Self-adhesive pads in defibrillation or cardioversion: risks due to unfamiliarity and recommendations

During cardiopulmonary resuscitation (CPR), defibrillation, or cardioversion, the use of self-adhesive pads instead of conventional paddles has gradually become common. In particular, it was recommended during the COVID-19 pandemic, as it allows defibrillation or cardioversion to be performed without close contact between the rescuer and patient.[1,2] Self-adhesive pads can minimize the downtime of chest compressions before and after defibrillation and protect the patient from electric arc formation, skin burns, and fire. Once the pads are attached, electrocardiographic rhythm analysis, defibrillation, synchronous cardioversion, and cardiovascular support are all possible. Unlike paddles, self-adhesive pads can save time because the application of conductive jelly, repeated positioning, and application of 10–12 kg of pressure on the chest are not needed. The European Resuscitation Council (ERC) Guidelines 2021 state that the use of self-adhesive pads is recommended in advanced cardiovascular life support (ACLS).[3] Nevertheless, some medical staff still tend to prefer the use of conventional paddles instead of self-adhesive pads in hospitals.

Insufficient experience with new medical devices can cause adverse events during medical procedures. Herein, I describe a case of accidental electric shock accident to a junior member of the medical staff while using self-adhesive pads during ACLS. This case study aims to improve safety by adding an option to the current electric shock protocol for medical staff who are unfamiliar with self-adhesive pads.

CASE

A man in his 40s was transferred from a local hospital. According to the paramedic who transferred the patient, ventricular fibrillation occurred during ambulance transfer, and when monitoring the patient’s vital signs, no pulse or blood pressure was detected; thus, CPR was performed in the vehicle using an automated external defibrillator (AED) and self-adhesive pads. After arrival at our hospital, there was no return of spontaneous circulation (ROSC); thus, ACLS was initiated. The AED was removed, but we kept the attached self-adhesive pads for connection to our defibrillator (Nihon Kohden Cardiolife TEC-5631, Japan). Cardiac massage and endotracheal intubation were performed, and 1 mg of epinephrine was administered intravenously every 3 min. As ventricular fibrillation persisted during ACLS, defibrillation was performed three times by the junior medical staff, with 200 J shocks from a biphasic defibrillator, and the ROSC ensued. The patient was admitted to the intensive care unit and put on a ventilator. As shown in Figure 1, a total of five staff members participated in ACLS (Figure 1). One person was responsible for the airway above the head, and two stood on the left or right side of the patient’s chest, applying chest compression on the left side and defibrillator on the right side (staff members on the left or right side alternated roles every 2 min). The other two persons stood on each side of the patient’s legs, with one administering intravenous drugs on the left and the team leader on the right. They kept a safe distance from the patient, only approaching to perform direct checks or to administer medication every 2–3 min, keeping their risk relatively low. Although the other three staff members were relatively closer, moving away from the patient is safer for both airway and compression personnel, who briefly halt their duties during shock delivery. However, until the last button is pressed, the defibrillator operator—who is the closest to the patient—faces the greatest risk.

Figure 1.

Member’s tasks and positions during advanced cardiovascular life support. Airway: insert airways and provide bag-mask ventilation; AED monitor/defibrillator: check the monitor and defibrillate, alternate with the compressor every 2 min; compressor: chest compression; the team leader coordinates all aspects of advanced cardiovascular life support; medication nurses initiate intravenous or intraosseous access and administer the medications.

In our case, a shock accident occurred to a junior member of the medical staff who was standing on the right side of the patient’s chest. He used his left hand to press the shock button of the defibrillator, and his right hand was free. During the third shock, his right hand momentarily touched the patient’s right arm, and he received a shock. In accordance with the existing ACLS protocol, he instructed and confirmed loudly that all team members, including himself, secure a safe distance from the patient and bedside. However, in the process of pressing the shock button, his visual focus temporarily shifted away from the patient’s body, causing a momentary mistake and a resultant contact accident.

The member of staff, a man in his 20s, did not lose consciousness but showed presyncope symptoms, such as severe dizziness and generalized weakness. He was hospitalized and observed, with bed rest, blood tests, and fluid therapy. He had no previous history of arrhythmia or underlying disease. After the incident, a first-degree atrioventricular block with a PR interval of 212 ms was confirmed on an electrocardiogram (ECG). The cardiac enzyme level was normal, but the creatine phosphokinase level was elevated to 187 U/L. After approximately one hour of treatment, the symptoms improved, and he was discharged. He experienced intermittent, stabbing chest pain lasting < 5 min for approximately two days after discharge, without any further pain thereafter. After six months, follow-up ECG was performed, and the atrioventricular block had disappeared.

DISCUSSION

Despite the multiple advantages of self-adhesive pads, conventional paddles are still widely used during defibrillation or cardioversion. The reason has been studied in 27 European countries within the realm of the ERC: economic reasons and the familiarity of medical personnel with traditional methods were found to be the main factors responsible for this preference.[4] Because self-adhesive pads are disposable, they are expensive to use. Since each country and hospital has different budgets, it has not been deemed appropriate to impose the universal use of pads. However, using only the traditional paddle prevents doctors from becoming familiar with the use of self-adhesive pads and can result in accidents. The rate of electric shock accidents was 1 per 1,700 for paramedics and 1 per 1,000 for emergency medical staff. However, the actual accident rate is estimated to be higher because the person concerned is reluctant to disclose it.[5] Electric shock accidents are known to cause burns, tingling sensations, rhabdomyolysis, hyperkalemia, acute renal failure, myocardial necrosis, ventricular fibrillation, or other less serious arrhythmias, depending on the degree of damage.[6-9]

Insufficient experience with new medical devices can cause accidents during medical procedures.[10,11] During defibrillation or cardioversion using a paddle, the rescuer’s hands and field of vision naturally point toward the patient’s body. This is because the rescuer must apply the pressure directly to the chest, and the shock button is also located on the paddle on some models. However, when using self-adhesive pads, the shock button is located on the defibrillator and not on the pads. Hence, when the button is pressed, the focus of vision temporarily moves away from the patient’s body. At this time, if the hand not pressing the button is close to the patient, the risk of contact with the patient increases. This unattended hand placed close to the patient is called the “resting hand” (Figure 2).

Figure 2.

Comparison of the field of vision between paddles and self-adhesive pads. A: paddles; B: self-adhesive pads. Rescuer’s field of vision: yellow fluorescent display; resting hand: a hand placed close to the patient.

When a rescuer unfamiliar with self-adhesive pads uses them to perform ACLS, the shock button should be pressed with the “resting hand.” This involves using the right hand if performing defibrillation from the patient’s right side or the left hand if performing defibrillation from the patient’s left side (Figure 3). We believe that adding this option to the current ACLS protocol would ensure improved safety for medical staff when using self-adhesive pads.

Figure 3.

Recommended guideline for defibrillation using self-adhesive pads. Press the shock button with the hand close to the patient. A: when a rescuer is on the patient’s right side; B: when a rescuer is on the patient’s left side.