chapter 21 resuscitation how do we bring people back to life start off with the pathophysiology of a cardiac arrest what is it how does it happen and then we will learn how to fix the problem we auto the heart functions to pump blood throughout the body this is caused first by the electrical function causing the muscle to contract and then the actual muscles contracting to force the blood through the body what we're still forcing through the body is oxygenated blood without that oxygenated blood the heart doesn't have the ability to create its own energy to pump the blood so mechanical failures loss of the muscle tone loss of the muscle structure that could be from a acute coronary event that causes decreased blood flow to the coronary muscle in the form of a myocardial infarction could be chronic hypertension the heart just gives up because it pumps so hard loss of normal heart valve function so when we push blood out instead of going out it goes backwards in the system because the valves are dysfunctional could be some type of trauma that causes damage to the muscle of the heart and then we also have a lack of communication or lack of reception of the electrical activity in the heart called postal electrical activity or pea it means the electrical signals are going through the heart just like it should but the muscle is not recognizing those signals and responding to them so the electrical dysfunctions something in the pathway has gone wrong the sa node the av node the purkinje fibers bundle of his something in that system has caused a malfunction a systole is a complete malfunction there is no signal going through the heart anywhere other problems uh could be some type of dysrhythmia of malfunction in the conductivity system and the heart is not picking up the signal correctly or reacting to the signal correctly so it could be too slow if it's too slow then you don't have the cardiac output you need if it's too fast then you don't have the ability for the blood to pick up the oxygen in the lungs and it just keeps flowing around so you don't have that gas exchange occurring we have two ventricular problems that could result in the cardiac arrest one would be ventricular tachycardia that's where the ventricles take over and start beating over a hundred to like 150 200 times a minute this is way too fast for it to actually fill and contract and then we have v-fib where the muscle quivers with inside the heart these all lead to car sudden cardiac arrest where the heart is just a comes to a standstill v fib and v-tac these are the two that we can correct with an aed that's why aed's are so important in the community cardiac arrest it's an abrupt concept of dysrhythmia if this could be precipitated by some type of myocardial infarction or some type of the trauma could be blunt short uh blunt force trauma to the chest the condition called come commotion cortes this is where you see the shirts that youth baseball players wear that have a little strike pad in the center of the chest that is preventing this condition from happening if you get a a sudden blow to the center of the chest at just the right time it can cause your heart to go into sudden cardiac arrest the good thing of the why the reason why we have good survival from sudden cardiac arrest is because the heart just stops the oxygen levels are fairly normal when it starts so we can recommend hands-only cpr because your body still has oxygen in the blood we can get the heart restarted quickly by stopping the bad rhythm and letting it take over letting it go back to a normal rhythm so we've got lots of opportunities here because it's such a sudden occurrence the asphyxial cardiac arrest this is when the heart runs out of oxygen you have some type of cardiac or respiratory event that causes hypoxia the blood levels of oxygen drop and then you lose your ability to contract the heart muscle uh ventilations on this type of cardiac arrest are really important because we got to get that air air of oxygen going back into the heart muscle so these are the more less common types of cardiac arrest for adults with kids this is the most common type of cardiac arrest because they don't have heart disease which causes the sudden cardiac arrest they have more asphyxial cardiac arrest because they have restorative problems that deprive the heart of oxygen and it slows down and gets to the point of not beating anymore that's why ventilations are so important in kiddos and adults we can do the hands only agonal respirations agonal respirations occur as the body's trying to get that one or lat one or two last breaths in to try to restart everything uh the medulla sends out a signal to the respiratory muscles and says hey you better take a breath or we're gonna all gonna die here so you take these real deep gasping breasts they're not really functional uh they don't get oxygen into the lungs enough to cause a change in the condition but they provide a good they provide some last-ditch efforts to try to get something in but what we want to make sure is we're not confused by agonal respirations being real respirations so got a little video going to show you that kind of how it shows how this function works hi it's stephanie again angle respirations are not considered normal breathing the patient may be gasping or bulking diagonal respirations are assigned cardiac arrest and may occur in up to 40 cases diagonal breathing is caused as the brain becomes hypoxic which means that it's lacking oxygen the patient is not exchanging air well and requires aggressive reciprocation attempts it is important to recognize abnormal respirations when performing cpr and giving rescue breaths most lay persons do not know how to identify agonal respiration and may misinterpret them for normal breathing if the rescuer isn't sure about the respiratory effort they should assume the victim is not breathing and begin intervention ems is trained to recognize agonal respirations and they can assist rescuers in determining of normal breathing during