Cardiac Arrest1

8/13/2019 Cardiac Arrest1

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Cardiac Arrest


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Cardiac arrest, also known as

cardiopulmonary arrest or circulatoryarrest, is the cessation of normal

circulation of the blood due to failure

of the heart to contract effectively.

Medical personnel may refer to an

unexpected cardiac arrest as a suddencardiac arrest (SCA).
http://en.wikipedia.org/wiki/Circulatory_systemhttp://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Hearthttp://en.wikipedia.org/wiki/Hearthttp://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Circulatory_system


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Arrested blood circulationprevents delivery of

oxygento the body. Lack of oxygen to the brain

causes loss of consciousness, which then results in

abnormal or absent breathing.

Brain injury is likely to happen if cardiac arrest goes

untreated for more than five minutes. For the best

chance of survival and neurological recovery,immediate and decisive treatment is imperative
http://en.wikipedia.org/wiki/Circulatory_systemhttp://en.wikipedia.org/wiki/Oxygenhttp://en.wikipedia.org/wiki/Unconsciousnesshttp://en.wikipedia.org/wiki/Respiratory_arresthttp://en.wikipedia.org/wiki/Respiratory_arresthttp://en.wikipedia.org/wiki/Unconsciousnesshttp://en.wikipedia.org/wiki/Oxygenhttp://en.wikipedia.org/wiki/Circulatory_system


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Classification

Clinicians classify cardiac arrest into "shockable" versus

"nonshockable", as determined by the ECGrhythm.

This refers to whether a particular class of cardiac

dysrhythmiais treatable using defibrillation.

The two "shockable" rhythms are ventricular fibrillation

and pulseless ventricular tachycardiawhile the two

"nonshockable" rhythms are asystoleand pulselesselectrical activity.[8]
http://en.wikipedia.org/wiki/Electrocardiogramhttp://en.wikipedia.org/wiki/Cardiac_dysrhythmiahttp://en.wikipedia.org/wiki/Cardiac_dysrhythmiahttp://en.wikipedia.org/wiki/Defibrillationhttp://en.wikipedia.org/wiki/Ventricular_fibrillationhttp://en.wikipedia.org/wiki/Pulseless_ventricular_tachycardiahttp://en.wikipedia.org/wiki/Asystolehttp://en.wikipedia.org/wiki/Pulseless_electrical_activityhttp://en.wikipedia.org/wiki/Pulseless_electrical_activityhttp://d/Cardiac%20arrest%20-%20Wikipedia,%20the%20free%20encyclopedia.htmhttp://d/Cardiac%20arrest%20-%20Wikipedia,%20the%20free%20encyclopedia.htmhttp://en.wikipedia.org/wiki/Pulseless_electrical_activityhttp://en.wikipedia.org/wiki/Pulseless_electrical_activityhttp://en.wikipedia.org/wiki/Pulseless_electrical_activityhttp://en.wikipedia.org/wiki/Asystolehttp://en.wikipedia.org/wiki/Pulseless_ventricular_tachycardiahttp://en.wikipedia.org/wiki/Pulseless_ventricular_tachycardiahttp://en.wikipedia.org/wiki/Pulseless_ventricular_tachycardiahttp://en.wikipedia.org/wiki/Ventricular_fibrillationhttp://en.wikipedia.org/wiki/Defibrillationhttp://en.wikipedia.org/wiki/Cardiac_dysrhythmiahttp://en.wikipedia.org/wiki/Cardiac_dysrhythmiahttp://en.wikipedia.org/wiki/Electrocardiogram


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Signs and symptoms

Cardiac arrest is an abrupt cessation of pump functionin the heart (as evidenced by the absence of a palpablepulse).

However, due to inadequate cerebral perfusion, thepatient will be unconsciousand will have stopped

breathing.

