Pro First Aid

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Hi my name is Roy Shaw, licensed paramedic and lead instructor for procpr and the profirstaid programs

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for protrainings. The highlights of the 2010 American Heart Association guidelines for CPR and ECC

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have come up with some recommendations and updates now that we're in the new 2010 guideline phase. As

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a health care professional, some of these may make sense to you and some may not make sense to you.

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The whole purpose of my being here and explaining this to you, is to try and synthesize this down and

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have it make sense. It's one thing to look at the science and to look at all the consensus and it's another

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to try and get our heads wrapped around it as professional rescuers or as health care providers and

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get behind it and believe in what we're doing and why we're doing it. My hopes are that I'll simplify

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the things that are maybe a little complicated and that I'll shine some light on the things that may

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seem ambiguous to you. Let's get started. In regards to the cardiac arrest victim that may be present

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with a short period of seizure activity or agonal gasps, that may confuse potential rescuers, we're now

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teaching dispatchers that they should be trained to identify the presentations of cardiac arrest

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that started this way. Okay, so let me explain. There was confusion when people would call 911 and the

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dispatcher would ask, is the person moving, are they breathing? And in reality, you know as well

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as I do, when a cardiac arrest victim stops circulating oxygen to the brain, it's a shock and it

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may cause a cardiac related seizure. Well, while they are seizing, they are in the tonic phase

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it could be misinterpreted as still being alive and moving. So, they might tell the dispatcher, yeah,

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the patient is moving. If they are in agonal respirations, which is extremely common, now get this, agonal

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respirations are extremely common in the first minute or two of cardiac arrest, the bystander who

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isn't trained, may interpret this as the patient is breathing. So now the dispatcher's information is

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that the patient is moving and breathing. Do you think that there's a chance that they will

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initiate CPR? Probably not, because the dispatcher cannot see the patient. So, based on that information

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and based on the science we've gathered, we now know that because most cardiac arrest patients, when

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they go into cardiac arrest with a bystander witnessing it, may be misinterpreted because we're not

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asking the right questions. So, these new 2010 guidelines are basically trying to train dispatchers

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how to ask the right questions, to be able to steer through the fog, in order to determine if the person

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is in a seizure or agonal respirations, thereby, giving the dispatcher the correct information and

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helping to tell the lay rescuer what to do next appropriately which in this case would be, start

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CPR and we're going to activate an ambulance get them right out there. So that's the idea behind

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the new information which is now out and released. It will be incorporated into the EMD classes so

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that they get up to snuff and know what good and qualifying questions to ask call-ins in order to determine

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what is actually happening on scene. Now, this next one is one of those pet peeves of mine, because I believe

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that with good training like ProTrainings, we can go the extra mile and teach lay people how to

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give good quality CPR Including rescue breathing with personal protective equipment. However,

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I understand that there are a lot of people that would never take advantage of the education

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for whatever reason they will not get trained proactively and thereby, will be reactive when responding

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to an emergency. Because that is commonly the case, dispatchers are now being instructed to tell lay

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rescuers who have never been trained before or who are not comfortable giving mouth to mouth resuscitation

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without personal protective equipment, to provide hands only compressions cpr, what they're calling hands

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only CPR, or compression only resuscitation for adults in sudden cardiac arrest.

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Now, I've told you the reasons why they're doing that now, so as a healthcare professional

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when you arrive on scene prehospital or you see a bystander do this out of hospital,

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remember, if they're doing chest compressions fast and hard only, and not giving rescue breaths,

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that's what they've been told to do. So be aware of that. The good news is, there is some decent

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science, limited as it may be, that is showing on pig, dog and some human models, that fast, deep compressions

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in the first few minutes of cardiac arrest is helping to stabilize the patient hemodynamically.

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Thereby, buying time, and saving brain and heart cells. So, let's think positively on this, and that's

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why we'll see bystanders doing hands only CPR. Alright, some changes have been made to the

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immediate recognition of no breathing or no normal breathing. Now, no normal breathing to a health

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care provider means, agonal respirations. The gasping type of trying to take a breath,

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the medulla oblongata, the brain stem activity which is last to die, when oxygen has been held back from

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the brain and yet still gives the autonomic nervous system response to try and take a breath diaphragmatically but

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doesn't have the tone quality or the strength to complete it. That is not breathing.

