Philips HeartStart MRx M3535A, HeartStart MRxM3536A User manual

M3535A/M3536A Instructor Guide

HeartStart MRx

Notice

About This Edition

Publication number 453564045041

Edition 1

Printed in the USA

To determine the product level version to which this guide applies to, refer to the version level on the back cover of this book or on the label of the User Documentation CD-ROM that accompanied the device. This information is subject to change without notice.

Philips shall not be liable for errors contained herein or for incidental or consequential damages in connection with the furnishing, performance, or use of this material.

Edition History

Edition Print Date

1 September, 2006

Copyright

Koninklijke Philips Electronics N.V.

All rights are reserved. Permission is granted to copy and distribute this document for your organization’s internal educational use. Reproduction and/or distribution outside your organization in whole or in part is prohibited without the prior written consent of the copyright holder.

SMART Biphasic is a registered trademark of Philips.

®

Microstream of Oridion Medical Ltd. Smart CapnoLine™ is a trademark of Oridion Medical Ltd. Q-CPR™ is a trademark of Laerdal Medical. The HeartStart MRx contains an Ezurio PC Card with Bluetooth wordmark and logos are owned by the Bluetooth SIG, Inc. and any use of such marks by Ezurio is under license. Coverage Plus trademarks of Steris Corp. CidexPlus Sterilization Products. Other trademarks and trade names are those of their respective owners.

and FilterLine® are registered trademarks

®

wireless technology. The Bluetooth

®

and Coverage Plus NPD® are registered

®

is a registered trademark of Advanced

Use of supplies or accessories other than those recommended by Philips may compromise product performance.

THIS PRODUCT IS NOT INTENDED FOR HOME USE.

IN THE U.S., FEDERAL LAW RESTRICTS THIS DEVICE TO SALE ON OR BY THE ORDER OF A PHYSICIAN.

Medical Device Directive

The HeartStart MRx complies with the requirements of the Medical Device Directive 93/42/EEC and carries the

mark accordingly.

0123

Manufacturer:

Philips Medical Systems 3000 Minuteman Road Andover, MA 01810

Authorized EU-representative:

Philips Medizin Systeme Böblingen GmbH Hewlett Packard Str. 2 71034 Böblingen Germany

Canada EMC:ICES-001

China:

After Sales Service: Beijing MEHECO-PHILIPS Medical Equipment Service Center. After Sales Service Address: No. 208, 2nd District, Wang Jing Li Ze Zhong Yuan, Chao Yang District, Beijing. Postal code: 100102. Telephone: 010-64392415. Registration number: SFDA(I)20043211207. Product Standard number: YZB/USA 52-21.

For the Declaration of Conformity Statement, please see the Philips Medical web site at http:// incenter.medical.philips.com/PMSPublic. Scroll over the Quality and Regulatory Tab located in the upper left corner of the window. Click to select Regulatory by Modality. Then click to select Defibrillators and select the entry for Declaration of Conformity (DoC)

Warning

Radio frequency (RF) interference from nearby transmitting devices may degrade the performance of the HeartStart MRx. Electromagnetic compatibility with surrounding devices should be assessed prior to using the monitor/defibrillator.

.

i

This Instructor Guide contain the following conventions:

“Voice” represents voice prompt messages Text represents messages that appear on the display

Text represents bolded directions to the instructor that appear in the guide and

options that appear on MRx menus

[Soft key] represents soft key labels that appear on the display above the

button to which they correspond.

ii

1Table of Contents

1 Introduction 1

2 Getting Acquainted 5

Lesson Introduction 5

Objectives 5 Time 5 Accessories Recommended 5

Lesson Presentation 6

Overview 6 Basic Orientation 6 Display View 10 Continued Use 15 Printing Waveforms 16 Return to Owner 16 Carrying Case and Accessory Pouch Assembly 18 Storing Accessories 20

Review 23

3 ECG and Arrhythmia Monitoring 25

Lesson Introduction 25

Objectives 25 Time 25 Accessories Recommended 25 Clinical Resources 25

Lesson Presentation 26

Overview 26 Monitor View 26 Preparation 27 Heart Rate and Arrhythmia Alarms 30 Displaying an Annotated ECG 35 Arrhythmia Learning/Relearning 36

Review 37

4 Semi-Automated

External Defibrillation 39

Lesson Introduction 39

Objectives 39 Time 39 Accessories Recommended 39

iii

Clinical Resources 39

Lesson Presentation 40

Overview 40 AED View 40 Preparation 41 AED Mode 42

Review 47

5 Manual Defibrillation

and Cardioversion 49

Lesson Introduction 49

Objectives 49 Time 49 Accessories Recommended 49 Clinical Resources 49

Lesson Presentation 50

Manual Mode 50 Code View 50 Manual Defibrillation Preparation 51 Manual Defibrillation 52 Synchronized Cardioversion 54 Synchronized Shock Delivery 55

Review 57

6 Q-CPR™ 59

Lesson Introduction 59

Objectives 59 Time 59 Accessories Recommended 59 Clinical Resources 59

Lesson Presentation 60

Overview 60 Q-CPR Preparation 61 Q-CPR in Manual Defib Mode 64 Q-CPR in AED Mode 67

Review 69

7 Noninvasive Pacing 71

Lesson Introduction 71

Objectives 71 Time 71 Accessories Recommended 71 Clinical Resources 71

Lesson Presentation 72

Pacer Mode 72

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Pacing View 73 Demand vs. Fixed Mode 74 Preparation 75 Demand Mode Pacing 76 Fixed Mode Pacing 78 Defibrillating During Pacing 79

Review 80

8 Pulse Oximetry Monitoring 81

Lesson Introduction 81

Objectives 81 Time 81 Accessories Recommended 81 Clinical Resources 81

Lesson Presentation 82

Overview 82 Selecting a Sensor 82 Applying the Sensor 83 Monitoring SpO Pleth Wave 85 Setting SpO2 Alarms 86 Setting Pulse Rate Alarms 88 Disabling the SpO2 Monitoring Function 88

2

Review 90

84

9 Noninvasive Blood Pressure Monitoring 91

Lesson Introduction 91

Objectives 91 Time 91 Accessories Recommended 91 Clinical Resources 91

Lesson Presentation 92

Overview 92 Preparing to Measure NBP 93 Measuring NBP 94 Alarms 96

Review 98

10 Carbon Dioxide Monitoring 99

Lesson Introduction 99

Objectives 99 Time 99 Accessories Recommended 99 Clinical Resources 99

Lesson Presentation 100

Overview 100

v

Preparing to Measure EtCO Measuring EtCO Setting Up the EtCO2 and AwRR Alarms 102 Disabling EtCO2 Monitoring 104

2

101 102

Review 105

11 Invasive Pressures Monitoring 107

Lesson Introduction 107

Objectives 107 Time 107 Accessories Recommended 107 Clinical Resources 107

Lesson Presentation 108

Overview 108 Pressure Measurement Set-up 108 Selecting a Pressure to Monitor 109 Pressure Waves 110 Zeroing the Pressure Transducer 111 Calibration 113 Alarms 114 Wedge 116 Pulse 116

Review 119

12 Temperature Monitoring 121

Lesson Introduction 121

Objectives 121 Time 121 Accessories Recommended 121

Lesson Presentation 122

Overview 122 Selecting a Temperature Label 122 Monitoring Temperature 123 Alarms 124 Disabling the Temperature Function 125

Review 126

13 12-Lead ECG Monitoring 127

Lesson Introduction 127

Objectives 127 Time 127 Accessories Recommended 127 Clinical Resources 127

Lesson Presentation 128

Overview 128 Preview Screen 128

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Preparation 129 Acquiring the 12-Lead ECG 130 12-Lead Report 131 Accessing Stored Reports 131 Adjusting Wave Size 132 12-Lead Filters 132

Review 133

14 12-Lead ECG via Bluetooth Transmission 135

Lesson Introduction 135

Objectives 135 Time 135 Accessories Required 135 Technical Resources 135

Lesson Presentation 136

Overview 136 Setting Up for Bluetooth Transmission 137 Transmitting to a Configured Site using Bluetooth 140 Transmitting to a Fax Number 140 Transmitting Stored 12-Lead Reports 140 Transmission Status 141 Cancelling Transmission 141

Review 142

15 Vital Signs Trending 143

Lesson Introduction 143

Objectives 143 Time 143 Accessories Recommended 143

Lesson Presentation 144

Overview 144 Reviewing Trending Data 144 Tre nd i n g R e p o r t I n t er va l s 145 Scrolling in the Trending Report 145 Printing the Trending Report 145 Exiting the Trending Report 145

Review 147

16 Data Management 149

Lesson Introduction 149

Objectives 149 Time 149 Accessories Recommended 149

Lesson Presentation 150

Overview 150 Marking Events 151

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Printing Events 151 Printing the Event Summary 152 Printing the Vital Signs Trending Report 152 Using Data Management - Internal Memory 153 Using Data Management - Data Card 153

Review 155

17 Maintenance 157

Lesson Introduction 157

Objectives 157 Time 157 Accessories Recommended 157 Maintenance Resources 157

Lesson Presentation 158

Overview 158 Automated Tests 159 Ready For Use Indicator 160 Shift Check 161 Weekly Sh oc k Test 162 Operational Check 163 Battery Maintenance 170 Cleaning Instructions 171

Review 174

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Instructor Guide

Instruction Time

1

1Introduction

This instructor guide is designed to assist you in the delivery of end-user training on the HeartStart MRx. It provides directions and suggestions for teaching the safe and proper operation of the device, and is intended only for ACLS personnel thoroughly trained in the use of the device.

It is estimated that this course will require 2-5 hours to complete, depending on class size, location, number of devices available for training, optional device parameters purchased, and student knowledge and needs.

Guide Structure

This guide is divided into sixteen (16) lessons, as follows:

• Getting Acquainted

• ECG and Arrhythmia Monitoring

• Semi-Automated External Defibrillation

• Manual Defibrillation and Cardioversion

•Q-CPR™*

• Noninvasive Pacing*

•Pulse Oximetry*

• Noninvasive Blood Pressure*

• Monitoring Carbon Dioxide*

• Invasive Pressures*

•Temperature*

•12-Lead ECG*

• 12-Lead ECG via Bluetooth Transmission*

•Vital Signs Trending

• Data Management

• Maintenance

* This is an optional parameter with the MRx, so ensure you teach only the lessons that match the organization’s device configuration.

1

1 Introduction

Preparation

Prior to each class:

• Contact the organization’s training coordinator to schedule training, if applicable. Suggest train-thetrainer sessions. Make sure students understand that they must be free from other responsibilities at the scheduled time for the duration of the course. A maximum of 10 students is recommended for each class.

• Talk to the training coordinator (if applicable) about which device functions students will be using on the job (AED Mode, Manual Mode, Pacing, SpO

, etc.). Use this information to select the

2

appropriate lessons and determine your lesson presentation.

• Recommend to the training coordinator that students watch the latest version of the HeartStart MRx User Training Video or DVD prior to the instructor-based training, if available. Also, suggest taking the HeartStart MRx Web-based User Training prior to or after the instructor-based training.

• Determine the number of devices needed for training and make arrangements to have them set up at the scheduled time, if possible. Try not to exceed grouping 2-3 students per device.

• Determine who in the organization makes decisions about configuration. Arrange a time to discuss the organization’s desired configuration and set up the devices used in training to that configuration. Use the configuration worksheet available on the User Documentation CD-ROM to help you complete the configuration procedure.

• Perform an Operational Check on each device to be used in training prior to

training. Refer to the

latest version of the HeartStart MRx Instructions For Use to complete the Op Check, if necessary.

• Try to have fully charged batteries and external power available if needed.

• Try to have one simulator for each device to be used in training, as well as extra batteries for the simulators.

• Try to have appropriate sets of parameter accessories, cables, etc. for each device.

• Try to have one copy of the latest HeartStart MRx User Training Workbook available for each student, if possible. The workbook contains a similar lesson flow to the guide, but only a summary of the content. Students can use the workbook to follow your instruction. Be sure to familiarize yourself with the workbook before

you teach. It is available on the User Documentation CD-ROM

that comes with the MRx.

• As appropriate and if possible, try to have one copy of each application note available for each student either before, during, or after the training. These notes relate to several lessons in the guide. They can be found on the User Documentation CD-ROM, as well as:

– www.medical.philips.com/goto/productdocumentation

• If possible, try to have one set of latest version of the HeartStart MRx Quick Reference Cards available for the training.

2

Teaching Guidelines

Consider the following guidelines for delivering the MRx training.

• Have students identify themselves and their role and/or responsibilities. This information gives you a better idea of what lessons/topics are suitable or most important for your audience.

• Provide a brief overview of the course structure and what is covered in each lesson.

• Advise students to read the HeartStart MRx Instructions For Use for details on device features and information not covered in the classroom:

– Device intended use

– Device and accessory set-up

– Configuration

– Device disposal

–Troubleshooting

– Specifications and safety

•For each lesson:

– Introduce the learning objectives (as listed in the guide), advise on how much time it will take to

complete a lesson, and point out what related resources (e.g., application notes) are available to students for further education.

– Present the lesson content. Annotate and/or highlight material (in your copy of the guide) to

ensure you stress information that you feel is important to your students’ needs. Note that instructor directions are in bold. Look for suggestions that raise the level of student interaction. There is also space for additional points or notes to be made at a topical level, depending on students’ needs.

– Review the content presented by completing the review questions at the end of each lesson. Note

that answers to the questions are in bold.

1 Introduction

• Periodically ask for questions to ensure comprehension.

• Periodically ask questions to engage students and increase learning effectiveness.

• Take breaks over the course of the training (if time allows) to ensure learning effectiveness.

• At the completion of a class, use the Skills Checklist to test students on various functions and features of the MRx.

Safety Considerations

Some warnings and cautions specific to a particular feature of the HeartStart MRx are provided in this guide; however, you and students should reference the Instructions For Use for a complete description of all safety warnings and cautions. Nonetheless, reinforce the fact that the MRx is a live device that can deliver high-energy therapy and should not be used by untrained personnel. Operation by untrained personnel can result in injury or death.

3

1 Introduction

Additional Documentation and Training

Available documentation and training for the HeartStart MRx includes:

• HeartStart MRx Instructions for Use - provides the most comprehensive review of MRx functionality and operation for students. It is available on the User Documentation CD-ROM or may be purchased in hardcopy form.