The main diagnostic criterion to diagnose a cardiacarrest (as opposed to respiratory arrestwhich sharesmany of the same features) is lack of circulation;

however, there are a number of ways of determiningthis. Near death experiencesare reported by 10-20% ofpeople who survived cardiac arrest.
http://en.wikipedia.org/wiki/Cerebral_circulationhttp://en.wikipedia.org/wiki/Unconsciousnesshttp://en.wikipedia.org/wiki/Breathhttp://en.wikipedia.org/wiki/Respiratory_arresthttp://en.wikipedia.org/wiki/Circulatory_systemhttp://en.wikipedia.org/wiki/Near_death_experienceshttp://en.wikipedia.org/wiki/Near_death_experienceshttp://en.wikipedia.org/wiki/Circulatory_systemhttp://en.wikipedia.org/wiki/Respiratory_arresthttp://en.wikipedia.org/wiki/Breathhttp://en.wikipedia.org/wiki/Unconsciousnesshttp://en.wikipedia.org/wiki/Cerebral_circulation


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Causes

Coronary heart disease is the leading cause of sudden cardiac arrest.Many other cardiac and non-cardiac conditions also increase one's risk.

Coronary heart disease : Approximately 6070% of SCD is related tocoronary heart disease.

Non-ischemic heart disease , including : cardiomyopathy, cardiacrhythm disturbances, hypertensive heart disease,congestive heartfailure. long QT syndrome

Non-cardiac : SCDs is unrelated to heart problems in 35% of cases.The most common non-cardiac causes: trauma, non-trauma relatedbleeding (such as gastrointestinal bleeding, aortic rupture, andintracranial

hemorrhage), overdose, drowningand pulmonaryembolism.
http://en.wikipedia.org/wiki/Coronary_heart_diseasehttp://en.wikipedia.org/wiki/Cardiomyopathyhttp://en.wikipedia.org/wiki/Cardiac_dysrhythmiahttp://en.wikipedia.org/wiki/Cardiac_dysrhythmiahttp://en.wikipedia.org/wiki/Hypertensive_heart_diseasehttp://en.wikipedia.org/wiki/Congestive_heart_failurehttp://en.wikipedia.org/wiki/Congestive_heart_failurehttp://en.wikipedia.org/wiki/Physical_traumahttp://en.wikipedia.org/wiki/Intracranial_hemorrhagehttp://en.wikipedia.org/wiki/Intracranial_hemorrhagehttp://en.wikipedia.org/wiki/Gastrointestinal_bleedinghttp://en.wikipedia.org/wiki/Overdosehttp://en.wikipedia.org/wiki/Gastrointestinal_bleedinghttp://en.wikipedia.org/wiki/Drowninghttp://en.wikipedia.org/wiki/Drowninghttp://en.wikipedia.org/wiki/Drowninghttp://en.wikipedia.org/wiki/Aortic_rupturehttp://en.wikipedia.org/wiki/Pulmonary_embolismhttp://en.wikipedia.org/wiki/Pulmonary_embolismhttp://en.wikipedia.org/wiki/Intracranial_hemorrhagehttp://en.wikipedia.org/wiki/Intracranial_hemorrhagehttp://en.wikipedia.org/wiki/Overdosehttp://en.wikipedia.org/wiki/Drowninghttp://en.wikipedia.org/wiki/Pulmonary_embolismhttp://en.wikipedia.org/wiki/Pulmonary_embolismhttp://en.wikipedia.org/wiki/Pulmonary_embolismhttp://en.wikipedia.org/wiki/Pulmonary_embolismhttp://en.wikipedia.org/wiki/Drowninghttp://en.wikipedia.org/wiki/Overdosehttp://en.wikipedia.org/wiki/Intracranial_hemorrhagehttp://en.wikipedia.org/wiki/Aortic_rupturehttp://en.wikipedia.org/wiki/Gastrointestinal_bleedinghttp://en.wikipedia.org/wiki/Physical_traumahttp://en.wikipedia.org/wiki/Congestive_heart_failurehttp://en.wikipedia.org/wiki/Congestive_heart_failurehttp://en.wikipedia.org/wiki/Hypertensive_heart_diseasehttp://en.wikipedia.org/wiki/Cardiac_dysrhythmiahttp://en.wikipedia.org/wiki/Cardiac_dysrhythmiahttp://en.wikipedia.org/wiki/Cardiomyopathyhttp://en.wikipedia.org/wiki/Coronary_heart_disease


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Causes

"Hs and Ts" is the name for a mnemonic used to aid in remembering the possible treatableOr reversible causes of cardiac arrest.

Hypovolemia- A lack of blood volume

Hypoxia- A lack of oxygen

Hydrogenions (Acidosis) - An abnormal pH in the body

Hyperkalemiaor Hypokalemia- Both excess and inadequate potassium can be life-

threatening.