this includes agonal respiration thank you for watching so that gives us an idea of what agonal respirations look like and how they kind of function within the body the effects of cardiac arrest the heart fails to pump so if it's not pumping you're not circulating blood you're not circulating oxygen you're not retrieving the nutrients and giving them to the end organs you're not getting the waste product removed from the body organs become damaged because of this change in the homeostasis eventually organs start to fail the kidneys are our first one that being without oxygen and without blood flow causes a serious problem if you don't fix this the patient will die so you can only go better from a cardiac arrest our goal is to get help to them as soon as possible and we're going to talk about the chain of survival and that's one of the goals of the chain of survival is getting the help there as quick as possible so that we can solve the problem and prevent cardiac death pediatric cardiac arrest as i mentioned before mainly due to asphyxia choking shock restorative problems kids just kind of slide down the hill when they're going into cardiac arrest they have a respiratory problem that decreases their breathing ability and the heart gradually slows down until it comes to a stop the way to fix it is start cpr and give them really good ventilations with lots of oxygen and you will you can bring things back to normal there so for your patient assessment what we want to do is two levels here we want to identify the cardiac arrest try to figure out what's wrong that caused it and then we need to be aware of what's going on around us to kind of get more clues as to what's going on with the patient in general so we've got a few few point pieces we got to put together really quick here so the primary assessment you find a patient that's unresponsive no breathing no pulse that is your true definition of cardiac arrest unresponsive no breathing no pulse you start cpr you need to get somebody on the chest as quick as possible within the first few seconds after you identify there's no pulse with kids infants we have the sudden unexpected infant death syndrome this is uh includes sids sudden infant death syndrome we really don't know what causes it there's a lot of coincidental uh common factors like most sids babies the parents uh the mother is over 35 the mother has a history of smoking the kids were placed in the bed face first but we really don't know what happens uh we do know that there's some some issues with bedding being too soft we do know his body position we do know there's some blocked airway issues but what we want to do is identify that there is a problem right away and start providing the treatment as quick as we can it's usually sleep apnea cardiac slow down they just quit breathing and go into cardiac arrest so the problem here is most of it happens during their sleep and the parents don't know it until the morning when they wake up and they find their kid is not is is deceased in the bed if you get to one of these do everything you can to support the parents there are times you may want to start cardiac resuscitation even if you're not sure the patient is viable if there is obvious rigor mortise dependent levity things that just tell you there is no chance of survival don't give the mom and dad extra hope go ahead and just call in to the physician advisor tell them what's going on and see if you can cease resuscitation right away get law enforcement involved get the corner involved get professional help involved call the the chaplain service if that's something you've got in your service offer to call family members whoever you can but biggest thing is now you've got three patients because you've got the child that was no longer a resuscitable and now you've got two parents that you've got to support so one thing we're doing is trying to improve our cardiac arrest survival in general so we've got the chain of survival five things we talk about in our book here is recognition and activation the emergency response system knowing there's an emergency immediate high quality cpr rapid defibrillation basic and advanced ems and then advanced life support and post arrest care once we get them back now we've got to keep them back and get them back to a normal lifestyle big thing we're gonna go on everything in ems is making sure we have good teamwork and good coordination so we're gonna work together in groups to try to figure out how to get this coordination and teamwork for cardiac arrest the first link in the chain of survival is recognition and activation the ems system we want to get the the call into 911 to get ems and route and then we want to provide that person some care before they get there so we're training people to recognize cardiac arrest don't just step over the person actually do something reach down check a pulse shake them and shout call 9-1-1 get the help on the way and then start resuscitation most of our dispatchers will give you instructions over the phone on how to do cpr they walk you through the whole process one thing we need to do is emts and ems in general is work on training the general public in the youtube channel you can go to the supplements for this section and you'll find a video of an event that we did at sky sock stadium a few years ago with colorado springs fire department and many other sponsors where we trained 4 200 people in cpr that night that's how you get more people trained in cpr there's also a system called pulsepoint it's sponsored by zol medical that you have an app on your phone and if the area has a cardiac arrest and you're within 500 feet of that cardiac arrest it alerts you on your phone and you have the option to go help so we're getting people who are trained to go to the cardiac arrest there's been twice that i've been in a restaurant where there was a cardiac arrest and i didn't realize until the ems showed up and i could have been over there doing something to help out so it's it's important to get