• HeartStart MRx Quick Reference Cards - provide visual, step-by-step summaries of key functions, parameters, and related operation

– Controls, Connections and Indicators

– Ready For Use Indicator

–Using Alarms

–Monitoring ECG

–Monitoring SpO

–Monitoring NBP

–Monitoring CO

– Monitoring Invasive PressuresNoninvasive Pacing

–Q-CPR

– 12-Lead ECG

–Operational Check

2

• HeartStart MRx Web-based User Training - provides a comprehensive self-paced training on the same content found in the instructor guide. It is located on Philips Medical Systems’ web site at: www.medical.philips.com/goto/mrxtraining.

Students need to enter the training access password meetMRx to get started.

• HeartStart MRx User Training Video - provides a 50-minute overview of MRx functions, features, and operation. The video serves as valuable preparation for the classroom or as a refresher after the training.

•Application Notes

– Arrhythmia Monitoring Algorithm

– AED Algorithm

– SMART Biphasic

– Noninvasive Pacing

– Philips Pulse Oximetry

– Noninvasive Blood Pressure Monitoring

– Uses of Capnography - The Microstream® Method

– Q-CPR™ Measurement and Feedback

• 12-Lead Algorithm Data Sheet

• Philips 12-Lead Algorithm Physician’s Guide, available from IntelliVue Information Center - User Materials under Patient Monitoring at http://www3.medical.philips.com/en-us/doc_downloads/ docdownload.asp

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Instructor Guide

Lesson Introduction

Introduce the lesson, including the learning objectives, estimated time to complete, and applicable resources.

This lesson provides an overview of the HeartStart MRx controls, indicators, operational modes, and display views. It also provides general information on use of the device.

2

2Getting Acquainted

Objectives

Upon completion of this lesson, students should be able to:

1. Identify the physical features, controls, and indicators of the MRx.

2. Identify the purpose of various controls and indicators.

3. Identify the display view characteristics associated with MRx’s operating modes.

4. Identify the correct procedure for responding to an alarm.

Time

15-25 minutes

Accessories Recommended

•Simulator

•Hands-free cable

• Multifunction electrode pads

• 3-, 5-, or 10-Lead monitoring electrodes

• Optional Pacing, SpO accessories

, CO2, NBP, invasive pressure, temperature, and/or Q-CPR parameter

2

5

2 Getting Acquainted Lesson Presentation

Lesson Presentation

Overview

Describe the high-level features of the MRx.

• It is designed for a variety of needs.

• It has controls, indicators, and menus organized to facilitate ease of use.

• It displays information specific to the current task.

Basic Orientation

Introduce the physical features, controls, and indicators on the front, left, right, top, and back panels of the MRx. Also, discuss the lithium ion battery.

Suggestion: Have students identify the features, controls, and indicators on their devices and the battery while following your orientation.

NOTE: Consider not turning on the MRx during your initial orientation so students focus on each panel and NOT the display. Then, turn on the device to illustrate display output of features and controls.

Front Panel

Controls and indicators on the front panel are organized by function, with the most general function buttons located along the left and bottom sides of the display, defibrillation controls to the right of the display, and soft keys immediately below the display.

Therapy Knob

Serves as the MRx power switch and can be set to:

• AED - to enable AED Mode for semi-automated external defibrillation and optional Q-CPR

parameter.

• Off

• Monitor - to enable Monitor Mode for 3- or 5-Lead ECG monitoring, optional 12-Lead ECG

acquisition, or monitoring of optional parameters such as SpO

• Pacer (optional) - to enable Pacer Mode for demand or fixed mode pacing.

• Manual Defib - to enable Manual Mode for asynchronous or synchronous defibrillation

(cardioversion) at the selected energy setting and optional Q-CPR parameter.

Energy settings are 1-9, 10, 15, 20, 30, 50, 70, 100, 120, 150, 170, and 200 Joules. If the device is equipped with optional Pacing, energy settings are 1-10, 15, 20, 30, 50, 70, 100, 120, 150, 170, and 200 Joules.

, CO2, and NBP.

2

6

Lesson Presentation 2 Getting Acquainted

General Function Buttons

Control monitoring or non-critical resuscitation activities

• Mark Event - inserts a time-stamped annotation in the Event Summary Report to note events as

they occur, including drug administration. A Mark Event button label appears at the top left corner of the display.

• Lead Select - changes the ECG lead in Wave Sector 1; cycles through the available ECG waves,

changing the displayed wave and label. The list of available ECG waves is based on the current lead set and device configuration, and includes pads or paddles if the corresponding cable is connected to the MRx.

• Alarm Pause - pauses all visual and audible physiological alarms and audible inops for the

configured time interval. At the end of the pause interval, each alarm returns to its previous setting (On or Off). Also returns alarms to their previous settings.

• Print - initiates a continuous print-out of the primary ECG and the waveform displayed in Wave

Sector 2, either real-time or with a 10-second delay, depending on device configuration.

• Summary - displays a menu from which you can print the current or most recent Event Summary

report or Vital Signs Trending Report.

• Menu Select - brings up the current menu or confirms a menu selection.

• Navigation - display the current menu just like Menu Select button does; move to the next or

previous item in a list; increase or decrease numbers or values in a sequence; may be held down to accelerate through the available choices.

Defibrillation Controls

• Therapy Knob - enables AED or selects an energy for Manual Mode defibrillation or cardioversion.

• Charge - charges the defibrillator to the selected Manual Defib energy setting. Used only in Manual

Mode. Defibrillator charges automatically in AED Mode.

• Shock

– delivers a shock through multifunction electrode pads or switchless internal paddles. In AED

Mode, a 150J shock is delivered. In Manual Mode, the shock is delivered at the selected energy setting.

– When external paddles or switched internal paddles are used, once the MRx is fully charged, the

shock is delivered by pressing the Shock button(s) on the paddles.

NOTE: Internal paddles should only be discussed with clinicians dealing with open chest defibrillation.

• Sync - toggles between asynchronous and synchronous (cardioversion) defibrillation.

Soft Keys

Perform functions presented as labels appearing immediately above the keys on the display. Labels (and related functions) change based on the mode of operation.

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2 Getting Acquainted Lesson Presentation

Indicators

Provide a visual display of device status

Ready For Use (RFU)

• A blinking black hourglass symbol indicates:

– Shock, pacing, and ECG functions are ready for use.

– Sufficient battery power is available for device operation.

– An installed battery is being charged, assuming the presence of external power (AC or DC).

• A blinking red “X” and a periodic audio chirp indicate:

– No battery is present or a low battery condition.

– The device can be used in a low battery condition, but its operation time is limited. If the device

is running only on external power, it takes longer to charge. If a battery is inserted and charging, the audio chirp is not present.

• A solid red “X” and a periodic audio chirp indicate:

– A failure that may prevent delivery of defibrillation therapy, pacing, or ECG acquisition. When

turned on, the device displays an error message for the first critical failure detected. Consider doing an Operational Check if the device is in this state to isolate the failure.

Side Panels

• A solid red “X” without periodic audio chirps indicates:

– Either no power is available or a catastrophic failure has occurred.

– The device cannot power on. If, after power is supplied, the indicator reverts to the blinking black

hourglass symbol, the device is once again ready for use.

Note the following: The RFU indicator may briefly display a solid red "X" when initially turning the device on, when switching between clinical and non-clinical operating modes, and at the start of any automated test.

External Power - lights green if power is being provided by an external AC or DC power source; momentarily goes out when charging for defibrillation with a charged battery installed, as the device switches power source to the battery for a faster charge time.

The front panel also includes the printer door and latch, speaker (for audible alarms and AED voice prompts), and the display (covered in detail later).

• The left panel has:

– Ports for monitoring cables (if ordered), including ECG (for 3-, 5-, or 10-Lead patient cable),

pulse oximetry (SpO2), noninvasive blood pressure (NBP), two invasive pressures, temperature, and carbon dioxide (CO

* For CO

, there is an Inlet port for monitoring tubing and an Outlet port when administering

2

)*.

2

anesthetic gases.

– An ECG Out jack to connect to an external monitor.

• The right panel has:

– A therapy port for paddles (external or internal) or multifunction electrode pads and/or Q-CPR

Compression Sensor.

– A slot for a data card to transfer patient information.

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Lesson Presentation 2 Getting Acquainted

Top Panel

The top panel has a handle and basic operating instructions. Optional external (adult/pedi) paddles also reside here, if present.

NOTE: Be sure to demonstrate access to the pediatric paddles.

Back Panel

The back panel has:

• Two compartments for lithium ion batteries. Compartment B also used to connect an AC power module.

NOTE: Be sure to demonstrate how to take batteries in and out of the compartments.

• A DC Power Input port.

• An RS-232 serial port for 12-Lead ECG transmission.

• A LAN port for future use.

M3538A Lithium Ion Battery

• Has a fuel gauge with 5 LED indicators, each representing a charge of approximately 20% of capacity. Press the fuel gauge button to illuminate the fuel gauge.

• Should be used as the primary power source, with AC/DC as a secondary source, if desired. If an AC/DC power module is used as the only power source, the MRx takes longer to charge to the desired energy level and, in the event of power loss, all settings reset to the default settings and a new incident is created when power is returned. All stored data remains intact and can be found by retrieving the previous incident. Keep your unit charged.

o

• A new, fully-charged M3538A battery, operating at room temperature 25 approximately 5 hours of monitoring, with ECG, SpO

, CO2, temperature, two invasive pressures

2

C(77oF), provides

monitored continuously, NBP measured every 15 minutes, and 20 200J discharges. A fully charged new battery provides approximately 3.5 hours of monitoring, with ECG, SpO

, CO2, temperature,

2

two invasive pressures monitored continuously, NBP measured every 15 minutes, and pacing at 180ppm at 160mA.

• Battery life depends on the frequency and duration of use. When properly cared for, useful life is approximately 2 years. To optimize performance, a fully (or nearly fully) discharged battery should be charged as soon as possible.

9

2 Getting Acquainted Lesson Presentation

Additional points/notes:

________________________________________________________________________________

Display View

Introduce the display view characteristics of the MRx, starting with a brief look at the various operating modes. Attach a simulator (set to a normal sinus rhythm), 3-, 5-, or 10-Lead ECG set, and all available parameter accessories to the MRx. Feel free to switch between modes to illustrate display view characteristics; however, consider spending most of your time in Monitor Mode, as it provides the most comprehensive view. You will cover details of the AED, Code, and Pacing views in related lessons later in this guide.

Suggestion: Have students set up their devices with accessories they will use and turn them on to the operating mode(s) you cover to follow your display view introduction. Ask students what they see in each display view you cover versus just telling them what they see.

Operating Modes

The MRx has four clinical modes of operation, each with a customized display view function being performed:

Note: Upon returning to a clinical mode from a non-clinical mode such as Configuration or Data Management, all settings are re-set to the device’s default values.

Mode of Operation Display View Description

Monitor Mode Monitoring View or

12-Lead View

AED Mode AED View Analyzes ECG and, if necessary, performs

Manual Defib Mode Code View Performs asynchronous and synchronous

Pacer Mode Pacing View Performs demand or fixed mode pacing,

Monitors ECG, takes an optional 12-lead ECG, and monitors optional parameters such as SpO Pressures, and Temperature, and for viewing Vitals Signs Trending data

semi-automated external defibrillation and optional Q-CPR

defibrillation (cardioversion) and optional Q-CPR, and monitors ECG

and monitors ECG

, EtCO2, NBP, Invasive

2

10

Lesson Presentation 2 Getting Acquainted

Password Security

Access to Manual Defib Mode and Pacer Mode may be password protected if configured. If enabled, you are prompted to enter the password when you move the Therapy Knob to either the Pacer position or an energy selection. Use the Navigation buttons to select the password numbers, select Done, and then press Menu Select to complete the entry. The Charge button and the [Start Pacing] soft key remain inactive until the password is entered. AED Mode is always available without a password.

Note the following: Use of the Manual Therapy Security password requires the clinician to know and remember the password, as defined in Configuration. Failure to enter the correct password prevents manual defibrillation delivery or pacing therapy. Prior to selecting this Configuration option, review this potential risk with your Risk Manager.

Display Layout

The MRx display layout is segmented as follows:

General Status

At the top, this area contains:

• Mark Event button label

•Date and time

• Battery icons

– Labeled “A” and “B” to match battery compartments on back panel.

– Display current available battery power, ranging from hollow (fully discharged) to full (fully

charged). If an AC Power Module is in Compartment B, the No Battery icon is displayed.

• Audio recording icon - If the option is enabled, an audio recording icon displays to the left of the battery icons in all clinical modes to indicate the audio recording status.

• Patient information

Some modes of operation permit patient information entry via a menu choice. If no information is

entered, the patient category is defaulted to Adult, unless configured otherwise, and the pacing status is set to Non-Paced, unless the Paced status has been previously set to Paced for an internally paced

patient or the MRx is pacing the patient. In Pacer Mode, Paced status is not displayed.

• Patient name -If entered, the patient’s name will appear above the patient type and paced status.

• Inop statements - appear in top left of display if equipment problems occur

• ECG/HR alarm status - alarm messages communicate arrhythmia alarms, as well as overall alarm status (alarms off, alarms paused)

• Event Timer - communicates elapsed time for the current patient incident

Wave Sectors

• MRx displays up to 4 wave sectors with a predetermined waveform, when powered on in Monitor, Manual, or Pacer Mode.

• A dashed line (in a wave sector) or empty wave sector indicates waveform source not connected to MRx.

• Sectors may contain a variety of information, as appropriate to the parameter, view, and task; ECG wave sectors contain a calibration bar.

11

2 Getting Acquainted Lesson Presentation

Wave Sector 1

• Will only contain an ECG waveform (used by the arrhythmia, heart rate derivation, and AED analysis algorithms); the waveform may be acquired through the therapy port for pads/paddles or the monitoring port for 3-, 5-, or 10-Lead electrodes.

• If the configured source is not connected to the device when turned on, the first valid ECG source is displayed in Wave Sector 1. Once the source is available, it automatically populates Wave Sector 1.

• The displayed lead/source is controlled primarily by the Lead Select button, although the Displayed Wave s menu can be used.

• This sector includes R-wave detection.

• When monitoring using a 3-lead ECG set, the MRx displays only one ECG lead at a time.

• If Pads are configured as the primary ECG source for Wave Sector 1, the ECG patient cable must be connected to the MRx and to the monitoring electrodes in order to change the ECG source to a Leads selection.

Wave Sectors 2-4

• Automatically populate when parameter sources (cables/tubing) are connected to the MRx. Q-CPR compression waveform automatically populates on 150J Manual Defib Mode setting.

• If parameter source is the configured choice of a particular wave sector, it is displayed in that sector.

• If you connect a parameter source that is not configured to be displayed, it displays in the first empty wave sector. If you subsequently connect the configured parameter source, it replaces the current parameter. For invasive pressures, you should label your waveforms as they are connected to avoid possible confusion..