Hypothermia- A low core body temperature

Hypoglycemiaor Hyperglycemia- Low or high blood glucose

Tabletsor Toxins Cardiac Tamponade- Fluid building around the heart

Tension pneumothorax- A collapsed lung

Thrombosis(Myocardial infarction) - Heart attack

Thromboembolism(Pulmonary embolism) - A blood clot in the lung

Traumatic cardiac arrest
http://en.wikipedia.org/wiki/Hypovolemiahttp://en.wikipedia.org/wiki/Hypovolemiahttp://en.wikipedia.org/wiki/Hypoxia_(medical)http://en.wikipedia.org/wiki/Hypoxia_(medical)http://en.wikipedia.org/wiki/Oxygenhttp://en.wikipedia.org/wiki/Hydrogenhttp://en.wikipedia.org/wiki/Hydrogenhttp://en.wikipedia.org/wiki/Acidosishttp://en.wikipedia.org/wiki/Hyperkalemiahttp://en.wikipedia.org/wiki/Hyperkalemiahttp://en.wikipedia.org/wiki/Hypokalemiahttp://en.wikipedia.org/wiki/Hypokalemiahttp://en.wikipedia.org/wiki/Hypothermiahttp://en.wikipedia.org/wiki/Hypothermiahttp://en.wikipedia.org/wiki/Body_temperaturehttp://en.wikipedia.org/wiki/Hypoglycemiahttp://en.wikipedia.org/wiki/Hypoglycemiahttp://en.wikipedia.org/wiki/Hyperglycemiahttp://en.wikipedia.org/wiki/Hyperglycemiahttp://en.wikipedia.org/wiki/Tablet_(pharmacy)http://en.wikipedia.org/wiki/Tablet_(pharmacy)http://en.wikipedia.org/wiki/Toxinshttp://en.wikipedia.org/wiki/Toxinshttp://en.wikipedia.org/wiki/Cardiac_tamponadehttp://en.wikipedia.org/wiki/Cardiac_tamponadehttp://en.wikipedia.org/wiki/Cardiac_tamponadehttp://en.wikipedia.org/wiki/Tension_pneumothoraxhttp://en.wikipedia.org/wiki/Tension_pneumothoraxhttp://en.wikipedia.org/wiki/Thrombosishttp://en.wikipedia.org/wiki/Thrombosishttp://en.wikipedia.org/wiki/Myocardial_infarctionhttp://en.wikipedia.org/wiki/Thrombosishttp://en.wikipedia.org/wiki/Thrombosishttp://en.wikipedia.org/wiki/Pulmonary_embolismhttp://en.wikipedia.org/wiki/Traumatic_cardiac_arresthttp://en.wikipedia.org/wiki/Traumatic_cardiac_arresthttp://en.wikipedia.org/wiki/Traumatic_cardiac_arresthttp://en.wikipedia.org/wiki/Traumatic_cardiac_arresthttp://en.wikipedia.org/wiki/Pulmonary_embolismhttp://en.wikipedia.org/wiki/Thrombosishttp://en.wikipedia.org/wiki/Thrombosishttp://en.wikipedia.org/wiki/Myocardial_infarctionhttp://en.wikipedia.org/wiki/Thrombosishttp://en.wikipedia.org/wiki/Thrombosishttp://en.wikipedia.org/wiki/Tension_pneumothoraxhttp://en.wikipedia.org/wiki/Tension_pneumothoraxhttp://en.wikipedia.org/wiki/Cardiac_tamponadehttp://en.wikipedia.org/wiki/Cardiac_tamponadehttp://en.wikipedia.org/wiki/Cardiac_tamponadehttp://en.wikipedia.org/wiki/Toxinshttp://en.wikipedia.org/wiki/Toxinshttp://en.wikipedia.org/wiki/Tablet_(pharmacy)http://en.wikipedia.org/wiki/Tablet_(pharmacy)http://en.wikipedia.org/wiki/Hyperglycemiahttp://en.wikipedia.org/wiki/Hyperglycemiahttp://en.wikipedia.org/wiki/Hypoglycemiahttp://en.wikipedia.org/wiki/Hypoglycemiahttp://en.wikipedia.org/wiki/Body_temperaturehttp://en.wikipedia.org/wiki/Hypothermiahttp://en.wikipedia.org/wiki/Hypothermiahttp://en.wikipedia.org/wiki/Hypokalemiahttp://en.wikipedia.org/wiki/Hypokalemiahttp://en.wikipedia.org/wiki/Hyperkalemiahttp://en.wikipedia.org/wiki/Hyperkalemiahttp://en.wikipedia.org/wiki/Acidosishttp://en.wikipedia.org/wiki/Hydrogenhttp://en.wikipedia.org/wiki/Hydrogenhttp://en.wikipedia.org/wiki/Oxygenhttp://en.wikipedia.org/wiki/Hypoxia_(medical)http://en.wikipedia.org/wiki/Hypoxia_(medical)http://en.wikipedia.org/wiki/Hypovolemiahttp://en.wikipedia.org/wiki/Hypovolemia