people that are trained in the right place and to train those that don't usually need this re uh this type of care we want high quality cpr push hard and fast in the center of the chest new slogan for cpr is harder deeper faster we want to push at least 100 times a minute 100 120 times a minute by doing this we're pushing the blood from the chest into the cerebral area and into the heart muscle the more oxygen we get into the brain and the heart muscle the better the chance of survival hand placement is very important we teach people the lower third of the patient's sternum used to be go to the xiphoid process two finger widths used to be nipple line lower third make it simple keep it as simple as possible knowing how many hands to put on the chest you need to have enough contact with the chest that you can push it in and two to two and a half inches or one third the depth of the chest if it's a adult maybe two hands if it's a child maybe one hand if it's a big child two hands if you're a strong person a little adult one hand it's going to be up to you to figure out how much force you need to push on the chest if it's an infant we're using two fingers if it's too rescuer then we're going to use two thumbs kind of putting your hands around the chest and squeezing the chest in at the same time so there's some different ways to do it we'll practice these in class but it's important to get everybody on on the same page and making sure all our all our community knows cpr the depth is at least two inches and it's key to let the chest rise after you're done with the compression you want half the time on the downstroke half the time in the upstroke so in on the infants and childhood children because it's harder to judge the depth we're just going one third hand should overlap with locking fingers there are no cpr police so if you don't lock your fingers you're okay uh let for your comfort your elbows should be locked so you can be using your shoulders to push up and down you shouldn't be using your arm muscles to push your waist should be bending not your elbows so the other thing with cpr is we want to switch out every two minutes if at all possible so the aeds will shock every two minutes so when they are attached and they say shocking that's a time to switch out we had some cardiac monitors at the fire department when i was there that would measure the quality of cpr and we found almost all the time you had a decrease of at least or the quality cpr after about two minutes so it was important to get that two minutes switch out on all your cardiac arrest shows you the kind of positioning we look at the fulcrum is at the hips so you're using the hips to bend and you're going up and down straight up and down on the chest good cpr saves lives compression rate 100 to 120 a minute you can use different sound songs to sing uh staying alive is the one we hear out all the time another one bites of dust although it's not one you want to sing out loud it does have the same time frame and the imperial march from star wars has about the right time so those are some good ones uh for you to do too slow you don't get a good compression good good circulation of the brain and we really don't want uh we we want to do that and too fast you don't have the time to refill so you're looking for 100 to 120. we want a compression fraction of at least 90 so that means ten percent of the time you're off the chest so to to to cut so you don't have to do calculations no more than ten seconds off the chest if you're charging to defibrillate you can do compressions if you're analyzing you shouldn't do compressions if you're shocking you shouldn't do compressions if you're doing ventilations you shouldn't do compressions every other time you should be pressing on the heart the chest pre-plan your changeouts have somebody ready to go and step in this is where you need somebody to step back and take charge and manage the cardiac arrest they need to be the conductor and tell people who to do what practice as a team look for who does what this is one of the parts of the american heart training video that you should have got to watch when you were doing your cpr class rescue breathing if you're doing two rescuer cpr or one rescuer cpr doesn't matter you need to do thirty to two on adults if it's pediatric and you're doing two rescuer it's 15 to two the reason we go to fif less compressions to ventilation ratio is because they need more oxygen like we discussed we also have options for mechanical cpr devices these are a very good tool it's highly recommended by the american heart association but the cost is around fifteen thousand dollars so you're not going to get these at every service because of the the the expense that it takes in the supplemental chapter or module 2 videos you have the videos for these different devices highly encourage you to go look at those one of the the ones you see around our local community is the lucas cpr device you put the device on it has a strap that goes around the patient secures a plunger in the center of the chest and it uses compressed air to make the plunger go up and down very efficient very complete compressions the other option is the zoll auto pulse it's a backboard with a strap that goes around and it's squeezes down on the chest and has circumferential compressions you can defibrillate with these on you can ventilate with these on some of them have built-in ventilation some of them tell you when to ventilate so know your system rapid defibrillation when the heart goes into that sudden cardiac arrest which is about eighty to ninety percent of the time they go into the fab or vtac what the aed does is apply electricity to the bad cardiac rhythm stops that rhythm long enough that hopefully the sa node can take over and create a normal heart rhythm again so we want to get aeds out there everybody trained in them or at least aware of them so they can grab them use them at any time they have two devices built into them one is the little mini computerized paramedic