• Displayed lead/source is controlled by the Displayed Wave s menu.

• Wave Sectors 2 and 4 may contain a cascaded ECG.

Parameter Blocks

• Provide measurements for displayed waveforms and monitored parameters. The position of most parameters are in fixed locations depending upon the options which were included in your HeartStart MRx.

• Block 1 always contains heart rate and HR alarm settings; may display Pulse, Temp, and NBP schedule, measurements, and alarm settings.

• Block 2 may contain Invasive Pressures, SpO

, EtCO2, and Airway Respiration Rate (AwRR)

2

measurements and related high/low alarm limit settings; “-?-” is displayed until a valid measurement is obtained; settings may contain the Alarms Off icon. Block 2 may also contain Q-CPR compression and ventilation values.

• Invasive Pressures, Temp, SpO

, and EtCO2 measurements are activated when associated cable/

2

tubing is connected; if a cable/tubing is disconnected, a prompt message requests approval to turn off the measurement.

12

• Alarm messages appear in the space above each numeric value, replacing a parameter label.

Suggestion: Have students disconnect and reconnect parameter accessories to see how parameter blocks are affected. Ask students what they see when detaching and attaching an accessory cable or tubing.

Lesson Presentation 2 Getting Acquainted

Soft Key Labels

• Correspond to soft key buttons.

• Change according to the current display view and function.

• Grey text labels indicate inactive soft keys (e.g., Disarm in Manual Mode).

Suggestion: Switch between modes to show different labels, with students following along.

Display Menus

• Provide controls and options specific to each function.

• Accessible through Menu Select and Navigation buttons.

• Used to adjust volume, select waveforms for display, set alarms, schedule measurements, enter patient information, perform an Operational Check, generate reports, etc.

• Press Menu Select button to activate selections; select Exit to close menus without activating

selections.

Suggestion: Access different menu options to illustrate various menu functionality (e.g., changing waveform for a sector, the patient’s age, alarm limits, etc.). If you access the Patient Info menu, point out that a patient’s full name is entered using 2 alphabetical lists, one to enter last name, followed by another to enter first name. When each name is complete, select Done. When entering names, follow your organization’s or HIPPA regulations.

Message Windows

• Provide status information.

• Alert you to an error or a potential problem.

• Direct you to take action.

• Use the Navigation and Menu Select buttons to respond to messages.

High Contrast Display

• Provides a High Contrast view to optimize visibility of the MRx display when used in bright sunlight.

• Display appears with a yellow background and all other screen elements appearing in black or shades of gray.

•Select High Contrast On from the Main Menu to enable the feature.

Note the following: The High Contrast view does not display the colors red or blue, therefore, be sure the MRx is configured correctly with the appropriate parameter color settings.

Suggestion: Have students set their devices to the High Contrast view any time during your discussion.

13

2 Getting Acquainted Lesson Presentation

Additional points/notes:

________________________________________________________________________________

Responding to Alarms

Create an alarm condition and cover the following steps to respond to the condition.

1. Attend to the patient.

2. Identify the alarm(s) indicated.

3. Silence the alarm(s). When a physiological alarm is announced, the Audio Pause label displays

above the Navigation and Menu Select buttons. Pressing any of these buttons silences the audio for all active alarms while you are attending to the patient. If the alarming condition continues to exist, it will re-alarm in two minutes. Silencing a specific alarm does not prevent another alarm condition from sounding. If you also silence the second alarm, it resets the two-minute audio pause for all active alarms.

When an INOP is announced without a concurrent physiological alarm, the Audio Off label displays above the Navigation and Menu Select buttons. Pressing any of these buttons silences the audio for all active alarms while you are attending to the patient. INOPs do not reannunciate after pressing audio off.

4. Address the alarm condition with one of the following options:

– Acknowledge - For latching alarms, acknowledge clears the alarm condition when the condition

no longer exists.

– New Limits - Adjust the parameter limits accordingly.

– Alarms Off - Turns the monitoring parameter’s alarms off and prevents real-time print strips.

The alarm message is no longer displayed, and the Alarm Off icon appears next to the parameter value.

Note the following: Turning off alarms turns them off indefinitely.

– Although the Alarm Pause button can be used when responding to alarms, the response

procedures described above are recommended. Alarm Pause removes audio and visual indications of active alarm conditions as well as inhibiting indications of new alarm conditions.

– A potential hazard exists if different alarm limits are used for the same or similar equipment in

any single area.

– Confirm the alarm limits are appropriate for the patient each time there is a new patient incident.

14

Lesson Presentation 2 Getting Acquainted

– Do not set alarm limits to such extreme values that render the alarm system useless.

Suggestion: Note that you will also cover alarm limits in detail in the ECG and Arrhythmia Monitoring lesson later in the training and students will be able to practice with alarm conditions at

that time.

Additional points/notes:

________________________________________________________________________________

Continued Use

Cover the characteristics associated with MRx’s continued use feature.

• Activated once a patient event is started.

• Facilitates continued treatment of the same patient by retaining current settings and the patient record when the MRx is turned off for less than 10 seconds or switching between modes (e.g., Monitor, AED, and Manual Defib).

• MRx retains the most recent settings, including:

–Alarm settings

– Wave Sector settings

–Event Timer

– QRS, alarm tone, and voice prompt volumes

–ECG gain

– Pacing settings

– Patient record in the Event Summary Report; new data is appended to the record

• This feature will not function if all power sources (battery and external AC/DC power modules) are removed from the device, even briefly.

Suggestion: Have students shut off MRx and turn it back on within 10 seconds. Then, ask them to state some of the settings that are retained. Consider having students complete this task before giving them the above list of retained settings.

15

2 Getting Acquainted Lesson Presentation

Printing Waveforms

Describe waveform printing characteristics and procedures.

• Obtain a continuous printout of the primary ECG and one additional waveform on a 50mm printer.

• Obtain a continuous printout of the primary ECG and two additional waveform on a 75mm printer.

• Certain waveforms (including invasive pressures and CO

• Printouts are generated either real-time or with a 10-second delay, depending on your configuration.

To change wave forms for the second wave printed with a 50mm printer:

1. Press the Menu Select button.

2. Using the Navigation buttons, select the Printed Waves option and press Menu Select.

3. Using the Navigation buttons, select the wave form you want to print in Wave 2 and press Menu

Select.

To change wave forms for the second or third wave printed with a 75mm printer:

1. Press the Menu Select button.

2. Using the Navigation buttons, select the Printed Waves option and press Menu Select.

3. Using the Navigation buttons, select Wave 2 or Wave 3 and press Menu Select.

4. Using the Navigation buttons, select the wave form you want printed and press Menu Select.

5. Repeat Steps 2 through 4 for the other printed wave.

Return to Owner

) include scale indications on the printout.

2

16

Discuss the Return to Owner feature and demonstrate how to enable and disable it.

• Lets the MRx owner specify a loan period, after which the MRx borrower is reminded to return the device to its owner.

• Password protected in Configuration. Each device should have a unique password.

• Monitoring and defibrillation functions are suspended while the Return to Owner set-up screen is displayed. Alarms Off is indicated on the display. Monitoring and defibrillation functions will return when exiting the Return to Owner screen

• The appearance of the loan expiration message does not disable monitoring and defibrillation functionality.

To e na bl e t hi s f ea tu re :

1. Press the Menu Select button.

2. Select Other and press Menu Select.

3. Select Return To Owner and press Menu Select.

4. Press the [Activate] soft key.

Lesson Presentation 2 Getting Acquainted

5. Enter the number of days in the loan period and press Menu Select.

6. Press the [Exit Return-To] soft key.

To disable this feature:

1. Press the Menu Select button.

2. Select Other and press Menu Select.

3. Select Return To Owner and press Menu Select.

4. Press the [Deactivate] soft key.

5. Enter the password and press Menu Select.

6. Press the [Exit Return-To] soft key.

Additional points/notes:

________________________________________________________________________________

17

2 Getting Acquainted Lesson Presentation

Carrying Case and Accessory Pouch Assembly

This topic should be covered for only customers who have carrying cases and accessory pouches, as appropriate. Discuss the following procedures for carrying case assembly and recommended accessory placement.

1. Disconnect all external power and remove all batteries.

2. Lower the device into the sleeve of the carry case. The rear base of the device fits in the sleeve

socket.

Paddle Tray

a. If paddles are connected, disconnect them from the Therapy port and remove them from the

paddle tray.

b. Remove the four T-15 screws from the tray plates.

c. Gently lift the paddle tray up, leaving all wires connected.

Handle Only

a. Remove the handle cover by pushing in on either side of the handle cover and lifting up.

b. Remove the two T-15 screws.

c. Remove the handle.

d. Gently lift the cap plate up.

3. Fold the two sleeve flaps over the top of the device, positioning them so that the screw holes are

exposed.

4. Replace the paddle tray or cap plate, as appropriate, so that the molded openings fit over the sleeve

flaps.

5. Secure the front and rear cinch straps using the metal rings provided.

6. Perform an Operational Check on the MRx.

7. Attach the side pouches using the snaps located inside the pouch pockets.

The following illustrations show carrying case and accessory pouch assembly.

18

Lesson Presentation 2 Getting Acquainted

19

2 Getting Acquainted Lesson Presentation

(

(((

(

((

(

((

(

Storing Accessories

1. Store parameter cabling and accessories as shown below.

2. Attach the Therapy cable and route it through the cable fastener loop, securing the cable just below

the strain relief. (See below left.)

3. Attach the rear pouch using the buckles provided. (See below right.)

Note: Depressions are provided on the inside of the rear pouch should you wish to make a cut-out to accommodate external power.

(

20

Lesson Presentation 2 Getting Acquainted

Here are recommended carry bag storage instructions for Q-CPR accessories for easy access.

Option 1

PHILIPS

Option 2

PHILIPS

Suggestion: Have students set up the carrying case and accessory pouches during your instruction.

21

2 Getting Acquainted Lesson Presentation

Additional points/notes:

________________________________________________________________________________

22

Review 2 Getting Acquainted

Review

Have students answer the following questions individually or as a group. (Correct answers are in bold.)

1. Identify at least three controls or buttons on the MRx involved with defibrillation. (Therapy

Knob, Charge button, Shock button, Sync button)

2. What does a solid red "X" and periodic audio chirp indicate on the RFU?

a. No battery is present (blinking red "X" and chirp)

b. No power is available (solid red "X" and no chirp)

c. A low battery condition (blinking red "X" and chirp)

d. Defibrillation therapy may not be available

3. The arrhythmia algorithm uses the ECG in which Wave Sector for analysis?

a. 1

b. 2

c. 3

d. all of the above

4. True or false? You can select the ECG lead for Wave Sector 2 using either the Lead Select button or

Displayed Wa ve s menu. (False - You can only use the Displayed Waves menu to select the ECG lead for Wave Sector 2.)

5. True or false? You should respond to alarms primarily by pressing the Alarm Pause button. (F - You

should respond to alarms by acknowledging them and changing limits, if needed vs. pressing the Alarm Pause button.)

23

Instructor Guide

Lesson Introduction

Introduce the lesson, including the learning objectives, estimated time to complete, and applicable resources.

3

3ECG and Arrhythmia

Monitoring

This lesson describes the basic ECG and arrhythmia monitoring functions of the HeartStart MRx.

Objectives

Upon completion of this lesson, students should be able to:

1. Locate pertinent information in Monitor View.

2. Prepare a patient for ECG and arrhythmia monitoring.

3. Set heart rate and arrhythmia alarms.

4. Display an annotated ECG.

5. Initiate manual relearning.

Time

10-20 minutes

Accessories Recommended

•Simulator

•Hands-free cable

• Multifunction electrode pads

• 3-, 5-, or 10-Lead monitoring electrodes

Clinical Resources

• Arrhythmia Monitoring Algorithm Application Note (M3535-95100)

25

3 ECG and Arrhythmia Monitoring Lesson Presentation

Lesson Presentation

Overview

Introduce MRx’s Monitor Mode specific to ECG and arrhythmia monitoring.

• Monitor Mode monitors ECG and arrhythmia using multifunction electrode pads or 3-, 5-, or 10Lead ECG sets.

• The MRx uses the ST/AR Basic Arrhythmia Algorithm for arrhythmia analysis.

• Monitor Mode generates heart rate and arrhythmia alarms, communicating patient status.

Monitor View

Attach multifunction electrode pads or 3-, 5-, or 10-Lead ECG set to the simulator and the MRx, attach parameter accessories (as appropriate), turn the Therapy Knob to Monitor, and discuss Monitor View characteristics.

• Monitor View displays up to four ECG waves or combination of ECG, pads/paddles, and parameter waves.

• Monitor View displays heart rate/parameter numeric values and active alarm settings.

• Change the primary lead with the Lead Select button.

• Change leads through the Displayed Waves menu.

• The first valid ECG source acquired displays in Wave Sector 1; it is replaced by the configured primary lead as soon as it is acquired.

• The ECG lead source in Wave Sector 1 determines heart rate and monitor arrhythmia.

Suggestion: Ask students to point out characteristics instead of YOU stating them.

Additional points/notes:

________________________________________________________________

26

Lesson Presentation 3 ECG and Arrhythmia Monitoring

Preparation

Discuss monitoring preparation using multifunction electrode pads or electrodes.

Multifunction electrode pads

1. Prepare the patient’s chest (i.e., remove clothing, remove moisture from chest, and remove excessive

hair).

2. Apply multifunction electrode pads to the patient according to the pads package directions or your

organization’s protocol.

3. If not pre-connected, insert the pads cable into the green Therapy port. DEMONSTRATE

4. Connect the pads to the pads cable. DEMONSTRATE

Suggestion: Have students complete steps 4 and 5.

Electrodes

1. Prepare the patient’s skin at the appropriate electrode sites.

– If necessary, clip hair at the electrode sites (or shave sites if needed).

– Clean and abrade the skin at each electrode site.

– Dry the electrode sites briskly to increase capillary blood flow in the tissues and to remove oil

and skin cells.

2. Attach the snaps to the electrodes.

3. Apply the electrodes.

Note: Review typical electrode placement for a 3-, 5-, V/C, and 10-Lead ECG set, and lead selection for an accurate QRS complex detection, as appropriate.

4. If not pre-connected, connect the ECG patient cable. DEMONSTRATE

Suggestion: Have students complete step 4.

Additional points/notes:

________________________________________________________________

.

27

3 ECG and Arrhythmia Monitoring Lesson Presentation

Lead Choices

Review the choice of leads available for 3-, 5-, and 10-Lead ECG sets if connected to the MRx.

