSE MUST Call Both Biomedical Engineering at (305-243-4025 or 786-586-4801) And The Education Department At (305-243-9192 or 786-299-0019) For Download Of Code Information From The LifePak 20 Defibrillator. The Patient Information Contained In the Memory may be lost after 24 to 48 hours so must be downloaded ASAP after the code. SUPERCEDES: 4/96, 6/99, 6/01, 4/06, 12/07 Page 3 of 8
B. Standard Hard Paddles Hands On" Defibrillation 1. Remove the "Quik Combo" Patient defibrillator cable from the front of the LifePak 20 Defibrillator by gently rotating the locking ring on the therapy cable in the direction of the white arrow (counterclockwise) until it stops. Gently pull out the cable. 2. Attach "Hands On" standard hard paddle cable by ensuring white arrow is facing upward and cable cord faces to the right. Gently push connector into receptacle until it snaps into place. 3. If other than 200 joules is desired, press Energy Select button and select the energy to be delivered as described in step 16 above. 4. Remove standard hard paddles from tray on top of LifePak 20 and apply defibrillation gel over entire paddle electrode surface. Never rub the two paddles metal surfaces together as damage to the metal surfaces will occur. 5. Place defibrillator paddles firmly on patient s chest. Standard Paddle Placement A. STERNUM paddle to the patient s right upper torso, lateral to the sternum and below the clavicle. B. APEX paddle lateral to the patient s left nipple in the midaxillary line, with the center of the paddle electrode in the midaxillary line, if possible. 6. Press CHARGE button on APEX paddle. 7. Prior to pushing the "RED Shock" buttons repeat mnemonic: "Oxygen clear, I'm Clear, You're Clear, Every Body Clear" visually check that no one is touching the patient or the bed and the 0 2 is clear. Call out "Shocking" and press both of the "RED Shock" buttons on the paddles simultaneously to defibrillate patient. If shock buttons are not pressed within 60 seconds, stored energy is internally removed. 8. Repeat steps 3 8, if further defibrillation is required as indicated by physician/practitioner. C. External Pacer 1. Press "Green On" button on LifePak 20. 2. Connect 3 ECG electrodes to ECG cable and apply electrodes to patient. 3. Select Lead I, II, or III to monitor. 4. Connect Quick-Combo electrode pads to LifePak 20 and attach to patient s chest. See page 1 #9 for Quik-Combo pad placement. SUPERCEDES: 4/96, 6/99, 6/01, 4/06, 12/07 Page 4 of 8
5. Press PACER ON button. Confirm the LED illuminates, indicating that the power is on. 6. Demand pacing message appears in the lower left corner of the monitor screen. 7. Observe the EKG rhythm on monitor screen, confirm that a triangle sense marker appears near the middle of each QRS complex. If sense markers do not appear or are displayed in the wrong location (for example, on the T-wave), select another lead. (It is normal for the sense marker location to vary slightly on each QRS complex.) 8. Select desired pacing rate by pressing the rate button rotate the speed dial to select desired rate. Push speed dial to set rate. Note: The rate button changes the rate in 10 pulse per minute (ppm) increments; the Speed Dial changes the rate in 5 ppm increments. 9. Activate pacing by pressing the current button then slowly rotate speed dial clockwise to increase current until electrical capture occurs. For each delivered pacing stimulus, the pacer indicator flashes off and a positive pace marker displays on the ECG waveform. Note: Increase current slowly to minimize patient discomfort. 10. Observe monitor screen for evidence of electrical pacing capture. Palpate the patients pulse, check blood pressure and compare the Sp02 pulse rate with the set pacing rate to assess for mechanical capture. Consider the use of sedation analgesia if patient is uncomfortable. Note: The current button changes the current in 10 ma increments; the Speed Dial changes the current in 5 ma increments. Use the Speed dial when patient is awake and can feel increment changes, to reduce patient discomfort. 11. To interrupt pacing and view the patient's intrinsic rhythm, press and hold the "Pause" button. This causes the pacer to pace at 25% of the set rate. Release the "Pause" button to resume pacing at the set rate. Avoid holding pause for extended length of time as patient's perfusion will decrease at lower pacing rate. 12. To stop pacing, reduce current to zero or press "Pacer" button. Note: Pacing will automatically stop when the defibrillator is charged or when the energy select button is pushed. SUPERCEDES: 4/96, 6/99, 6/01, 4/06, 12/07 Page 5 of 8