that looks at the rhythm and tells you if it's v favorite v-tac if it's b-fib or v-tac the defibrillator takes over and sends the electrical current through the patient if it does not recognize v-fib or v-tac it will not arm the defibrillator so it will not shock somebody that does not need it like we said it hits the v5 vtax most important button on any defibrillator no matter what the brand is the on button it's the big green button in the upper corner here some of them are so simple you just open the lid and it turns on once you turn it on follow the instructions it will tell you what's needed to be done we have two types of eight ads we have a monophasic aed which sends a signal from the right shoulder to the left our lower chest it's one complete shot biphasic will actually send it from both pads at the same time and meet in the middle so with this technology you're sending half the energy that you would for the monophasic the other advance we have on these biphasic defibrillators is we have impedance compensation it measures the resistance between the two pads and adjust the amount of shock given to the size of the patient this allows it to give just enough shock to stop the heart without causing extra damage so it goes down fairly small but it still does not go down to a pediatric dose for a pediatric patient you have separate defibrillator pads that have a shock attenuator built into the pads and it will to reduce the shock down even further so that you don't over defibrillate a pediatric patient if you do not have that pediatric adapter you can use the adult size on a pediatric patient if they need to be shocked they need to be shocked so it's okay to shock them a little bit too much because they can fix the damage later if they live link four the basic life support we want to get trained ems providers quickly there so that they can manage the situation provide good compressions and good defibrillation once we get the advanced life support there the aemts and paramedics they can give medications to stabilize the heart and to fix the problems that cause the cardiac arrest and get the patient to the hospital so that we can resuscitate them back fully what we want to do when we're there on scene is we establish this triangle life you've got one person doing compressions one hooking up the aed and one maintaining the airway and then you have the third the fourth person being the uh leader kind of guiding what's going on making sure that everybody's on the same page and then they can also be aware of the surroundings what is the family doing what can i get if what kind of information can i get from the family and try to figure out what may cause the cardiac arrest which will help you understand how to best resuscitate the person the advanced life support and post arrest care once we get return of circulation our return of spontaneous circulation our rosc rosk when the heart starts beating on its own the patient starts to breathe that is when we do some high fives real quick and then start stabilizing our patient make sure they have good oxygen make sure they have a secured airway and start moving forward we need to get into the hospital so they can do whatever interventions necessary to fix what caused the cardiac arrest maintain normal vitals call als you need them there get a 12 lead akg and maintain the airway when we're managing cardiac arrest you want to know that know when to do see one person's cpr and when to do the team based based on your resources you always use precautions you don't do mouth-to-mouth anymore you make sure you get the defibrillator hooked up uh call als get oxygen oxygen is really good for your cardiac arrest patients know when to move the patients no have a plan on when you move them so that you're not stopping cpr any longer than necessary maintain the airway add adjuncts if needed and then the important thing is to interview the bystanders and family members understand what happened why how did you get to this point where you got the patient in cardiac arrest have a coordinated resuscitation team so what this means is everybody works together everybody has a plan you know who's going to switch around cpr make sure you have the right people there als and bls you can ha the survival rate goes up when you have a mixture of als and bls als has a very specific role in cardiac arrest and bls has a very specific role you need to keep the blood flowing while they solve the problem that caused the cardiac arrest work as a team have a team leader somebody needs to be in charge make sure everything's done in order the best you can now have a plan when you get there and then like every good plan it needs to be adjust adjusted as as things change so identify the cardiac arrest patient that's as simple as checking a pulse checking breathing determining you have neither and then you've got a cardiac arrest patient start compressions get your team organized call for extra resources work on your patient where they lay remember the more you move them the more time you have before you're doing cpr get the aed hooked up as you're doing compressions you don't have to stop cpr took an aed up you can put the pads around where they are if you're alone hook up the aed then start the compressions if you're with a child we're going to do cpr first this is again because they have respiratory problems that cause the cardiac arrest not cardiac problems aeds fix cardiac problems so if we can get the heart moving with oxygen and then to get the aed there we might have something to shock showing good compressions and getting ready to hook up the pads notice it's a clean bare dry chest very important for hooking the aed up everything comes off the chest is bare if there's hair shave it we have 80 or razors in our aed boxes biggest thing and it's a test question on a few places turn on the aed that's the most important thing you can do follow the instructions on the pads they have pictures they show you where to put them they're idiot proof any cop could