If you are using: These leads are available: The maximum number of leads

displayed is:

a 3-Lead ECG set I, II, III One

a 5-Lead ECG set I, II, III, aVR, aVL, aVF, V Four

a 10-Lead ECG set I, II, III, aVR, aVL, aVF, V1-V6 Four

Lead Selection

Discuss the guidelines for lead selection.

• Select a suitable lead for monitoring so that a QRS complex can be accurately detected.

• For non-paced patients, the:

– QRS complex should be tall and narrow (recommended amplitude > 0.5mV).

– R-wave should be above or below the baseline (but not biphasic).

– P-wave should be smaller than 1/5 R-wave height.

– T-wave should be smaller than 1/3 R-wave height.

• For paced patients with internal/transvenous pacemakers, in addition to the above, the pace pulse should be:

– not wider than the normal QRS complex.

– large enough to be detected (half the height the height of the QRS complex), with minimal re-

polarization.

• Adjusting the ECG wave size on the display does not affect the ECG signal which is used for arrhythmia analysis.

The ECG lead for Wave Sector 1 is selected through the Lead Select button or through the Displayed

Wave s menu. Demonstrate ECG lead selection for Wave Sectors 2-4, which is accomplished through the Displayed Waves menu.

1. Press the Menu Select button.

2. Select Displayed Wa ve s and press Menu Select.

3. Select the appropriate Wave Sector and press Menu Select.

4. Select the desired lead and press Menu Select.

28

Lesson Presentation 3 ECG and Arrhythmia Monitoring

Practice Exercise 1

Have students attach a simulator and 3-, 5-, and 10-Lead ECG set to the MRx (5- or 10-Lead set preferred), set the simulator to a normal sinus rhythm, and complete a variety of lead selections for Wave Sectors 2, 3, and 4, as appropriate. Try adding a parameter to see how a wave sector is affected. Pose the following questions:

1. How do Wave 2, 3, and/or 4 menus differ from each other in terms of available leads? From Wave

1 menu?

2. What wave size(s) provide the clearest wave form?

3. What happens when you add a parameter?

Additional points/notes:

________________________________________________________________

29

3 ECG and Arrhythmia Monitoring Lesson Presentation

Heart Rate and Arrhythmia Alarms

Introduction

Set the simulator and the MRx to produce a variety of alarm conditions and discuss MRx alarm characteristics, latching, and INOP messages, as follows.

• Alarm conditions are detected by comparing ECG data to a set of pre-defined criteria.

• Alarms are triggered by rate exceeding threshold, abnormal rhythm, or ectopic event.

• Alarm messages appear in the alarm status area located just above the HR numeric; accompanied by both audible and visual alert signals.

• Multiple alarm conditions are possible; the most serious or highest priority alarm condition takes priority (i.e., is announced first) and overrides lower priority alarms (e.g., extreme BRADY over low HR).

• Because the ST/AR Basic Arrhythmia Algorithm is the HeartStart MRx’s cardiotach source and is needed to generate heart rate and heart rate alarms, the algorithm can never be disabled. However, if desired, arrhythmia and heart rate alarms can be turned off.

Arrhythmia Alarm Latching

Review the arrhythmia alarm categories.

• Latching alarms are announced and remain present, regardless of whether the alarm condition still exists, until either acknowledged or a higher priority condition occurs.

• Non-latching alarms are automatically removed when a condition no longer exists.

HR/Arrhythmia Red Alarms

Alarm Message Condition Indicator Latching/

Non-Latching

Asystole No detectable beats for four

seconds in the absence of Vfib

VFIB/VTACH A fibrillatory wave detected

for four seconds

VTACH Consecutive PVCs and HR

exceed defined limits

Extreme Brady 10 bpm below HR Low

limit, capped at 30 bpm

Extreme Tachy 20 bpm above HR High

limit capped at 200 bpm (adult) or 240 bpm (pedi)

Red alarm message, alarm tone

Latching

30

Lesson Presentation 3 ECG and Arrhythmia Monitoring

HR/Arrhythmia Yellow Alarms

Alarm Message Condition Indication Latching/

Non-Latching

HR High The HR exceeds the configured

HR high limit

HR Low The HR is below the configured

HR low limit

PVC/min. High (value > limit)

The number of detected PVCs in a minute exceeds the limit of 15 (adult/pedi)

Pacer Not Capture No QRS following a pacer pulse Yellow alarm

Pacer Not Pacing No QRS or pacer pulse detected Yellow alarm

Alarm Chain for Basic Arrhythmia Monitoring

(RED ALARMS)

Extreme Tachy

Asystole

V-Fib/V-Tach

V-Tach

Extreme Brady

Yellow alarm message, alarm tone

message, alarm tone

Non-Latching

Latching

Frequent PVCs

PVCs>xx/Min.

(YELLOW ALARMS)

Beat Detection Alarms Rate AlarmsPVC Alarms

PNC*

PNP*

First level timeout period

Second level timeout period

* PNC = Pacer Not Capture PNP = Pacer Not Pacing

High HR Low HR

31

3 ECG and Arrhythmia Monitoring Lesson Presentation

INOP Messages

Review INOP messages. Produce only 1-2 messages for reference purposes.

• Communicate conditions preventing ECG monitoring or analysis.

• Displayed just above the HR/Arrhythmia alarm status area.

• Multiple messages alternate every 2 seconds.

Alarm Message Condition Indication

Practice Exercise 2

Have students set the simulator and MRx to produce a variety of latching, non-latching, and INOP conditions, as appropriate. Pose the following questions:

Cannot Analyze ECG Cannot reliably monitor the ECG in

Wave Sec t or 1.

ECG Cable Failure During the Operational Check, a short

has been detected between a lead wire and ground.

Leads Off An electrode used for Wave Sector 1

may be off or not attached securely.

Pads /Paddles Off The multifunction electrode pads used

as the source for the Wave Sector 1 may be off or not attached securely.

ECG Unplugged The primary ECG is derived from leads

and the ECG cable is not connected.

ECG Equip Malfunction A malfunction has occurred in the

ECG hardware.

Pads/Paddles Cable Failure

Pads ECG Equip Malfunction

During the Operational Check, a failure was detected in the pads or paddles cable during the pads/paddles ECG test.

A device hardware failure was detected. INOP message, INOP tone

INOP message, INOP tone

INOP message, INOP tone, dashed line

INOP message, INOP tone

32

1. What do you see and hear when a red alarm goes off? A yellow alarm? An INOP message?

2. If you acknowledge the Alarm Pause message in response to an alarm, will you be alerted if the

patient’s condition persists or recurs?

Lesson Presentation 3 ECG and Arrhythmia Monitoring

Additional points/notes:

________________________________________________________________

Setting Alarms

Introduce setting alarms.

• Alarms are automatically enabled in Monitor and Pacer Modes.

• In Manual Defib Mode, alarms are automatically enabled if the Sync function is enabled. If the Sync function is not enabled, alarms are enabled using the Alarm Pause button.

• Alarms alert you when values exceed or fall below defined limits.

• Heart rate (HR) and VTACH alarm settings are as configured but may be changed during operation for the current patient.

• The PVC rate limit setting may only be changed in response to a PVC rate alarm condition.

• Other HR and arrhythmia alarms may not be changed.

Changing Heart Rate or VTACH Alarm Limits

Demonstrate the steps to change HR or VTACH limits.

1. Press the Menu Select button.

2. Select Measurements/Alarms and press Menu Select.

3. Select HR/Arrhythmia and press Menu Select.

4. Select HR Limits and press Menu Select.

5. Select new values and press Menu Select.

6. Select VTACH Limits and press Menu Select.

7. Select new values and press Menu Select.

Enabling/Disabling Heart Rate and Arrhythmia Alarms

Demonstrate the steps to enable or disable HR and arrhythmia alarms.

1. Press Menu Select.

2. Select Measurements/Alarms and press Menu Select.

3. Select HR/Arrhythmia and press Menu Select.

4. Select Alarms On/Off and press Menu Select.

33

3 ECG and Arrhythmia Monitoring Lesson Presentation

Note the following: Disabling alarms prevent all alarms associated with HR measurements from being annunciated. If an alarm condition occurs, no alarm indication will be given.

Responding to HR and Arrhythmia Alarms

Discuss and demonstrate how to respond to alarms.

• The Audio Pause label appears when an alarm is announced.

• Menu Select or Navigation buttons silence alarm audio.

• Two minutes after being paused, if an alarm condition still exists, the alarm audio re-sounds.

• Respond to an HR or Arrhythmia alarm, as follows:

1. Acknowledge the alarm condition.

2. Adjust the limits using the New Limits menu.

Practice Exercise 3

Have students change HR or VTACH limits, and enable/disable and respond to HR and arrhythmia alarms.

Additional points/notes:

________________________________________________________________

34

Lesson Presentation 3 ECG and Arrhythmia Monitoring

Displaying an Annotated ECG

Demonstrate how to display an annotated ECG.

• Beat labels appear in Wave Sector 2 based on the ST/AR Algorithm analysis.

• Beat labels appear in Wave Sector 1 after a six second delay.

• Below are the various beat labels with related descriptions.

Label Description Displayed Location

NNormal Above QRS

VVentricular Ectopic Above QRS

P Paced Above QRS

' Pacer spike Above the waveform where the pacer spike is

detected. (If the patient is both atrially and ventricularly paced, the display will show two ' marks above the waveform aligned with the atrial and ventricular pacing.)

L Learning Patient’s ECG Above QRS

A Artifact (noisy episode) Above the waveform where the noise is

detected.

? Insufficient information to classify beats Above QRS

I Inoperative condition (e.g. LEAD OFF) Above the waveform at start of INOP, every

second of INOP, and at end of INOP

M Pause, Missed Beat, No QRS at beginning of

asystole

Above the waveform where the condition is detected

To display an annotated ECG:

1. Press Menu Select.

2. Select Displayed Waves and press Menu Select.

3. Select Wave 2 and press Menu Select.

4. Select Annotated ECG and press Menu Select.

Practice Exercise 4

Have students display an annotated ECG. Pose the following question:

1. Where does the annotation first appear?

Additional points/notes:

________________________________________________________________

35

3 ECG and Arrhythmia Monitoring Lesson Presentation

Arrhythmia Learning/Relearning

Discuss and demonstrate how the MRx learns and relearns automatically and manually.

• To ensure the ST/AR Algorithm can properly analyze the patient’s normal and/or paced complexes,

MRx automatically performs arrhythmia learning/relearning:

– when the Therapy Knob is turned to Monitor, Pacer, or Manual Defib.

– when there is a change in the lead selection for Wave Sector 1.

– after the correction of a “Leads or Pads Off” INOP condition that has been active longer than

60 seconds.

•Initiate manual relearning if beat detection is not occurring or if beat classification is incorrect and

results in a false alarm. To initiate relearning manually:

1. Press Menu Select.

2. Select Measurements/Alarms and press Menu Select.

3. Select HR/Arrhythmia and press Menu Select.

4. Select Relearn Rhythm and press Menu Select.

The messages “Learning ECG” and “Learning Rhythm” appear in the rhythm status area of the display.

Practice Exercise 5

Have students complete the steps to initiate manual relearning, as appropriate.

Additional points/notes:

________________________________________________________________

36

Review 3 ECG and Arrhythmia Monitoring

Review

Have students answer the following questions individually or as a group. (Correct answers are in bold. Consider having students correct FALSE statements to ensure comprehension.)

1. Identify the Monitoring View elements. (4 wave sectors, INOP area, ECG/HR alarms, HR

values, alarm settings)

2. True or false? You can select the ECG lead for Wave Sectors 1-4 using the Lead Select button. (F -

The Lead Select button can only be used with Sector 1.)

3. Which of the following alarms can ONLY be changed while IN RESPONSE TO AN ALARM

CONDITION?

a. HR

b. PVC

c. VTACH

4. Which of the following statement(s) are TRUE?

a. All arrhythmia alarms are classified as "latching" alarms. (F - Some are non-latching.)

b. Yellow alarms can communicate equipment failures. (F - INOP messages do this.)

c. Alarms are enabled as soon as you enter Manual Defib Mode if the Sync function is enabled.

(T)

d. Menu Select AND Navigation buttons can acknowledge alarms. (T)

5. True or false? The MRx automatically performs arrhythmia learning/relearning when there is a

lead selection change for Wave Sector 1 or 2. (F - Automatic relearning takes places when there is

a lead change for Wave Sector 1 only.)

37

Instructor Guide

Lesson Introduction

Introduce the lesson, including the learning objectives, estimated time to complete, and applicable resources.

4

4Semi-Automated

External Defibrillation

This lesson describes how to use AED Mode. It highlights the AED display view and explains the steps and associated prompts that guide users through the defibrillation process.

Objectives

Upon completion of this lesson, students should be able to:

1. Locate pertinent information in AED View.

2. Prepare a patient for AED defibrillation.

3. Defibrillate in AED Mode.

Time

10-15 minutes

Accessories Recommended

•Simulator

•Hands-free cable

• Multifunction electrode pads

Clinical Resources

• AED Algorithm Application Note (M3500-91040)

• SMART Biphasic Application Note (M3535-91040)

39

4 Semi-Automated External Defibrillation Lesson Presentation

Lesson Presentation

Overview

Introduce the Semi-Automated External Defibrillation (AED) Mode.

• AED Mode guides users through standard treatment algorithms for cardiac arrest.

• It includes voice and screen prompts for defibrillation preparation, ECG analysis, and shock delivery.

• You can customize AED Mode configuration to meet your organization’s needs.

• AED Mode is not intended for children under 8 years of age. For children 8 years of age and older, the American Heart Association recommends that standard operating procedures for AEDs be followed.

• AED Mode may include Q-CPR measurement and feedback, if so equipped. (See the Q-CPR lesson for details.)

AED View

Connect a simulator to the MRx, set it to normal sinus rhythm (NSR), and turn the Therapy Knob to AED. Then, introduce the unique AED View characteristics.

• Enlarged ECG (Wave Sectors 1 and 2 combined)

•Enlarged Event Timer

• Shock Counter (with total number of shocks delivered in AED/Manual Defib Modes)

• Text message window, accompanied by related voice prompts

Suggestion: Ask students to point out characteristics instead of YOU stating them.

Additional points/notes:

________________________________________________________________

40

Lesson Presentation 4 Semi-Automated External Defibrillation

Preparation

Discuss the AED defibrillation preparation.

1. Confirm the patient’s condition (i.e., unresponsive, not breathing, and/or pulseless).

2. Prepare the patient’s chest. Wipe moisture away and, if necessary, clip or shave excessive chest hair.

3. Apply multifunction electrode pads to the patient as directed on the pads package, using the

anterior-anterior electrode placement.