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Diagnosis

Cardiac arrest is synonymous with clinical death.

A cardiac arrest is usually diagnosed clinically by

the absence of a pulse. In many cases lack ofcarotid pulseis the gold standardfor diagnosing

cardiac arrest, but lack of a pulse (particularly in

the peripheral pulses) may result from other

conditions (e.g. shock), or simply an error on thepart of the rescuer.
http://en.wikipedia.org/wiki/Clinical_deathhttp://en.wikipedia.org/wiki/Pulsehttp://en.wikipedia.org/wiki/Gold_standard_(test)http://en.wikipedia.org/wiki/Shock_(circulatory)http://en.wikipedia.org/wiki/Shock_(circulatory)http://en.wikipedia.org/wiki/Gold_standard_(test)http://en.wikipedia.org/wiki/Pulsehttp://en.wikipedia.org/wiki/Clinical_death


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Management

Sudden cardiac arrest may be treated via attempts at resuscitation.This is usually carried out based upon basic life support(BLS) /advanced cardiac life support(ACLS),[19]pediatric advanced lifesupport(PALS)[30]or neonatal resuscitation program(NRP)guidelines.

Cardiopulmonary resuscitationCPRis a critical part of the management of cardiac arrest. It shouldbe started as soon as possible and interrupted as little as possible.

Defibrillation

Shockable and nonshockable causes of cardiac arrest is based on

the presence or absence of ventricular fibrillationor pulselessventricular tachycardia. The shockable rhythms are treated withCPR and defibrillation.
http://en.wikipedia.org/wiki/Resuscitationhttp://en.wikipedia.org/wiki/Basic_life_supporthttp://en.wikipedia.org/wiki/Advanced_cardiac_life_supporthttp://d/Cardiac%20arrest%20-%20Wikipedia,%20the%20free%20encyclopedia.htmhttp://d/Cardiac%20arrest%20-%20Wikipedia,%20the%20free%20encyclopedia.htmhttp://en.wikipedia.org/wiki/Pediatric_advanced_life_supporthttp://en.wikipedia.org/wiki/Pediatric_advanced_life_supporthttp://d/Cardiac%20arrest%20-%20Wikipedia,%20the%20free%20encyclopedia.htmhttp://en.wikipedia.org/wiki/Neonatal_resuscitation_programhttp://en.wikipedia.org/wiki/CPRhttp://en.wikipedia.org/wiki/Ventricular_fibrillationhttp://en.wikipedia.org/wiki/Pulseless_ventricular_tachycardiahttp://en.wikipedia.org/wiki/Pulseless_ventricular_tachycardiahttp://en.wikipedia.org/wiki/Pulseless_ventricular_tachycardiahttp://en.wikipedia.org/wiki/Pulseless_ventricular_tachycardiahttp://en.wikipedia.org/wiki/Pulseless_ventricular_tachycardiahttp://en.wikipedia.org/wiki/Ventricular_fibrillationhttp://en.wikipedia.org/wiki/CPRhttp://en.wikipedia.org/wiki/CPRhttp://en.wikipedia.org/wiki/Neonatal_resuscitation_programhttp://d/Cardiac%20arrest%20-%20Wikipedia,%20the%20free%20encyclopedia.htmhttp://en.wikipedia.org/wiki/Pediatric_advanced_life_supporthttp://en.wikipedia.org/wiki/Pediatric_advanced_life_supporthttp://d/Cardiac%20arrest%20-%20Wikipedia,%20the%20free%20encyclopedia.htmhttp://en.wikipedia.org/wiki/Advanced_cardiac_life_supporthttp://en.wikipedia.org/wiki/Basic_life_supporthttp://en.wikipedia.org/wiki/Resuscitation


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Automated External Defibrillator

(AED) AEDs come in various

models.