D. Synchronized Cardioversion 1. Press "Green On" button. 2. Place ECG and Quik-Combo electrodes on patient as previously described. 3. Select lead with optimum QRS complex amplitude. 4. Press SYNC button. Confirm that the sync LED blinks with each detected QRS complex. 5. Observe monitor screen. Confirm that triangle sense marker appears near the middle of each QRS complex. If the sense markers do not appear or are displayed in the wrong locations (For example on the T-wave), select another lead or reposition the ECG electrodes so SYNC markers occur only on the QRS complex. (It is normal for the sense marker location to vary slightly on each QRS complex.) 6. Press Energy Select button and rotate the speed dial button to highlight desired joules, press speed dial button to select desired joules then Press Yellow Charge button. 7. Shout Oxygen Clear, I m Clear, You're Clear, Everybody Clear when charging is complete and make sure all personnel are clear of patient and bed. 8. Press and HOLD Red Shock button(s) until discharge occurs with next detected QRS complex and then release "Red Shock" button(s). If shock button(s) are not pressed within 60 seconds, stored energy is internally removed. 9. Observe patient and monitor screen. If synchronized cardioversion needs to be reattempted, repeat steps 4 9. Note: When cardioverting you must hold the "Red Shock" button until the shock is delivered, the LifePak 20 will only deliver the shock at the appropriate time on the QRS complex to avoid the R on T phenomenon. E. Sp02 Monitoring Procedure 1. Power to the pulse oximeter is controlled by the defibrillator. When the Defibrillator is turned on; the oximeter turns on and performs a self-test that takes up to 10 seconds. 2. To conserve battery power, the pulse oximeter goes into sleep mode when not in use. Sleep mode is activated within 10 seconds of disconnecting the sensor. The oximeter will return to normal mode after detecting a sensor or a patient SUPERCEDES: 4/96, 6/99, 6/01, 4/06, 12/07 Page 6 of 8
signal. The oximeter performs the self test when it returns from sleep mode to active mode. During sleep mode, the screen does not display Sp02 information. 3. The pulse oximeter measures Sp02 levels between 1% and 100%. When Sp02 levels are between 70% and 100%, oximeter measurements are accurate from + 3 digits. Connect the Sp02 cable to the monitor. Attach the sensor to the Sp02 cable and the patient. Press "Green On" button. Observe the pulse bar for fluctuation. Amplitude of the pulse bar indicates relative signal strength. Adjust sensitivity, averaging time, and Sp02 volume as necessary. 4. The Sp02 waveform can be displayed on waveform channel 2 by selecting waveform channel 2 and then selecting Sp02 from the waveform menu. The Sp02 waveform automatically sizes itself to provide optimum waveform viewing. Note: For more information on Sp02 Volume, Sensitivity and Averaging Time please see Medtronic LifePak 20 Operating Instructions Manual, page 3-11. F. Documentation 1. Be sure to print 2 full code summary strips and attach one to the CPR record placed in patient's chart. Attach the second to the photocopy of the CPR record that is sent to Sylvester Performance Improvement Office. See code Blue policy & Procedure Code # 166 for details on paperwork distribution. 2. Document events of code on CPR record and progress note as needed. G. Daily LifePak 20 Defibrillator/Monitor User Test 1. Defibrillator/monitor user test must be performed at the beginning of each shift by assigned personnel. 2. Steps to perform Defibrillator/monitor test: Check Printer Strip for Successful 03:00am Self Test and unit was plugged into AC power. Unplug Defibrillator Before User Test. Press "Green On" Button. Do Not Push Analyze Open the AED door to convert LifePak 20 to ACLS (manual) mode and stop the analyze prompt. SUPERCEDES: 4/96, 6/99, 6/01, 4/06, 12/07 Page 7 of 8
Press Options Button. Rotate Speed DIAL To Highlight User Test. Push Speed Dial to Select. Rotate Speed DIAL To Highlight YES. Push Speed Dial to Select. Close The DOOR. Allow User Test to Run Wait For Test Strip To Say User Test Successful. Defibrillator Turns Self Off. Plug The Defibrillator Back Into AC Power. H. Biomedical Engineering Bi-Annual preventative maintenance (PM) tests 1. Biomedical Engineering will perform PM test on all LifePak 20 Defibrillator/Monitors every 6 months. Test and documentation to include verification of proper function of standard hands on hard paddles. REFERENCE: - Medtronic LifePak 20 Defibrillator/Monitor with ADAPTIV Biphasic Technology Operating Instructions Manual - AHA Guidelines 2005 - Sylvester Code Blue Policy # 166 SUPERCEDES: 4/96, 6/99, 6/01, 4/06, 12/07 Page 8 of 8