Note the following: The AED algorithm used by the MRx has not been validated using anterior-

posterior pads placement.

4. If not pre-connected, insert the pads cable into the green Therapy port. DEMONSTRATE

5. Connect the pads to the pads cable. DEMONSTRATE

Suggestion: Have students complete steps 4 and 5.

Additional points/notes:

________________________________________________________________

41

4 Semi-Automated External Defibrillation Lesson Presentation

AED Mode

Demonstrate the AED defibrillation steps with the simulator set to VF (V-Fib).

1. Turn the Therapy Knob to AED.

2. Follow the voice and screen prompts.

3. Press the orange Shock button, if prompted.

Mention the following AED Mode characteristics during the demonstration.

• Device capabilities are limited to those essential to AED.

• Only the ECG acquired through pads is displayed. No other parameters appear.

• Shockable rhythms are VTACH-High and V-Fib.

• Previously-set alarms and scheduled measurements are indefinitely paused.

• Entry of patient information is disabled.

• Sync, Lead Select, and Alarm Pause buttons are inactive.

• The voice prompt volume is easily adjusted.

Suggestion: Ask students to help point out characteristics instead of YOU stating them all.

Additional points/notes:

________________________________________________________________

42

Lesson Presentation 4 Semi-Automated External Defibrillation

Turn the Therapy Knob to AED

When the MRx is turned to AED, it checks for proper pads cable and pads connection, as follows.

If the:

pads cable is not properly attached

- pads are not connected to the pads cable,

- pads are not applied to the patient, or

- pads are not making proper contact with the patient’s skin

you are prompted to:

Connect Pads Cable

Apply Pads and Plug in Connector

Practice Exercise 1

Have students turn the Therapy Knob to AED without a pads cable and/or pads connected to see what prompts are generated.

Additional points/notes:

________________________________________________________________

43

4 Semi-Automated External Defibrillation Lesson Presentation

Follow the Screen and Voice Prompts

Next, connect the pads and pads cable, set the simulator to a shockable rhythm (e.g., VF), and complete the defibrillation process (steps 2 and 3).

Note the following:

• Once an ECG is detected, MRx automatically analyzes the patient’s heart rhythm and warns not to touch the patient.

If:

artifact interferes with analysis

artifact persists

• Analysis is suspended during pause time. Ensure good pads contact and minimize movement. Analysis resumes automatically after 30 seconds or when you press

Discuss impedance related to patient preparation and pads and paddles placement, and its impact on delivering an effective shock.

• Impedance is the resistance between the defibrillator’s multifunction electrode pads or paddles that the defibrillator must overcome to deliver an effective discharge of energy. The degree of impedance differs from patient to patient and is affected by several factors including the presence of chest hair, moisture, hand lotions or powders on the skin.

• The MRx’s low-energy SMART Biphasic waveform is an impedance-compensating waveform designed to be effective across a wide range of patients, with no influence of body weight on shock success. However, if you receive a "No Shock Delivered" message, check that the patient’s skin has been washed and dried and that any chest hair has been clipped. If the message persists, change the pads and/or the pads cable.

Suggestion: Reference and read through the SMART Biphasic Application Note (M3535-91040) for further details on the SMART Biphasic waveform, as appropriate.

you get the message:

Analyzin g Interrupte d , Do N o t Touch the Pat i e n t

Cannot Analyze and Paused. Attend To Pati ent

[Resume Analyzing].

Shock Advised

Mention that if a shockable rhythm is detected, the MRx:

• Automatically charges to 150J.

• Generates voice and screen prompts and a steady high-pitched tone.

• Displays a flashing Orange Shock button when fully charged.

• Analyzes heart rhythm while charging.

• Disarms if a rhythm change is detected before a shock is delivered and no longer appropriate.

Note the following: You can disarm a fully charged device by turning the Therapy Knob to Off or by pressing the [Pause for CPR] soft key. Resume monitoring by turning the Therapy Knob back to AED.

44

Lesson Presentation 4 Semi-Automated External Defibrillation

Additional points/notes:

________________________________________________________________

Press the Orange Shock Button, if Prompted

Now complete the Shock step. Note the following:

• MRx prompts Deliver Shock Now; Press the Orange Button Now once charging is complete.

• No one should be touching patient or anything connected to patient. Call out clearly and loudly “Stay Clear!” Then, press the orange Shock button.

•The Shock Delivered message confirms shock delivery.

• The shock counter gets updated.

• An annotated strip is automatically printed.

• MRx prompts Paused. If Needed, Begin CPR, and commences analysis at the completion of the pause

period or when you press the [Resume Analyzing] soft key.

• The CPR pause length is defined by the configured CPR timer period. Q-CPR may be activated if the MRx is equipped with this option.

Practice Exercise 2

Have students attach a simulator to the MRx, set it to a shockable rhythm (e.g., VF), and complete defibrillation (with one shock). Pose the following questions:

1. What screen prompts do you see and voice prompts do you hear initially?

2. How do you know the device is ready to deliver a charge?

3. What do you see and hear after delivering a shock?

4. What happens when you press the [Resume Analyzing] soft key?

45

4 Semi-Automated External Defibrillation Lesson Presentation

Additional points/notes:

________________________________________________________________

No Shock Advised (NSA)

Finally, set the simulator to a normal sinus rhythm (NSR). Tell users how their MRx is configured for NSA (Monitor or a pause time setting). Mention that if a shockable rhythm is not detected, MRx:

•Informs that No shock advised

If the NSA is set to: MRx:

Monitor • monitors the ECG and periodically prompts If needed, press

Pause and begin CPR.

Pause Time • suspends analysis, during which time you can administer CPR

and attend to the patient.

• displays a Pause status bar and resumes analysis at the completion of the pause period.

Practice Exercise 3

Have students set the simulator to NSR. Consider both Monitor and Pause Time configuration choices. Pose the following questions:

1. What screen prompts do you see and voice prompts do you hear?

2. What happens when you press the [Pause for CPR] soft key?

Additional points/notes:

________________________________________________________________

46

Review 4 Semi-Automated External Defibrillation

Review

Have students answer the following questions individually or as a group. (Correct answers are in bold.)

1. Identify the AED View elements. (Event timer, enlarged ECG, shock counter, message window)

2. Apply multifunction electrode pads using anterior-posterior placement for AED. (F - anterior- anterior)

3. What are the three basic steps for AED using the MRx?

a. Turn the Therapy Knob to AED.

b. Follow the voice and screen prompts.

c. Press the orange Shock button, if prompted.

4. Which of the following statement(s) about AED Mode are TRUE?

a. The MRx automatically checks for proper pads cable and pads connection. (T)

b. If artifact interferes with ECG analysis and persists, analysis will suspend but resume

automatically after 60 seconds.

c. The MRx automatically disarms if a shock becomes unnecessary. (T)

(F - Analysis resumes automatically after 30 seconds.)

d. The MRx automatically analyzes the patient’s heart rhythm after a shock is delivered. (T)

47

Instructor Guide

Lesson Introduction

Introduce the lesson, including the learning objectives, estimated time to complete, and applicable resources.

5

5Manual Defibrillation

and Cardioversion

This lesson explains how to prepare for and perform manual asynchronous and synchronous (cardioversion) defibrillation using multifunction electrode pads and external/internal paddles.

Objectives

Upon completion of this lesson, students should be able to:

1. Locate pertinent information in Code View.

2. Prepare a patient for asynchronous and synchronous defibrillation.

3. Perform asynchronous and synchronous defibrillation.

Time

10-20 minutes

Accessories Recommended

•Simulator

•Hands-free cable

• Multifunction electrode pads

• External paddles

• Internal paddles (include M4740A Paddle Adapter Cable for switchless paddles)

• 3-, 5-, or 10-Lead monitoring electrodes

Clinical Resources

• SMART Biphasic Application Note (M3535-91040)

49

5 Manual Defibrillation and Cardioversion Lesson Presentation

Lesson Presentation

Manual Mode

Introduce the Manual Defib Mode.

• The entire defibrillation process is under your control (i.e., you assess the ECG, decide if

defibrillation or cardioversion is indicated, select the appropriate energy setting, charge the device, and deliver the shock).

• Text messages are present; voice prompts are not present.

• Defibrillation is always performed through paddles or pads.

• You can monitor the ECG using an alternate ECG source (3-, 5-, or 10-Lead monitoring

electrodes).

• You should be ACLS certified to use this mode.

• This mode may be password protected, as defined in Configuration.

• This mode may include Q-CPR measurement and feedback, if equipped on the MRx.

Code View

Connect a simulator to the MRx, set it to a normal sinus rhythm (NSR), and turn the Therapy Knob to Manual Defib on the MRx. Introduce the unique Code View characteristics.

•Enlarged Event Timer

•Heart rate

• Enlarged ECG (Wave Sectors 1 and 2 combined)

• Shock counter (with total number of shocks delivered in AED/Manual Defib Modes)

• Text message window

Suggestion: Ask students to point out characteristics instead of YOU stating them.

Additional points/notes:

________________________________________________________________

50

Lesson Presentation 5 Manual Defibrillation and Cardioversion

Manual Defibrillation Preparation

Discuss defibrillation preparation using multifunction electrode pads, external paddles, and/or internal paddles.

Multifunction electrode pads

1. Confirm the patient’s condition (i.e., unresponsive, not breathing, and/or pulseless).

2. Prepare the patient’s chest (i.e., remove clothing, remove moisture from chest, and remove excessive hair).

3. Apply multifunction electrode pads to the patient according to pads package directions or organization’s protocol.

4. If not pre-connected, insert the pads cable into the green Therapy port. DEMONSTRATE

5. Connect the pads to the pads cable. DEMONSTRATE

Suggestion: Have students complete steps 4 and 5.

External paddles

1. Confirm the patient’s condition (i.e., unresponsive, not breathing, and/or pulseless).

2. If not pre-connected, insert the paddles cable into the green Therapy port. DEMONSTRATE

3. Remove the paddles from the paddle tray. DEMONSTRATE

4. Apply the paddles to the patient’s bare chest, using the anterior-anterior placement or your

Suggestion: In your demonstration, mention the patient contact indicator (PCI) on the sternum paddle and how once proper contact is made, the PCI shows a green LED. Also, include access to the pediatric paddles. Have students complete steps 2 and 3. Consider discussing impedance related to patient preparation and pads and paddles placement, and its impact on delivering an effective shock.

• Impedance is the resistance between the defibrillator’s pads or paddles that the defibrillator must

overcome to deliver an effective discharge of energy. The degree of impedance differs from patient to patient and is affected by several factors, including the presence of chest hair, moisture, and lotions or powders on the skin.

• The low-energy SMART Biphasic waveform is an impedance-compensating waveform that is

designed to be effective across a wide range of patients. However, if you receive a "No Shock Delivered" message, check that the patient’s skin has been washed and dried and that any chest hair has been clipped. If the message persists, change the pads and/or the pads cable.

Internal Paddles

1. Select the appropriate switched or switchless paddle electrode size.

organization’s protocol.

2. If using switchless paddles, connect the paddles to the M4740A Paddle Adapter Cable.

DEMONSTRATE

3. Connect the paddles cable (or the paddle adapter cable) to the MRx. DEMONSTRATE

51

5 Manual Defibrillation and Cardioversion Lesson Presentation

Additional points/notes:

________________________________________________________________

Manual Defibrillation

Start with a brief demonstration of the manual defibrillation steps with a simulator set to VF (VFib).

1. Turn the Therapy Knob to Manual Defib and select an energy setting.

2. Press the Charge button on the MRx (or external paddle).

3. Make sure no one is touching patient or anything connected to patient before shock; call out

loudly and clearly “Stay Clear”.

4. Press the orange Shock button on the MRx (or the buttons on both external paddles).

Mention the following Manual Mode characteristics during the demonstration.

• The energy range is 1 to 200J, with 150J the recommended level for adult patients; 50J is maximum

energy for internal paddles.

• 1-10 (or 1-9) energy setting displays the Select Energy menu, with a default setting of 6J; use the

Navigation buttons to increase or decrease the desired setting and the Menu Select button to complete your selection.

• The energy selection in the Shock Status area changes and a continuous, low-pitch charging tone

sounds as the defibrillator charges.

• The current energy displays and a continuous, high-pitch ‘charge done’ tone sounds at the end of

the charge.

• Monitoring alarms are indefinitely paused once energy is selected for defibrillation; alarms are active

once the Therapy Knob is moved to Monitor or Pacer, or if the Alarm Pause button is pressed

• Automatic NBP measurements are discontinued once energy is selected; manual NBP measurement

can be requested and displayed in its normal position on the display.

• Selected energy can be increased or decreased at any time during charging or after charging is

complete; the defibrillator charges to the selected energy level automatically.

.

52

•Press [

• Do not leave patients unattended when the MRx is in Manual Defib Mode with pads applied to the

Suggestion: Ask students to help point out characteristics instead of YOU stating them all.

Disarm] to disarm the device; if the Shock button is not pressed within the time period

specified in the Time to Auto Disarm configuration setting, the MRx disarms automatically.

patient.

Lesson Presentation 5 Manual Defibrillation and Cardioversion

Practice Exercise 1

Have students attach a simulator and parameter accessories (if appropriate) to the MRx, set the simulator to a shockable rhythm (e.g., VF), and complete manual defibrillation (with 1 shock). Try changing the energy level during and/or after a charge. Pose the following questions:

1. What do you see and hear during a charge?

2. How do you know the device is ready to deliver a charge?

3. What do you see and hear after delivering a shock?

4. How do you know if alarms are active?

5. What happens when you press the [Disarm] soft key?

Additional points/notes:

________________________________________________________________

53

5 Manual Defibrillation and Cardioversion Lesson Presentation

Synchronized Cardioversion

Introduce synchronized cardioversion.

• Synch cardioversion allows synchronized shock delivery with the ECG R-wave monitored in Wave

Sector 1.

• It can be performed through either multifunction electrode pads or external paddles.

• You should monitor ECG through 3-, 5-, or 10-Lead monitoring electrodes when using external

paddles.

Preparation

Discuss cardioversion preparation.

1. Perform the tasks as described in the previous Manual Defibrillation Preparation topic.

2. If monitoring through a 3-, 5-, or 10-Lead ECG cable, plug the cable into MRx’s ECG port, and apply monitoring electrodes to the patient.

3. Use the Lead Select button to select pads, paddles, or a lead from attached monitoring electrodes.

Suggestion: Have students complete steps 2 (using a simulator) and 3.