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You know that, I know that, that does not qualify as breathing but it may be misinterpreted as breathing

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to a lay rescuer. So, when we as health care professionals see agonal respirations, or no respirations

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we're activating the code team or calling for emergency response right away. If that has taken place

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and we've already activated the emergency response system, to retrieve an AED or we've sent

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someone to do that, we are no longer taking more than 10 seconds to check for a carotid pulse.

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Now catch this, because it can be difficult to determine whether an unresponsive, non breathing

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patient, has a pulse, a weak pulse, a thready pulse or has an irregular pulse, if we can't

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easily identify a definite pulse within 10 seconds and the patient is not breathing normally or moving

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they get CPR period. So, no more extended time checking for pulses or pulse quality.

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Check for no longer than 10 seconds and if it's not definite that you've found a pulse and

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the patient is not breathing and not responsive...CPR. Okay? So, that's the emphasis for 2010

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guidelines. Now check this out. Look, listen and feel...gone! For 2010, we are no longer

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doing the head tilt, chin lift, look, listen and feel. The montra we've trained with forever,

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is gone. I don't really know why it's gone. It's not a difficult skill in my opinion, in fact

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it's one of the easier ones. In fact, I could have seen throwing out pulse checks before I could have

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seen throwing out the look, listen and feel and no breathing. That's my opinion, however, maybe it saves

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a little time. Maybe...Yeah. I don't know why they changed it, but they did. So, no longer look

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listen and feel, we're just going to say if they're not breathing and they're not moving and we

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can't feel a pulse...CPR. Chest compressions right away. The emphasis has been placed on the

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high quality of the CPR which I believe is a good thing. The compressions are going to be fast,

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they are going to be deep, we're going to allow for full recoil of the chest. We're not bouncing our

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hands off the chest, but we're fully recoiling on the chest before we perform another compression.

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And we're going to minimize interruptions. So, we're still giving 30 compressions to 2 rescue

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breaths, but we're going to minimize the amount of time between giving the breaths and getting

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right to chest compressions. The other major change is that we're doing chest compressions

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first and then giving the two rescue breaths. So different than the airway, breathing, circulation

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open the airway, give two breaths, check a pulse...no more. Not breathing normally, can't feel pulse,

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right into chest compressions. 30 chest compressions deep and fast and then two full rescue breaths.

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To get chest rise and fall. This high quality chest compression, high rate with full recoil,

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is being shown through studies to increase intrathoracic pressures, as well as increase

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circulatory percentages, which adds to better hemodynamics and ideally, better recovery and

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better quality of life after resuscitation. That's what the science is pointing towards

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that's why it's been implemented. So, good news in that area. Remember back when it was around 100

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times per minute? Now, looking at the high quality chest compressions, it's at least 100 times per minute.

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So, If I wanted to be kind of "bunk" about it, you could say, "well you don't want to go

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160 times per minute!" No, that's true, but it's a pretty big stretch to think that we could do 160

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compressions per minute. I don't think we have to worry about that. And if we're doing 120

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compressions in a minute, that's what our heart rate is at if you're excited or exercising moderately.

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So even that is not supraventricular tachycardia or ventricular tachycardia. So, it's going to be at

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least 100 beats per minute or even a bit faster. In order to get pulse pressures up and increase

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circulatory percentages. That's the idea behind it. And, we used to say between 1 and 1/2 and 2 inches

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deep, now at least 2 inches deep. The pattern is that we're not compressing deep or fast enough.

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It's not that we're doing to much. That's why the emphasis has come back. When it comes to

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children and infants, we're going at least a third of the depth of the chest. You with me now?

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Instead of 1/2 inch to 1 inch for infant 1 to 1 and 1/2 for a child, now we're doing

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one third and that's it. It doesn't matter what the age of the patient is, we're going a third of the

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depth of the chest. On an infant and a child. Again, trying to get full, deep, fast compressions

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to get circulation up. Now, here's an interesting one. In some of your regions you haven't been

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doing this anyway. That's the rule here for me. Cricoid pressure during ventilations is no longer

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recommended. I don't think it's been recommended for some time in my region.