A specialized computerrecognizes heart rhythmsthat require defibrillation.


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Medications

This includes the use of epinephrine, atropine, and amiodarone.Vasopressionoverall does not improve or worse outcomes but maybe of benefit in those with asystoleespecially if used early.

The 2010 guidelines, from theAmerican Heart Associationhasremoved its recommendation for using atropine in pulseless

electrical activityand asystoledue to the lack of evidence for itsuse.

Evidence is insufficient for lidocaine and amiodarone may beconsidered in those who continue in ventricular tachycardiaorventricular fibrillationdespite defibrillation.

Thrombolyticswhen used generally may cause harm but may be ofbenefit in those with a pulmonary embolismas the cause ofarrest.[43]
http://en.wikipedia.org/wiki/Epinephrinehttp://en.wikipedia.org/wiki/Atropinehttp://en.wikipedia.org/wiki/Amiodaronehttp://en.wikipedia.org/wiki/Vasopressionhttp://en.wikipedia.org/wiki/Asystolehttp://en.wikipedia.org/wiki/American_Heart_Associationhttp://en.wikipedia.org/wiki/Pulseless_electrical_activityhttp://en.wikipedia.org/wiki/Pulseless_electrical_activityhttp://en.wikipedia.org/wiki/Asystolehttp://en.wikipedia.org/wiki/Ventricular_tachycardiahttp://en.wikipedia.org/wiki/Ventricular_fibrillationhttp://en.wikipedia.org/wiki/Thrombolyticshttp://en.wikipedia.org/wiki/Pulmonary_embolismhttp://d/Cardiac%20arrest%20-%20Wikipedia,%20the%20free%20encyclopedia.htmhttp://d/Cardiac%20arrest%20-%20Wikipedia,%20the%20free%20encyclopedia.htmhttp://en.wikipedia.org/wiki/Pulmonary_embolismhttp://en.wikipedia.org/wiki/Thrombolyticshttp://en.wikipedia.org/wiki/Thrombolyticshttp://en.wikipedia.org/wiki/Ventricular_fibrillationhttp://en.wikipedia.org/wiki/Ventricular_tachycardiahttp://en.wikipedia.org/wiki/Asystolehttp://en.wikipedia.org/wiki/Pulseless_electrical_activityhttp://en.wikipedia.org/wiki/Pulseless_electrical_activityhttp://en.wikipedia.org/wiki/Pulseless_electrical_activityhttp://en.wikipedia.org/wiki/American_Heart_Associationhttp://en.wikipedia.org/wiki/Asystolehttp://en.wikipedia.org/wiki/Vasopressionhttp://en.wikipedia.org/wiki/Amiodaronehttp://en.wikipedia.org/wiki/Atropinehttp://en.wikipedia.org/wiki/Epinephrine


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Therapeutic hypothermia

Cooling a person after cardiac arrest with return ofspontaneous circulation (ROSC) but without returnof consciousness improves outcomes.

This procedure is called therapeutic hypothermia.People are cooled over a 24 hour period, with atarget temperature of 3234 C (9093 F).

Death rates in the hypothermia group were 35%lower. While associated with some complicationsthese are generally mild
http://en.wikipedia.org/wiki/Therapeutic_hypothermiahttp://en.wikipedia.org/wiki/Therapeutic_hypothermia


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Implantable cardioverter

defibrillators

A technologically based intervention to prevent

further cardiac arrest episodes is the use of an

implantable cardioverter-defibrillator(ICD).

This device is implanted in the patient and acts as

an instant defibrillator in the event of arrhythmia.
http://en.wikipedia.org/wiki/Implantable_cardioverter-defibrillatorhttp://en.wikipedia.org/wiki/Implantable_cardioverter-defibrillatorhttp://en.wikipedia.org/wiki/Implantable_cardioverter-defibrillatorhttp://en.wikipedia.org/wiki/Implantable_cardioverter-defibrillatorhttp://en.wikipedia.org/wiki/Implantable_cardioverter-defibrillator


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Automatic Implantable Cardiac

Defibrillators (2 of 2)

Monitor heart rhythm

and deliver shocks as

needed. Low electricity will not

affect rescuers.