figure out how to use these remove the clothing of your patient the jewelry medication patches if you are removing medication patches you really should have your gloves on because whatever's on that patch can be absorbed so if you're getting a nitro patch you get a dose of nitro and get your headache if you get a estrogen patch you get your dose of estrogen and you get moody trim the extra hair shave the chest if you have to wipe away the sweats and and blood liquids all the blood if the patient's in water get them out of the water stop cpr and analyze the machine will tell you stop cpr analyzing as soon as it's done it'll say charging you can do cpr while it charges you only have to be off the chest while it's analyzing and uh and while it's shocking when it gets ready to shock it'll tell you it's ready and then you have to push the button to shock before you push the button to shock you need to make sure that you're clear your partner's clear and everybody else is clear from the body because if you shock while they're touching it will shock their heart and stop their heart too so it's very important to get that in in in your habit of i'm clear you're clear everybody's clear before you shock push the big red flashing button or orange depending on the manufacturer but you need to push it and make sure they're clear or make sure they're clear and then push as soon as the shock is done you start cpr you do not have to check a pulse if you shock the heart it is not going to jump right back up and start running it's going to wait a second before the heart starts moving again so we're going to do two minutes of cpr and give it time to get a rhythm build up before we check again if you ever seen anybody get tased they don't just get up and run what we've done is tase the heart to shock the ventricles to make them stop and lets the normal part of the heart take over the sa node and so we're going to do cpr while it recovers and starts getting the back in its normal rhythm here's the integration the aed you get the patient that's haptic pulseless one person does cpr the second person does the aed turn it on bear and attach clear the patient shock them or no shock advised go back to doing cpr very important to continuously do cpr on your patient you breathe once every 30 compressions unless as a child then it's every 15 compressions you have two good breaths if you get an advanced airway if you drop a i gel in there you can do one breath every six seconds it doesn't matter on the compression rate so you want to have good quality teamwork good corrective uh comments you do you don't have to hold back let somebody do bad cpr say hey you're doing good push it faster push deeper check a pulse while they're doing cpr you should feel a pulse remember that's what we're trying to do is create a pulsation so you should feel a pulse while they're doing compressions if you have the resources available start asking the medical history what happened look for a secondary assessment to be done get the physical findings try to find out what's going on around the patient do a little investigating here to figure out what caused cardiac arrest question continually comes up should family members be allowed to watch the resuscitation you need to make some decisions at the time of but just understand that family members know what you're doing and understand the effort you're putting into saving their loved one if they're allowed to watch a friend of mine did cpr on her husband he was i think 32 and then she was allowed to watch the rest of his resuscitation she knows that everything possible was done to try to save him but if they would have been pushed out she would have never known what was done so it's up to you to make those decisions if you see that the family members are getting upset or they're becoming extremely emotional or becoming disruptive to the scene you can ask them if they can leave but don't just let them take off on their own assign somebody to go with them i always like to be the second crew in on a cardiac arrest because i can assign my partner to go help with the cardiac arrest and i can look for the family and kind of be with them and explain what's going on they can understand what we're doing to try to save their loved one and that gave them a little comfort you do not jump in there and say it looks like he's moving towards a light or do you have a donor card we need to know that right now you give them encouraging information but be honest with them say we're doing everything possible if it's successful you've got to shift to post arrest care rapid transport maintain airway and call als we need to get them to the advanced care levels as quick as possible check pulse every 30 seconds i think it's kind of long if i've got brought them back from the dead i want to make sure they've still maintain a pulse i'm going to probably assign somebody to keep their finger on their pulse and let me know if something changes if no pulse is found we start back at the beginning start with your abcs start cpr if they're in a shockable rhythm shock them right now the heart's still good because they had a pulse and we just caught them again and then follow the every two minutes for cpr and shocking you can stop doing resuscitation if you have a couple things happen if the patient asks you to stop you can stop where you are they say ouch that hurts that's perfectly fine to stop you get the spontaneous respirations start doing a back valve mask or if you get spontaneous circulation if you get spontaneous circulation and breathing you just support them and make sure they're taken care of if somebody else of equal or greater training takes over you can stop you turn the care over to person with higher level of training that's what we want uh you're too exhausted to continue you've been doing cpr for an hour and you just physically cannot go on anymore it is perfectly fine to stop the resuscitation process certain systems have uh plans in place if you get a cardiac arrest and you've