CPR Question

[Guest guest]

Cardiac Science AED does this Dr. Krin...if I'm not mistaken...one set of pads

and energy delivered based upon impedance and pt size.

Dudley

Re: CPR Question

In a message dated 1/30/2007 3:31:44 PM Central Standard Time,

bbledsoe@... writes:

Kids rarely die from V-fib and thus the cost of having duplicate pedi and

adult AEDs is cost-prohibitive. A pedi AED might be justified in a

pediatric ambulatory care clinic or a day care for special needs

kids-otherwise it will never be used. An adult AED is just as effective and

when the shock is administered to an otherwise health pediatric heart, the

heart can most likely tolerate the increased energy levels.

what I'd like to see would be a set up where there would be two sets of pads

and one AED. apply the smaller set of pads (either for a pedi or a

small/frail adult), and the machine would be smart enough to limit the max

Joules

applied...

shouldn't be hard, but then again, with one of the major players going out

of the market at least for awhile, who knows?

ck

S. Krin, DO FAAFP

[Guest guest]

Danny,

Read through all the posts and saw the outcome...but my first thought to this

was AHA is saying it is " last resort " ...if the pediatric heart with healthy

nodes is in v-fib...and we don't give them any electricity...isn't it proven

that the healthy pediatric heart will quickly become a healthy but dead

pediatric heart....so give electicity, even if it is a little too much...because

a slightly damaged beating pediatric heart is much better than a healthy heart

in a dead kid.....

When I see last resort...that is what I see as the choice.

Dudley

CPR Question

I have a question for the general learned and professional subscribers to

the list.

Who can explain the rationale behind the new CPR Guideline of using an adult

AED on a pediatric patient?

I understand it is a last resort but are we not burning the nodes when we

give them too much energy? Am I missing something?

Please help.

Danny L.

Owner/NREMT-P

PETSAR INC.

(Panhandle Emergency Training Services And Response)

Office

Fax

[Guest guest]

I am really not trying to sound like a rep but I have to share what I learned

when I asked this very question directly relating to some protocol changes and

the new statement of use on pediatrics;

1. MEDTRONIC - ADAPTIV biphasic = big science for the little people.

I am not familiar with the others

2. Most Aed's that are new will have a pediatric adapter

3. Like Dr. Bledsoe initially stated, Kids hearts are able to tolerate it

better

4. Old monophasic AED's are better than none if a shock state is present

Chris

Danny wrote:

I am not meaning to be argumentative ( or maybe I am) but how is it

that we know electricity kills but yet we are quick to say that the energy

delivered (en masse and directly to the nodes) is not a danger. Does that make

sense?

My point being are we again teaching our students the wrong information because

we think they are incapable of handling the right information or do we really

think that this will be of benefit to the patient in cardiac arrest?

If there is no benefit then why waste our time and energy in the treatment?

" Bledsoe, DO " wrote:

Most are healthy hearts. They fibrillate because of toxins, carbon

monoxide, electrical shock-things like that. Few have intrinsic heart

disease per se. Those that have congenital anomalies will die from failure.

BEB

_____

From: texasems-l [mailto:texasems-l ] On

Behalf Of Danny

Sent: Tuesday, January 30, 2007 3:53 PM

To: texasems-l

Subject: RE: CPR Question

So there is not a problem with damage to the nodes in a healthy pediatric

heart.

How many healthy pediatric patients go into V-Fib?

" Bledsoe, DO " <bbledsoe (AT) earthlink (DOT) <mailto:bbledsoe%40earthlink.net>

net> wrote:

Kids rarely die from V-fib and thus the cost of having duplicate pedi and

adult AEDs is cost-prohibitive. A pedi AED might be justified in a

pediatric ambulatory care clinic or a day care for special needs

kids-otherwise it will never be used. An adult AED is just as effective and

when the shock is administered to an otherwise health pediatric heart, the

heart can most likely tolerate the increased energy levels.

_____

From: texasems-l@yahoogro <mailto:texasems-l%40yahoogroups.com> ups.com

[mailto:texasems-l@yahoogro <mailto:texasems-l%40yahoogroups.com> ups.com]

On

Behalf Of Danny

Sent: Tuesday, January 30, 2007 3:14 PM

To: texasems-l

Subject: CPR Question

I have a question for the general learned and professional subscribers to

the list.