Additional points/notes:

________________________________________________________________

54

Lesson Presentation 5 Manual Defibrillation and Cardioversion

Synchronized Shock Delivery

Demonstrate synchronized cardioversion with a simulator set to AFib.

1. Turn the Therapy Knob to Monitor and press the Sync button.

2. Confirm that the Sync marker appears with each R-wave. If the marker does not appear, select another lead.

3. Turn the Therapy Knob to Manual Defib and select an energy setting.

4. Press the Charge button on the MRx (or external paddle).

5. Make sure no one is touching the patient or anything connected to the patient before delivering a shock.; call out loudly and clearly “Stay Clear”.

6. Press and hold the Shock button on the MRx (or orange buttons on both paddles). The shock will be delivered when the next R-wave is detected.

Mention the following cardioversion characteristics during the demonstration.

• The selected energy can be changed at any time during charging or after charging is complete; the

MRx charges to the selected energy level automatically.

•Press [

• This point is important to emphasize: Continue to hold the Shock button (or the paddle shock

• Confirm sync markers on the R-wave are appropriate and repeat above steps 4-6 to deliver

• The Sync function can be configured to either be enabled or disabled after each shock is delivered. If

• Press the Sync button again to turn off the Sync function.

• This point is important to emphasize: REMEMBER to turn Sync off if manual defibrillation is

Suggestion: Ask students to help point out characteristics instead of YOU stating them all.

Disarm] to disarm the defibrillator; if the Shock button is not pressed within the time period

specified in the Time to Auto Disarm configuration setting, the MRx disarms automatically.

buttons) until the shock is delivered so the defibrillator shocks the next detected R-wave.

additional synchronized shocks, assuming Sync is enabled. If Sync is off, complete steps 1-6.

enabled and the Therapy Knob is moved to either Monitor or Pacer, the Sync function is still active. If the Therapy Knob is moved to either Off or AED, the Sync function is disabled.

required.

55

5 Manual Defibrillation and Cardioversion Lesson Presentation

Practice Exercise 2

Have students attach a simulator and pads to the MRx, set the simulator to a shockable rhythm (e.g., VF), and complete synchronized cardioversion. Pose the following questions:

1. What do you see when you press the Sync button?

2. How do you know if sync is active?

3. How long do you need to press the Shock button?

4. Once in Sync mode, what happens when you turn the Therapy Knob to a position other than Manual Defib?

5. What happens when you press the Sync button again?

Additional points/notes:

________________________________________________________________

56

Review 5 Manual Defibrillation and Cardioversion

Review

Have students answer the following questions individually or as a group. (Correct answers are in bold.)

1. Identify the Code View elements. (Event timer, heart rate, enlarged ECG, shock counter)

2. What are the three basic steps for manual defibrillation using the MRx?

a. Turn the Therapy Knob to Manual Defib on a desired energy level.

b. Press the Charge button.

c. Press the Shock button.

3. Which of the following statement(s) indicate that the MRx is ready to deliver a shock via pads?

a. The device sounds a continuous high-pitched tone. (Y)

b. The Charged value on the display matches the Therapy Knob setting. (Y)

c. The disarm soft key is disabled. (N)

d. The Shock button flashes. (Y)

4. What are the four basic steps for synchronized cardioversion using the MRx?

a. Turn the Therapy Knob to Monitor and press the Sync button.

b. Turn the Therapy Knob to Manual Defib on a desired energy level.

c. Press the Charge button.

d. Press and hold the Shock button.

57

Instructor Guide

6

Lesson Introduction

Introduce the lesson, including the learning objectives, estimated time to complete, and applicable resources.

This lesson describes how to set-up and use the Q-CPR™ option available on the HeartStart MRx.

Objectives

Upon completion of this lesson, students should be able to:

1. Identify intended use and preparation for use related to Q-CPR.

2. Identify characteristics related to Q-CPR in Manual Defib and AED Modes.

Time

15-20 minutes

Accessories Recommended

•Pads/CPR cable

6Q-CPR

™

• Compression sensor

• Compression sensor adhesive pads

• Philips multifunction electrode pads

•Ambu bag

• Resusci Anne manikin (to perform compressions only)

Note: To perform and measure both compressions and manikin and Q-CPR Trainer are required.

Clinical Resources

• Q-CPR™ Measurement and Feedback Application Note (M3535-91980)

Note: Q-CPR™ is a trademark of Laerdal Medical.

ventilations, the Resusci Anne SkillReporter

59

6Q-CPR™ Lesson Presentation

Lesson Presentation

Overview

Introduce the Q-CPR option and its intended use.

• Q-CPR offers real-time measurement and corrective feedback on compression rate, depth, and

duration, as well as ventilation rate, volume, and flow rate (inflation time). It also provides notification of CPR inactivity.

• Compressions are measured through the signal acquired by the Compression Sensor. Ventilation

data is acquired through multifunction defib electrode pads in conjunction with signals from the sensor.

• Q-CPR is intended for use with only the HeartStart MRx and available in Manual Defib Mode and

AED Mode. Both modes provide audio prompts and visual indicators when CPR performance deviates outside of target ranges and in accordance with AHA/ERC guidelines.

• Q-CPR is contraindicated for use:

– on neonatal and pediatric patients (under 8 years of age or weighing less than 25 kg).

– when CPR is contraindicated.

– in a moving environment (e.g., ambulance). Additional movement introduced during patient

transport may reduce compression and ventilation measurement accuracy. If Q-CPR must be used in a moving environment, do not rely on the Q-CPR feedback during such conditions. There is no need to remove the Compression Sensor from the patient.

– with any other CPR compression devices (aside from the Q-CPR Compression Sensor)

• Events related to Q-CPR are not stored in the HeartStart MRx Event Summary.

• There is a Q-CPR Data Capture option available that allows you to capture data on CPR quality

from the HeartStart MRx using the Q-CPR option. The Q-CPR Data Capture option stores CPRrelated data for retrospective review and analysis using Q-CPR Review software available from Laerdal Medical Corporation. (See the Q-CPR Review Directions for Use for more information on Q- CPR Review software.)

Additional points/notes:

________________________________________________________________

60

Lesson Presentation 6Q-CPR™

Q-CPR Preparation

Discuss cable connections and preparation for Q-CPR.

Pads/CPR Cable to the MRx

The Q-CPR option requires the use of the Pads/CPR cable (M4763A). To connect the Pads/CPR cable:

1. Align the white pointer on the cable with the white arrow on the green Therapy port and insert the cable into the port. Push until you hear it click into place. DEMONSTRATE

Suggestion: Have students complete this step.

Note the following, as appropriate:

• Pre-connect the Pads/CPR cable to the MRx (prior to a resuscitation event or rescue) to save on set-

up time.

• The Q-CPR option requires the Pads/CPR cable to be connected to the HeartStart MRx. CPR

feedback is not available if the standard pads or paddles cable is connected.

Compression Sensor to the Pads/CPR Cable

1. Align the key marker on the Compression Sensor cable with the key marker on the receptacle end of the Pads/CPR cable. Push until you hear it click into place. DEMONSTRATE

Suggestion: Have students complete this step.

Note the following:

Pre-connect the Compression Sensor cable to the Pads/CPR cable to save time on set-up.

Compression Sensor Adhesive Pad

1. Peel the white rear liner from the bottom of the Compression Sensor Adhesive Pad. (The rear liner is blank.) DEMONSTRATE

2. Align the Compression Sensor Adhesive Pad with the yellow area of the Sensor and press into place. DEMONSTRATE

Suggestion: Have students complete steps 1 and 2.

Note the following:

• The Compression Sensor Adhesive Pad is intended for single-patient use only.

• Pre-attach the Compression Sensor Adhesive Pad to the Compression Sensor to save time on set-up.

For pre-connection storage, refer to the Setting Up section of the MRx Instructions for Use.

61

6Q-CPR™ Lesson Presentation

Multifunction Electrode Pads

1. Check the expiration date on the pads package and inspect the packaging for any damage.

2. Prepare the patient’s chest.

3. Apply the pads to the patient as directed on the pads package, using the anterior-anterior placement. DEMONSTRATE (if manikin available)

4. Connect the pads to the Pads/CPR cable. DEMONSTRATE

Suggestion: Have students complete steps 3 (if a manikin is available) and 4.

Note the following:

• The ventilation algorithm used by Q-CPR requires an anterior-anterior pads placement. Anterior-

posterior pad placement should not be used.

• Pads need to be applied securely and maintain good contact to ensure a good signal for ventilation

detection. The inop message Poor Pads Contact or Pads Off displays if there is a contact problem.

Compression Sensor on the Patient

1. Ensure the patient’s skin is clean and dry. If necessary, clip or shave the hair from the sternum area.

2. Peel the green liner away from the Compression Sensor Adhesive Pad using the yellow pull tab on the top liner. DEMONSTRATE

3. Position the Compression Sensor on the patient as shown in the graphic displayed on the green liner. The proper location is on the lower half of the sternum, which is at the normal CPR hand location. DEMONSTRATE

4. When the Compression Sensor is on the patient’s chest, the flat grey surface should be facing up. Place the heel of your hand on the flat grey surface in the same way that you would position your hand on the patient’s chest if performing CPR without the Compression Sensor. Perform compressions according to AHA/ERC guidelines. DEMONSTRATE (with shallow, simulated

compressions if on a person and full compressions if on a manikin)

Suggestion: Have students complete steps 2-4.

Note the following:

• Do not apply the Compression Sensor to an open wound or recent incision site.

• CPR is best performed when the patient is lying on a firm surface. If the patient is on a compliant

surface such as a mattress, the patient should be placed on a backboard.

• The accuracy of ventilation feedback may be decreased when the patient is handled or moved, or

when the Q-CPR option is used on patients with certain conditions such as trauma, seizures, reduced lung volume, or high cardiac ejections.

62

Lesson Presentation 6Q-CPR™

Practice Exercise 1

Have students make all cable attachments and then detach a cable (e.g., Pads/CPR or Compression

Sensor cable) to see what inop is produced. For example, the message Connect Pads/CPR Cable displays if not pre-connected. Loosen a multifunction pad to see what inop is produced (e.g., Poor Pads Contact or Pads Off. Make sure students attach the Compression Sensor pad properly and the

Compression Sensor is placed properly on the patient (or manikin).

Additional points/notes:

________________________________________________________________

63

6Q-CPR™ Lesson Presentation

Q-CPR in Manual Defib Mode

Demonstrate Q-CPR in manual defibrillation mode with a simulator set to VF (VFib).

1. Turn the Therapy Knob to Manual Defib and select the 150J energy setting to automatically display the Q-CPR sub view.

Note the following:

• The Sync function must be disabled, the patient category must be Adult, and patient age must be

equal to or greater than 8 years old to automatically display the Q-CPR sub view.

• If Manual Therapy Security is enabled, the CPR sub view is not automatically displayed. The CPR

sub view is automatically displayed after the Manual Therapy Security password is entered.

• When the Therapy Knob is set on any other Manual Defib setting, patient category is Adult, and

patient age is equal to or greater than 8 years old, the first CPR compression displays the Q-CPR sub view.

Mention the following Manual Defib Q-CPR view characteristics while performing CPR (preferably on a manikin). Consider enlisting two students to perform compressions and ventilations so that you can focus on discussion of the characteristics.

• Wave forms for ECG, invasive pressure (ABP, ART Ao or PAP), and CO

during the use of Q-CPR. If an ABP, ART Ao or PAP pressure measurement is active, the waveform always appears in Wave Sector 3 and the pressure value displays in Parameter Block 2. If two pressures labeled ABP, ART, Ao or PAP are available, the label assigned to Pressure 1 is displayed. If no pressure is active, then the compression waveform appears in Wave Sector 3. Parameter Block 2 displays compression and ventilation measurement information. The EtCO in Wave Sector 4 if present. AwRR numeric values are not displayed.

Compression waveform

• The compression waveform appears in Wave Sector 3, is labeled Comp, and represents

approximately 10 seconds of compressions.

• As the chest is compressed, the chest compression is shown as a downward stroke of the wave,

rebounding up to a baseline as compression pressure is released.

• The wave sector contains horizontal lines drawn at 38 mm and 51 mm (or 1.5” and 2”) that define

a target zone for appropriate chest compression depth. Good compression depth is achieved when the peak, or minimum value, of the waveform appears between the lines.

• An asterisk (*) annotates when pressure is not released between compressions, also referred to as

“leaning”.

• If the Compression Sensor signal becomes invalid (e.g. the sensor is disconnected), the waveform

appears as a dashed baseline. Suggestion: Disconnect the sensor to display the dashed baseline.

parameters can be viewed

2

waveform will appear

2

64

Lesson Presentation 6Q-CPR™

Parameter Block 2

• Parameter Block 2 displays numeric values for compression and ventilation rates. Both rates are a

moving average rate, measured per minute. Based on the Q-CPR algorithm, the target compression rate is 100 compressions per minute within an acceptable range of 90-120 compressions per minute. The acceptable range for ventilation rate while CPR is being administered is 4-16 ventilations per minute (to reflect 2005 resuscitation guidelines)

• The acceptable range for ventilation rate following 60 seconds without compressions (such as while

rescue breathing is being administered) is 9-16 ventilations per minute.

• The ventilation volume icon depicts an approximate level of ventilation volume. A set of lungs

graphically shows four states of the ventilation’s magnitude: empty, one-third full, two-thirds full, and full. After a brief display, the icon returns to the empty state. Lungs marked with a “?” indicate when ventilation cannot be measured.

Note the following: The graphical lungs do not signify the actual filling or presence of both lungs in the patient. The actual ventilation volume associated with filling of the lung icon varies from patient to patient. Actual lung expansion is based upon chest rise and checking bilateral breath sounds.

• The No Flow Time value represents time without a detectable chest compression, beginning at 2

seconds and incremented with each additional second. A voice prompt is given every 15 seconds that compression activity is not detected. The No Flow Time value is reset when a compression occurs or when the Shock button on the HeartStart MRx is pressed. If the No Flow Time value exceeds 1 minute, it is assumed that CPR compression activity has stopped intentionally and the value is cleared.

Soft Keys

• If monitoring CO

, the EtCO2 numeric value is displayed in Parameter Block 2, along with its

2

alarms off indicator.

Note the following:

•SpO

monitoring functionality is not available during Q-CPR use.

2

• Compression, ventilation, and No Flow measurement values are printed in the annotation area of

the ECG printed strip. Suggestion: Print a strip to exhibit the values.

Toggle between the soft keys in manual defibrillation mode and discuss the following characteristics.

• The Q-CPR sub view is manually displayed by pressing the [Start CPR] soft key from any

energy setting (excluding 150J). This soft key is then labeled [Stop CPR] and may be used to switch between the Q-CPR sub view and the standard Code View. The Q-CPR sub view and [Stop CPR] soft key display automatically upon the first CPR compression from any energy setting (excluding 150J).