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Chain of survival

Several organisations promote the idea of a "chain of survival". The chain

consists of the following "links":

Early recognition - If possible, recognition of illness before the patientdevelops a cardiac arrest will allow the rescuer to prevent itsoccurrence. Early recognition that a cardiac arrest has occurred is keyto survival - for every minute a patient stays in cardiac arrest, theirchances of survival drop by roughly 10%.

Early CPR - improves the flow of blood and of oxygen to vital organs -an essential component of treating a cardiac arrest. In particular, bykeeping the brain supplied with oxygenated blood, chances ofneurological damage are decreased.

Early defibrillation - is effective for the management of ventricularfibrillationand pulseless ventricular tachycardia[7]If defibrillation is

delayed the rhythm is likely to degenerate into asystolefor whichoutcomes are worse.

Early advanced care - EarlyAdvanced Cardiac Life Supportis the finallink in the chain of survival.
http://en.wikipedia.org/wiki/Chain_of_survivalhttp://en.wikipedia.org/wiki/Ventricular_fibrillationhttp://en.wikipedia.org/wiki/Ventricular_fibrillationhttp://en.wikipedia.org/wiki/Ventricular_tachycardiahttp://d/Cardiac%20arrest%20-%20Wikipedia,%20the%20free%20encyclopedia.htmhttp://en.wikipedia.org/wiki/Asystolehttp://en.wikipedia.org/wiki/Advanced_Cardiac_Life_Supporthttp://en.wikipedia.org/wiki/Advanced_Cardiac_Life_Supporthttp://en.wikipedia.org/wiki/Asystolehttp://d/Cardiac%20arrest%20-%20Wikipedia,%20the%20free%20encyclopedia.htmhttp://en.wikipedia.org/wiki/Ventricular_tachycardiahttp://en.wikipedia.org/wiki/Ventricular_fibrillationhttp://en.wikipedia.org/wiki/Ventricular_fibrillationhttp://en.wikipedia.org/wiki/Chain_of_survival


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Thanks You


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Non-Shockable Rhythms

Asystole

Pulseless electrical activity


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Using an AED (1 of 8)

Assess responsiveness.

Stop CPR if in progress.

Check breathing and pulse.

If patient is unresponsiveand not breathing

adequately, give two slow

ventilations.


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If there is a delay in

obtaining an AED, have

your partner start or

resume CPR.

If an AED is close at

hand, prepare the AED

pads.

Turn on the machine.


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Remove clothing from

the patients chest

area. Apply pads to the

chest.

Stop CPR.

State aloud, Clear the

patient.


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Push the analyzebutton, if there is one.

Wait for the computer.

If shock is not needed,

start CPR.

If shock is advised,make sure that no oneis touching the patient.

Push the shock button.


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After the shock is delivered, begin 5 cycles of CPR,beginning with chest compressions.

After 5 cycles, reanalyze patients rhythm.

If the machine advises a shock, clear the patient

and push shock button. If no shock advised, check for pulse.


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If the patient has a

pulse, check breathing.

If the patient is

breathing adequately,

provide oxygen via

nonrebreathing mask

and transport.


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If the patient is not

breathing adequately,

use necessary airway

adjuncts and proper

positioning to open

airway.

Provide artificial

ventilations with high-

concentration oxygen.

Transport.


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If the patient has no pulse, perform 2 minutes of CPR.

Gather additional information on the arrest event.

After 2 minutes of CPR, make sure no one is touchingthe patient.

Push the analyze button again (as applicable).

If necessary, repeat alternating CPR/Analyze/Shockuntil ALS arrives.

Transport and check with medical control.

Continue to support the patient as needed.


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After AED Shocks

Check pulse.

No pulse, no shock advised

No pulse, shock advised

If a patient is breathing independently:Administer oxygen.

Check pulse.

If a patient has a pulse but breathing is

inadequate, assist ventilations.


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Transport Considerations

Transport:

When patient regains pulse

After delivering six to nine shocks

After receiving three consecutive noshock advised messages

Keep AED attached.

Check pulse frequently.

Stop ambulance to use an AED.

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