done 20 minutes of care with shocks and you've got to the point of no shock advised for a set number of times you can call the physician on the medical control and ask for permission to stop resuscitation the goal here is to get return to circulation if we don't get that in the first 20 30 minutes we're not going to get it no matter what we do with the patient so we're going to reduce our risk of injury and not transport the patient to a hospital if success resuscitation is not successful you're gonna have to let the family know don't sugarcoat it don't add things that you don't know basic information is we've done a lot of things to try to revive your loved one unfortunately they they did not respond to anything we did and we've had a conversation with our physician and they feel that it's best at this time to just go ahead and cease resuscitation we're so sorry for your loss you can let the family in with the deceased now because if it's outside of a hospital there's some law enforcement issues they've got to work through so i would always ask the law enforcement at scene if they can be around the patient if you suspect anything is strange kind of keep them away until law enforcement gets there you need to be patient with them ask if they have a some type of spiritual care person they would like you to call or if you can call your fire department or police or ambulance chaplain to come help just be honest with them i've had to tell way too many people that their loved one is deceased being in a small town you end up knowing a lot of them or have connections so uh it's never easy but it's it's it's relieving to know that you're the one that gave them that last opportunity to be with their friend their family their loved one so it's it's part of the job and we we deal with special consideration if you get there and the bystanders have 80s on your patient let them go ahead and finish around and when the aed shocks then you take over maybe you leave it connected to their aed maybe you hook up yours depends on what you have going on some aeds we take to the hospital so we can keep an eye on what's going on they can download the data most of them we just leave at the scene if you're in the ambulance you should try to stop the ambulance if you're doing defibrillation with an aed it can pick up the road noise as interference and it will not shock so you want to stop the ambulance and turn off the engine so you can analyze once you do that hopefully you've asked for als because they do not have to stop the ambulance to shock it's just your aeds your automated external infigurators that get confused if you have a patient that has been in cold water or they've been outside in the cold we're going to have some special challenges with resuscitation and just so you know every body of water in colorado or at least our area is considered cold water drowning even in the summertime it's cool enough that we'll get hypothermia on our patients so we're going to resuscitate them until we warm them up if their temp is below 86 degrees fahrenheit the core temp you're not going to get a good defibrillation the heart will not respond to shocking so what we want to do is quality cpr and we're going to transport them to the facility most appropriate and shock as we can but you're going to keep going a friend or one of my emt students was telling me that his brother had been under the ice for 60 minutes before they found him brought him out and resuscitated him and he had no deficits at all he even brought the articles in from the newspaper to to show us that how long it had been and it was 60 minutes he was under the ice so there is documented cases where people have survived from being underwater and in a cold environment because it chills the brain and puts them in the hibernation basically and then we can bring them back to life treat them just as any other cardiac arrest good quality cpr airway management and then make sure you're being careful with the wet patients with defibrillation there was a rescue show back in the 90s where they would defibrillate in the water and that's not the safest option electricity will go through the water and cause a shock to you too so get them out of the water onto the shore onto the boat onto a backboard and you're fine if you're on ice it doesn't connect to the electricity very good so you're safe there and if you're just on a wet surface like wet grass you'll be fine too it's where you're in standing water that you get the conductivity do not defibrillate a soaking wet patient you're going to dry them off the pads won't stick unless you do remove medication burning they don't burn implants and surgeries if a patient has an implanted defibrillator and they're in cardiac arrest you've just proved to yourself that the defibrillator is not working if it was working they wouldn't be in cardiac arrest so what we want to do is attach the pads to the patient we do not put the pads directly over the device underneath the skin it looks about the size of a skull can underneath the skin so it looks like a the back pocket of a cowboy and so you just move it to the side just cut in the same area but not sitting directly on top of it and let the machine go just like normal you may see pacemakers could be implanted defibrillators we're going to talk about the ventricular assist devices these are they pull the blood out into a pump on the outside and bypass the left ventricle and then push the blood back into the aorta you do not have to defibrillate these you do not have to do anything if they've got that left ventricular assist device then that is their their heart so the only way they would go into cardiac arrest is that their battery dies and there's a hand crank on it so you have to crank it i think 60 times a minute and have to look look at that or read the instructions when you get there so as with always if you have questions stories ideas things you want to discuss bringing the class happy to have a chat with you so have a great night thanks guys