• If the Sync button is pressed to initiate synchronized cardioversion, Q-CPR is deactivated.

Reactivate Q-CPR by pressing the [Start CPR] soft key or performing chest compressions.

• If the Alarm Pause button is used to turn alarms on, Q-CPR is deactivated.

65

6Q-CPR™ Lesson Presentation

•The [Intubate] soft key displays in the Q-CPR view in both Manual Defib Mode and AED

Mode. When intubation is indicated by pressing the [Intubate] soft key, the soft key then becomes inactive and its label changes to [Intubated].

Note the following:

– When intubation is indicated, the Ventilate Less Forcefully and Ventilate a Little Less Forcefully

audio feedback is suppressed.

– The Q-CPR option should not be used to verify placement of airway adjuncts, such as

endotracheal tubes and laryngeal masks.

Suggestion: Ask students to help point out compression waveform, parameter block, and soft key characteristics instead of YOU stating all characteristics.

Practice Exercise 2

Have students turn to 150J manual defibrillation setting and practice performing CPR alone and with another student on a manikin (to experience 1- and 2-rescue person situations) according to AHA guidelines for compression-to-ventilation ratio. Make sure each student has proper hand, arm, and body position to perform CPR. Also, press the Sync button to show what happens to Q-CPR when you switch to synchronized cardioversion or the Alarm Pause button to show what happens to Q-CPR. Pose the following questions:

1. What voice prompts do you hear when performing CPR? What is the most frequently heard prompt? (Note: The prompt will vary depending on the student.)

2. How long can you perform CPR without getting a voice prompt? How long could you perform CPR before getting totally fatigued?

3. What range of compression and ventilation rates do you achieve?

4. How full does the ventilation (lungs) icon get when you do ventilations?

5. How often do you get ‘No Flow’ times and how long are those times?

6. What happens to Q-CPR when you press the Sync and or Alarm Pause buttons?

Additional points/notes:

________________________________________________________________

66

Lesson Presentation 6Q-CPR™

Q-CPR in AED Mode

Demonstrate Q-CPR in AED mode. Turn the Therapy Knob to AED, press the Pause for CPR soft key, and mention the following AED Q-CPR view characteristics while performing CPR. Consider enlisting two students to perform compressions and ventilations so that you can focus on discussion of Q-CPR characteristics.

• In AED Mode, Q-CPR provides CPR feedback automatically during the CPR Pause period of the

AED protocol or manually when the [Pause for CPR] soft key is pressed.

• If your No Shock Advised (NSA) Action configuration item is set to provide a CPR Pause interval,

Q-CPR can be activated by delivering a compression with the Compression Sensor.

• AED Mode issues voice prompts like Manual Defib Mode; however, it also displays the same

prompts as momentary text messages. For details on all Manual Defib and AED Mode feedback prompts, refer to the CPR Feedback Prompts section of the Q-CPR Instructions for Use Addendum.

• A configurable CPR Timer status bar is also displayed. The time period of the CPR Timer is

determined by the Configuration setting for CPR Pause Time.

• The Q-CPR view in AED Mode displays only the ECG waveform. There is no compression

waveform.

Suggestion: Ask students to help point out characteristics instead of YOU stating them all.

Practice Exercise 3

Have students turn to AED Mode and practice performing CPR alone and with a another student on a manikin (to experience a 1- and 2-rescue person situation) according to AHA guidelines for compression-to-ventilation ratio. Make sure each student has proper hand, arm, and body position to perform CPR. Pose the following questions:

1. What voice and text prompts do you get when performing CPR? What is the most frequent voice or text prompt produced? (Note: The prompt will vary depending on the student.)

2. How long can you perform CPR without getting a voice or text prompt? How long could you perform CPR before getting totally fatigued?

Additional points/notes:

________________________________________________________________

67

6Q-CPR™ Lesson Presentation

CPR Feedback Volume Adjustment

Turn the MRx Therapy Knob to a Manual Defib setting (e.g., 150J) and demonstrate the volume adjustment. Press the Start CPR soft key and mute the voice prompts.

To mute the CPR feedback voice prompts (once you start CPR):

1. Press Menu Select.

2. Select Mute CPR Voice and press Menu Select.

Note the following: When muted, a CPR Voice Muted text message displays in the middle of the

compression waveform, and CPR inactivity time is indicated by an audible tone.

To resume voice prompts set at the previously selected volume:

1. Press Menu Select.

2. Select Resume CPR Voice and press Menu Select.

To adjust the volume of CPR feedback voice prompts:

1. Press the Menu Select button.

2. Select Vol um e and press Menu Select.

3. Select Voi ce and press Menu Select.

4. Select the desired volume level and press Menu Select.

A sample voice prompt is annunciated to confirm your selection.

Suggestion: Have students complete the above volume adjustment steps during or after your demonstration.

68

Review 6Q-CPR™

Review

Have students answer the following questions individually or as a group. (Correct answers are in bold.)

1. True or false? Q-CPR can be used on patients 8 years and older. (T)

2. True or false? The multifunction pads should be placed in an anterior/posterior position to ensure the ventilation algorithm interprets ventilations properly. (F - The pads need to be in an anterior/

anterior position for interpretation.)

3. True or false? The compression sensor should be positioned on the upper half of the patient’s sternum to perform compressions. (F - The sensor should be placed on the lower

sternum, at the normal CPR hand location.)

4. True or false? In Manual Defib Mode, good compression depth is indicated by the downward “peak” of the waveform appearing between the horizontal lines representing the target zone. (T)

5. True or false? The ventilation volume icon indicates ventilation has been detected but not the actual filling of both lungs. (T)

6. True or false? Only AED Mode provides voice and text prompts associated with compression and ventilation activity. (T)

half of the

69

Instructor Guide

Lesson Introduction

Introduce the lesson, including the learning objectives, estimated time to complete, and applicable resources.

This lesson describes the noninvasive transcutaneous pacing option available with the HeartStart MRx and how to perform pacing.

7

7Noninvasive Pacing

Objectives

Upon completion of this lesson, students should be able to:

1. Identify pertinent information in Pacing View.

2. Prepare a patient for pacing.

3. Perform demand or fixed mode pacing.

Time

10-20 minutes

Accessories Recommended

•Simulator

•Hands-free cable

• Multifunction electrode pads

• 3-, 5-, or 10-Lead monitoring electrodes

Clinical Resources

Noninvasive Pacing Application Note (M3500-91060)

71

7 Noninvasive Pacing Lesson Presentation

Lesson Presentation

Pacer Mode

Introduce the Pacer Mode.

• Pacer Mode delivers pace pulses to the heart through multifunction electrode pads.

• The ECG strip and Event Summary are easily annotated (using the Mark Event button) in Pacer

Mode.

• Waveforms, ECG monitoring, measurements, and most alarms (from Monitor or Manual Defib

Mode) remain active and retain their settings while in Pacer Mode.

– The waveform in Wave Sector 4 is replaced by the pacing status bar.

– Arrhythmia alarms for Pacer Not Pacing and Pacer Not Capture (associated with non-

transcutaneous pacing) are off in Pacer Mode. All other red and yellow alarms are active if enabled and their limits may be changed while in Pacer Mode. ECG INOPs are also annunciated.

– If the ECG source for Wave Sector 1 becomes invalid (e.g., a Leads Off condition or the ECG

cable is disconnected) in demand mode pacing, a latching red alarm is generated along with a Pacing Stopped. Leads Off. message, and pacing is stopped. Once the condition is corrected, resume pacing by pressing the [Resume Pacing] soft key.

– Also, while in demand mode, if you are using a 3-lead ECG set and the lead in Wave Sector 1 is

changed, a latching red alarm is generated as well as a Pacing Stopped. Leads Off. message, and pacing is stopped. Once the condition is corrected, resume pacing by pressing the [Resume Pacing] soft key.

– If a Pads Off condition occurs or the pads cable is disconnected, a latching red alarm and Pacing

Stopped. [Pads Off.] [Pads Cable Off.] message is generated and pacing is stopped. Once the condition is corrected, resume pacing by pressing the [Resume Pacing] soft key.

Note the following: The Pacing Stopped red alarm cannot be disabled.

– Heart rate displays and alarms can be unreliable during pacing, so keep close observation on the

patient. Do not rely on the indicated heart rate or related alarms as a measure of the patient’s perfusion status.

– When pacing is stopped due to a power interruption, a red Pacing Stopped. Power Interrupted

alert will appear on the MRx display when power is eventually restored.

72

• For treatment of patients with implantable devices (permanent pacemakers or cardioverter-

defibrillators), consult a physician and the instructions for use provided by the device’s manufacturer.

• The use of Pacer Mode may be password protected, as defined in Configuration.

Lesson Presentation 7 Noninvasive Pacing

Pacing View

Turn the Therapy Knob to Pacer on the MRx and introduce the unique Pacing View characteristics.

• A status block appears in Wave Sector 4. The first line communicates status (active or paused) or

pacing by batteries (if configured) and the second line identifies the pacing mode (demand or fixed), pacing rate (ppm), and pacing output (mA).

• Soft keys set the pacing status (Start/Pause/Resume) and adjust the pacer rate and output.

• White R-wave markers appear on the ECG waveform until capture occurs (if pacing in demand

mode); R-wave markers do not appear on pace beats.

• White pacing markers appears on the Wave Sector 1 ECG waveform with each pacer pulse delivery.

Suggestion: Ask students to point out characteristics instead of YOU stating them.

Additional points/notes:

________________________________________________________________

73

7 Noninvasive Pacing Lesson Presentation

Demand vs. Fixed Mode

Introduce demand and fixed mode pacing.

emand mode

D

• Pace pulses are delivered when the patient’s heart rate is lower than the selected pacing rate.

• Use this mode whenever possible.

• MRx requires a 3-, 5-, or 10-Lead ECG cable and monitoring electrodes as the ECG source while

pace pulses are delivered through pads.

• ‘Pads’ is not displayed in Wave Sector 1. The monitored lead is displayed in Wave Sector 1.

Fixed mode

• Pace pulses are delivered at the selected rate.

• Use when motion artifact or other ECG noise makes R-wave detection unreliable or when

monitoring electrodes are not available.

Note the following: The ECG derived from pads need not be displayed in a wave sector to deliver pacing therapy.

Additional points/notes:

________________________________________________________________

74

Lesson Presentation 7 Noninvasive Pacing

Preparation

Demonstrate preparation for pacing.

1. Prepare the patient’s chest. Wipe moisture away and, if necessary, clip or shave excessive chest hair.

2. Apply multifunction electrode pads to the patient as directed on the pads packaging or according to your organization’s protocol.

3. If not pre-connected, connect the pads cable to the green Therapy port on the MRx.

DEMONSTRATE

4. Connect the pads connector to the pads cable. DEMONSTRATE

5. If pacing in demand mode, apply monitoring electrodes and connect the ECG cable to the ECG port on the MRx. DEMONSTRATE the ECG cable connection.

Note the following: If pacing for long periods of time, check the patient’s skin; apply new multifunction electrode pads, as necessary. Reposition new pads (in a slightly different location) to help prevent skin burns. Refer to the manufacturer’s documentation for replacement recommendations.

Suggestion: Have students complete steps 2-4, using a simulator.

Additional points/notes:

________________________________________________________________

75

7 Noninvasive Pacing Lesson Presentation

Demand Mode Pacing

Demonstrate how to pace in demand mode.

1. Turn the Therapy Knob to the Pacer position. Note the following:

a. The message Pacing Paused appears in the status block, indicating that the pacing function is

enabled, though pace pulses are not being delivered.

b. Pacing is enabled in demand mode, with the configured lead displayed in Wave Sector 1. If the

configured lead is set to Pads, Lead II or the first available monitoring lead is displayed in place of Pads.

2. Press the Lead Select button to select the best lead with an easily detectable R-wave.

3. Verify white R-wave markers appear above or on the ECG waveform, with a single marker for each R-wave. If no R-wave markers appear coinciding with the R-wave, select another lead.

4. Press the [Pacer Rate] soft key and use the Navigation and Menu Select buttons to select the desired number of pace pulses per minute. The initial rate is configurable.

5. If needed, adjust the initial pacer output before you start pacing. Press the [Pacer Output] soft key and use the Navigation and Menu Select buttons to select the desired output. The initial output is configurable and has a default setting of 30mA.

6. Press [Start Pacing]. The message Pacing appears.

7. Verify white pacing markers appear above or on the ECG waveform.

8. Press [Pacer Output]. Then use the Navigation and Menu Select buttons to:

a. increase the output until cardiac capture occurs. Capture is indicated by the appearance of a

QRS complex after each pacing marker.

b. decrease the output to the lowest level that still maintains capture.

9. Verify the presence of a peripheral pulse.

To stop delivery of pace pulses, press [Pause Pacing]. Once paused, press [Resume Pacing] to resume delivery. You may also stop delivery of pace pulses by moving the Therapy Knob off the Pacer position.

Note the following, as appropriate:

• The ECG cable must be directly connected to the MRx when in demand mode. If a sync cable is

used, connect the cable using the ECG Out port on the MRx and the ECG In port on the Philips bedside monitor.

• If you are pacing with battery power and the Low Battery Alarm sounds, connect the device to

external power or insert a fully charged battery.

• Routinely assess the patient’s peripheral pulses.

• When pacing in demand mode, the ECG cable must be directly connected from the patient to the

HeartStart MRx.

76

Lesson Presentation 7 Noninvasive Pacing

• Pacing will not start if a pads connection or patient contact problem exists; pace pulses will not be

delivered if a monitoring electrodes connection problem exists. An inop message alerts you to either connection problem. For the pads problem, you should check the pads cable is connected, the pads are properly applied, or apply new pads, as needed. For the electrode problem, ensure the ECG cable is connected, the electrodes are applied properly, or reduce patient motion. Resume pacing once either problem is corrected.

Practice Exercise 1

Have students attach pads and electrodes to the MRx and a simulator, set the simulator to bradycardia, and complete demand mode pacing. Pose the following questions:

1. What display changes do you see when completing each step (i.e., turn on pacing, set pacing status, adjust pacer rate and output, and stop pacing)?

2. How do you know when pace pulses are being delivered?

Additional points/notes:

________________________________________________________________

77

7 Noninvasive Pacing Lesson Presentation

Fixed Mode Pacing

Demonstrate how to pace in fixed mode.

1. Turn the Therapy Knob to Pacer.

Note the following: The message Pacing Paused appears in the status block, indicating that the

pacing function is enabled, though pace pulses are not being delivered.