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Here's why they were using it. They believed that if cricoid pressure was applied, which is

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usually used when you can't see the epiglottis well. The Sellick's manoeuvre, cricoid pressure was suppose

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to help air go into the trachea instead of the esophogus and the stomach.

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That was the idea, to help reduce regurgitation and reduce gastric distention.

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That's not recommended anymore. So, if you were in the group that was still using that

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procedure, it is no longer consistent with the 2010 guidelines. There has been a continued

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emphasis placed on the need to reduce the time between the last compression and shock delivery

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and the time between shock delivery and resumption of cardiac compressions. That's pretty

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consistent in ACLS and for BLS it's being re-emphasized not changed.

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The goal is, get the chest compressions going and get the pulse pressures up, get the hemodynamics

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stabilized, they're acidic most likely after 6 minutes, so by circulating well, and blowing off

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CO2 with a bag valve mask even with room air and delivering chest compressions fast, hard, and deep,

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the goal is that we can bring the ph balance back into it's parameters and all the things that go

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with that so that when the patient is defibrillated, in V-fib or in V-tack, we can hopefully get them

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into an autonomous rythm that is circulating on its own. And really getting those

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pulse pressures up and getting really good circulation and getting everything stabilized

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hemodynamically again. That's the goal. And the faster we get the chest compressions to defibrillation

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and defibrillation to chest compressions the better. And that's where the emphasis is coming back

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again. So, what we're really trying to say is let's minimize distractions like, hey, could you print

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a strip off for me so I can take a look at that strip, get to the compressions and defibrillation and

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back again, you know where your strip is? It's when they're taking better quality breaths on their

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own because they are reviving and beginning to move. The best thing that someone could ever do if I

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cardioverted them and give me the best success rate, is push my hands off their chest and say

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they don't need CPR anymore, that would be awesome. So, let the signs and symptoms be the vote to say

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now, we can chill out a bit and see how things are going or keep resuscitating.

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There's an increased focus on using the team approach on CPR. This looks similar to the ACLS megacode.

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Now, in our training library, we've added this, and I think it's a great idea. In group settings

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where you have at least two to four team members, there's a way to choreograph that resuscitation

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effort where you have many hands. Now, in my training what I did is I showed that the airway

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management person, like in ACLS, has the birds eye view of the code. They make a great team leader,

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now your protocols and algorithm may call for something different, follow you local protocols.

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But, if you don't have one, I think that's a good default. The person who takes the airway management

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and is doing the bag valve mask and is in a really good position to call out and direct and choreograph

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who is going to do AED, chest compressions, how's airway management going, we're going to have to

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log roll the patient because they vomited, and the team approach really makes for a smooth effective resuscitation.

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And we have multiple people to change out for compressions so that fatigue doesn't degrade CPR

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and we can continue the quality of compressions.

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Last but not least, AED's have come a long ways. Because they are computers, the infant/child pads

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send a message to the AED that we've got a different size patient and due to that, the joules dosage is

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appropriate for infants one year and less. That's great news. Many of you were still overriding that

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with adult pads or manual defibrillation, but AEDs with pediatric pads will reduce the joules

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appropriately and attenuate the joule dosages properly for the pediatric patient.

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It will show right on the pads where the pads go. We are still using the anterior/posterior method for infants

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but that's great news to be able to use the AED. And these are the same AEDs that are coming

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off child daycare walls and are located in schools and are becoming more readily available.

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But that is something we needed to mention and I think that it is valuable and I hope you keep that in

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mind as we move forward into this new five year, this half a decade of new science and new

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recommendations. I'm excited to continue training for you and with you. Keep your questions coming

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whether it's through RoyOnRescue.com or through the support@protrainings.com customer

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solutions department. Let's get going training and let's get you recertified. I hope this

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update was helpful for you, dryer than a bone but thank you for hanging in there and staying with me,

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and until next time, take care and we'll see you soon.