2. Change the pacer mode to Fixed, using the Pacer Mode menu off the Main Menu.

3. Press the Lead Select button to select the desired lead for viewing.

Note that the remaining steps are similar to demand mode pacing.

4. Press [Pacer Rate] and use the Navigation and Menu Select buttons to select the desired number of pace pulses per minute. The initial rate is configurable.

5. If needed, adjust the initial pacer output by pressing [Pacer Output] and using the Navigation and Menu Select buttons to select the desired output. The initial output is configurable.

6. Press [Start Pacing].

7. Verify the presence of a peripheral pulse.

8. Press [Pacer Output] and use the Navigation and Menu Select buttons to adjust the output, as needed.

9. To pause or stop pacing:

– Press [Pause Pacing] or

– Move the Therapy Knob off the Pacer position.

Practice Exercise 2

Have students attach pads and electrodes to the MRx and a simulator, set the simulator to bradycardia, and complete fixed mode pacing. Pose the following questions:

1. What display changes do you see when completing each step (i.e., turn on pacing, set pacing status, adjust pacer rate and output, and stop pacing)?

2. How do you know when pace pulses are being delivered?

Additional points/notes:

________________________________________________________________

78

Lesson Presentation 7 Noninvasive Pacing

Defibrillating During Pacing

Discuss how switching to Manual or AED Mode affects pacing.

• Once the Therapy Knob is moved from Pacer to Manual Defib or AED, pacing is stopped.

• To resume pacing after defibrillation, repeat the pacing procedure. When pacing is resumed, pacing

settings selected prior to defibrillation (mode, rate, and output) are retained. Be sure to confirm that cardiac capture has been maintained.

• Turn off pacing before defibrillating with a second defibrillator to prevent damage to the MRx.

Additional points/notes:

________________________________________________________________

79

7 Noninvasive Pacing Review

Review

Have students answer the following questions individually or as a group. (Correct answers are in bold. Consider having students correct FALSE statements to ensure comprehension.)

1. Which of the following statement(s) are TRUE related to pacing with the MRx?

a. The device requires a 3-, 5- or 10-Lead ECG cable and monitoring electrodes during

demand mode pacing. (T)

b. The device always delivers pace pulses in demand mode. (F - In demand mode, pace pulses are

delivered when the patient’s heart rate is lower than the selected pacing rate.)

c. The Pacing status area indicates pacing mode, status, rate, and output. (T)

d. If you exit Pacer Mode to defibrillate and then return to Pacer Mode, the settings from the

previous pacing session must be re-entered. (F - The settings remain in effect.)

2. Which ONE of the following steps should be performed before pacing is initiated in demand mode?

a. Verify that a white pacing marker appears in front of each QRS complex.

b. Verify that white R-wave markers appear above or on the ECG waveform.

c. Increase pacer output until capture occurs.

d. Decrease pacer output to the lowest level that still maintains capture.

80

Instructor Guide

8Pulse Oximetry Monitoring

Lesson Introduction

Introduce the lesson, including the learning objectives, estimated time to complete, and applicable resources.

8

This lesson describes how to use the HeartStart MRx to monitor Pulse Oximetry (SpO

Objectives

Upon completion of this lesson, students should be able to:

1. Monitor SpO

2. Set SpO

.

2

and pulse rate alarms.

2

Time

10-15 minutes

Accessories Recommended

•SpO2 sensor

Clinical Resources

• Philips Pulse Oximetry Application Note (M3535-92901)

).

2

81

8 Pulse Oximetry Monitoring Lesson Presentation

r

Lesson Presentation

Overview

Discuss pulse oximetry respective to its use with the MRx.

• Pulse oximetry is a noninvasive method of continuously measuring oxygen saturation (SpO

arterial blood; SpO

reading indicates percentage of hemoglobin molecules in the arterial blood

2

) in

saturated with oxygen.

• A pulse oximetry sensor sends light through patient tissue to a receiver on the other side of the

sensor. Light emitting diodes transmit red and infrared light through peripheral areas of the body, such as a finger.

Light Emmitting Diodes

Photodetecto

A photodetector positioned opposite the light emitting diodes compares light absorption before and after pulsation. The amount of light getting through reflects the blood flow in the arterioles. This measurement of light absorption during pulsation is translated into an oxygen saturation percentage and an SpO

• For accurate SpO

value is displayed.

2

measurements, the following conditions must apply:

2

– The patient must have perfusion in that extremity.

– The light emitter and the photodetector must be directly opposite each other.

– All of the light from the emitter must pass through the patient’s tissue.

– The sensor site should be free of vibration and excessive motion.

– Power cables should be kept away from the sensor cable and connector.

• You can monitor SpO

Q-CPR option, SpO

Selecting a Sensor

Discuss the criteria for selecting a sensor.

• The most important factor when selecting a sensor is the position of the light emitting diodes in

relation to the photodetector. When a sensor is applied, the diodes and the photodetector must be opposite each other. Select a sensor appropriate for the patient’s weight.

• Select a sensor site with adequate perfusion. Improve perfusion at the site by rubbing or warming

the site.

• Avoid application to sites with edematous tissue.

82

in Monitor, Manual Defib, or Pacer Modes on the MRx. When using the

2

monitoring functionality is not available.

2

Lesson Presentation 8 Pulse Oximetry Monitoring

• Reusable sensors may be reused on different patients after they have been cleaned and disinfected.

(See the manufacturer’s instructions supplied with the sensor.)

• Disposable sensors should be used only once and then discarded. They may be relocated to another

sensor site on the patient if the first location does not give the desired results. These sensors must not be reused on different patients.

Applying the Sensor

Follow the manufacturer’s directions for applying and using the sensor, making sure to observe any warnings or cautions. For the best results:

• Make sure the sensor is dry.

• If the patient is moving, secure the sensor cable loosely to the patient.

• Make sure the transducer is not too tight. Too much pressure can cause venous pulsation or can

impede the blood flow, resulting in low readings.

• Keep power cables away from the sensor cable and connection.

• Avoid placing the sensor in an environment with bright lights. If necessary, cover the sensor with

opaque material.

• Avoid placing the sensor on an extremity with an arterial catheter, blood pressure cuff, or

intravenous infusion line.

• Failure to apply the sensor properly may reduce the accuracy of the SpO

• Inspect the sensor application site at least every two hours for changes in skin quality, correct optical

alignment, and proper sensor application. If skin quality is compromised, change the sensor site. Change the application site at least every four hours. More frequent checking may be required due to an individual patient’s condition.

•Using an SpO

the cable so that no inductive loops are formed. If the sensor does not appear to be operating properly, remove it immediately from the patient.

sensor during MR imaging can cause severe burns. Minimize this risk by positioning

2

measurement.

2

Additional points/notes:

________________________________________________________________

83

8 Pulse Oximetry Monitoring Lesson Presentation

Monitoring SpO

Attach an SpO2 sensor cable to the MRx, the sensor to yourself, and demonstrate preparation for monitor SpO

1. Connect the appropriate sensor cable to the MRx.

2. Apply the sensor to the patient. If a finger sensor is used, the cable should come down the back of the hand.

3. Turn the Therapy Knob to Monitor.

Suggestion: Have students complete the above steps during or after your demonstration.

Discuss SpO

•A -?- displays in Parameter Block 2 while oxygen saturation is initially measured and an SpO

is calculated; a value replaces -?- and is updated continuously as the patient’s oxygen saturation

changes.

• Alarm limits display to the right of the value if SpO

default.

• The Alarms Off symbol displays if SpO

• The patient’s pulse rate (derived from pulse oximetry) is displayed in Parameter Block 1.

• Alarm limits display to the right of the pulse rate value if pulse rate alarms are turned on; alarms are

“off ” by default.

2

.

2

display characteristics.

2

alarms are turned on; alarms are “on” by

2

alarms are turned off.

2

value

2

• The Alarms Off symbol displays if pulse rate alarms are turned off.

Suggestion: Ask students to point out characteristics instead of YOU stating them.

Additional points/notes:

________________________________________________________________

84

Lesson Presentation 8 Pulse Oximetry Monitoring

Pleth Wave

Mention the following characteristics associated with the pleth wave.

• The wave displays in the configured Wave Sector, if available; otherwise, the wave fills the first

available empty Wave Sector.

• The wave is drawn at an approximate speed of 25 mm/second.

• The wave is auto scaled to grid lines when signal quality is good.

• Wave size is proportionately decreased when signal quality is poor.

• The wave continues to display when the Therapy Knob is moved to Manual Defib, as long as it is

not located in Wave Sector 2 or you’re in Q-CPR View. The SpO Defib Mode but not in Q-CPR View.

• The pacing status bar replaces the wave in Wave Sector 4 when the Therapy Knob is moved to

Pacer; however, SpO

•SpO

and pulse information is no longer monitored when the Therapy Knob is moved to AED.

2

Additional points/notes:

and Pulse values and alarm settings are retained.

2

value is also retained in manual

2

________________________________________________________________

85

8 Pulse Oximetry Monitoring Lesson Presentation

Setting SpO2 Alarms

Mention the following SpO2 alarm characteristics.

• Alarms sound if measurements fall outside the configured high or low SpO

configured SpO

•SpO

alarms are all categorized as “non-latching” alarms, meaning they are automatically removed

2

when their alarm condition no longer exists.

• Alarms are enabled unless turned off during use; they remain disabled until re-enabled.

• If an alarm condition occurs when alarms are disabled, no alarm indication is given.

Changing Alarm Limits

Demonstrate how to change the SpO2 alarm limits.

1. Press the Menu Select button.

2. Using the Navigation buttons, select the Measurements/Alarms menu and press Menu Select.

3. Select SpO

4. Select SpO

5. Using the Navigation buttons, select the new high limit value and press Menu Select.

6. Select the new low limit value and press Menu Select.

Desat Alarm

Discuss the following Desat alarm characteristics.

Desat limit.

2

and press Menu Select.

2

Limits and press Menu Select.

2

limits or below the

2

• This alarm provides an additional limit setting below the low limit setting to notify you of

potentially life threatening decreases in oxygen saturation.

•If the SpO

low limit is set below the preset Desat limit, the Desat limit automatically adjusts to the

2

low limit value; if the SpO

Enabling/Disabling Alarms

Demonstrate how to enable the SpO2 alarms.

1. Press the Menu Select button.

2. Using the Navigation buttons, select the Measurements/Alarms menu and press Menu Select.

3. Select SpO

4. Select Alarms On/Off and press Menu Select.

Note the following: SpO measurement is in progress.

and press Menu Select.

2

reading falls below the low limit, the Desat limit alarm sounds.

2

INOP messages are suppressed for up to 60 seconds while an NBP

2

86

Lesson Presentation 8 Pulse Oximetry Monitoring

Practice Exercise 1

Have students change SpO2 limits, and enable/disable and respond to related alarms. Pose the following questions:

1. What happens when you change a limit? Disable an alarm? Respond to an alarm?

Additional points/notes:

________________________________________________________________

87

8 Pulse Oximetry Monitoring Lesson Presentation

Setting Pulse Rate Alarms

Mention the following pulse rate alarm characteristics.

• Alarms sound if measurements fall outside the configured high and low pulse rate limits.

• Pulse rate alarms are all categorized as “non-latching” alarms, meaning they are automatically

removed when their alarm condition no longer exists.

• Alarms are disabled unless enabled during use.

• Limits can be changed during use.

Changing Pulse Rate Alarm Limits

Demonstrate how to change pulse rate alarm limits.

1. Press the Menu Select button.

2. Using the Navigation buttons, select the Measurements/Alarms menu and press Menu Select.

3. Select Pulse and press Menu Select.

4. Select Pulse Limits and press Menu Select.

5. Using the Navigation buttons, select the new high limit value and press Menu Select.

6. Select the new low limit value and press Menu Select.

Enabling/Disabling Pulse Rate Alarms

Demonstrate how to enable pulse rate alarms.

1. Press the Menu Select button.

2. Using the Navigation buttons, select the Measurements/Alarms menu and press Menu Select.

3. Select Pulse and press Menu Select.

4. Select Alarms On/Off and press Menu Select.

Practice Exercise 2

Have students change pulse rate limits, and enable/disable and respond to related alarms. Pose the following questions:

1. What happens when you change a limit? Disable an alarm? Respond to an alarm?

Disabling the SpO2 Monitoring Function

Demonstrate how to disable the SpO2 monitoring function.

• Disconnect the sensor cable from the SpO

appears. Select Ye s and press the Menu Select button.

port. The message SpO

2

Unplugged. Turn off SpO

2

?

2

88

• Should the sensor cable be disconnected accidentally, the message SpO

appears. Select No and press Menu Select. Then, secure the connection to re-enable the function.

Unplugged. Turn off SpO

2

?

2

Lesson Presentation 8 Pulse Oximetry Monitoring

Additional points/notes:

________________________________________________________________

89

8 Pulse Oximetry Monitoring Review

Review

Have students answer the following questions individually or as a group. (Correct answers are in bold.)

1. True or false? You can monitor SpO (F - Not AED)

2. True or false? The pleth wave is auto scaled to grid lines when the signal quality is poor. (F - The

wave is auto scaled with a good signal.)

3. True or false? SpO turned off during use. (F - SpO

alarms are off unless turned on.)

4. How many seconds are SpO

a. 15

b. 30

c. 45

d. 60

alarms are off unless turned on during use while pulse rate alarms are on unless

2

INOP messages suppressed during an NBP measurement?

2

in all MRx modes (Monitor, Manual Defib, AED or Pacer).

2

alarms are on unless turned off during use while pulse rate

2

90

Philips HeartStart MRx M3535A, HeartStart MRxM3536A User manual

Specifications and Main Features

Frequently Asked Questions

User Manual

Instruction Time

1Introduction

Guide Structure

Preparation

Teaching Guidelines

Safety Considerations

Additional Documentation and Training

Lesson Introduction

2Getting Acquainted

Objectives

Time

Accessories Recommended

Lesson Presentation

Overview

Basic Orientation

Front Panel

Side Panels

Top Panel

Back Panel

M3538A Lithium Ion Battery

Additional points/notes:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Display View

Operating Modes

Password Security

Display Layout

Additional points/notes:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Responding to Alarms

Additional points/notes:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Continued Use

Printing Waveforms

Return to Owner

Additional points/notes:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Carrying Case and Accessory Pouch Assembly

Storing Accessories

Additional points/notes:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Review

Lesson Introduction

Objectives

Time

Accessories Recommended

Clinical Resources

Lesson Presentation

Overview

Monitor View

Additional points/notes:

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Preparation

Multifunction electrode pads

Electrodes