Who can explain the rationale behind the new CPR Guideline of using an adult

AED on a pediatric patient?

I understand it is a last resort but are we not burning the nodes when we

give them too much energy? Am I missing something?

Please help.

Danny L.

Owner/NREMT-P

PETSAR INC.

(Panhandle Emergency Training Services And Response)

Office

Fax

[Guest guest]

Now the real answer as I found it;

Either is appropriate as needed (although no one would argue that lower energy

biphasic would be best, but if VT/VT is present then delivery of a shock is the

best treatment, regardless of waveform type).

Also, at 9J/kg, 360 joules would typically be the max delivery anyway (which

is probably still clinically acceptable when urgently needed).

One cannot exclude the use of monophasic shocks because a particular provider

does not yet have biphasic capable AEDs since VF is pretty rare in kids.

2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation

and Emergency Cardiovascular Care

Part 5: Electrical Therapies

Automated External Defibrillators, Defibrillation, Cardioversion, and Pacing

AED Use in Children

Cardiac arrest is less common in children than adults, and its causes are more

diverse.69–71 Although VF is not a common arrhythmia in children, it is observed

in 5% to 15% of pediatric and adolescent arrests.71–75 In these patients rapid

defibrillation may improve outcomes.75,76

The lowest energy dose for effective defibrillation in infants and children is

not known. The upper limit for safe defibrillation is also not known, but doses

>4 J/kg (as high as 9 J/kg) have effectively defibrillated children77,78 and

pediatric animal models79 with no significant adverse effects.

Based on adult clinical data17,24 and pediatric animal models,79–81 biphasic

shocks appear to be at least as effective as monophasic shocks and less harmful.

Recommended manual defibrillation (monophasic or biphasic) doses are 2 J/kg for

the first attempt (Class IIa; LOE 582 and 679) and 4 J/kg for subsequent

attempts (Class Indeterminate).

Many AEDs can accurately detect VF in children of all ages65,66 and

differentiate shockable from nonshockable rhythms with a high degree of

sensitivity and specificity.65,66 Some are equipped with pediatric attenuator

systems (eg, pad-cable systems or a key), to reduce the delivered energy to a

dose suitable for children.

For children 1 to 8 years of age the rescuer should use a pediatric

dose-attenuator system if one is available.78,83,84 If the rescuer provides CPR

to a child in cardiac arrest and does not have an AED with a pediatric

attenuator system, the rescuer should use a standard AED.

There is insufficient data to make a recommendation for or against the use of

AEDs for infants <1 year of age (Class Indeterminate). During infancy the risk

of VF SCA is unknown, and most cardiac arrest is thought to be related to

progression of respiratory failure or shock. As a result there is concern that

repeated interruption of CPR to try to detect and treat a rhythm uncommon in

that age group may introduce more risk than benefit.83

If an AED program is established in systems or institutions that routinely

provide care to children, the program should be equipped with AEDs with a high

specificity for pediatric shockable rhythms and with a pediatric attenuator

system (eg, pediatric pad-cable system or other method of attenuating the shock

dose). This statement, however, should not be interpreted as a recommendation

for or against AED placement in specific locations where children are present.

Ideally healthcare systems that routinely provide care to children at risk for

cardiac arrest should have available manual defibrillators capable of dose

adjustment.83

Chris

Weinzapfel wrote:

I am really not trying to sound like a rep but I have to share what I

learned when I asked this very question directly relating to some protocol

changes and the new statement of use on pediatrics;

1. MEDTRONIC - ADAPTIV biphasic = big science for the little people.

I am not familiar with the others

2. Most Aed's that are new will have a pediatric adapter

3. Like Dr. Bledsoe initially stated, Kids hearts are able to tolerate it better

4. Old monophasic AED's are better than none if a shock state is present

Chris

Danny wrote:

I am not meaning to be argumentative ( or maybe I am) but how is it that we know

electricity kills but yet we are quick to say that the energy delivered (en

masse and directly to the nodes) is not a danger. Does that make sense?

My point being are we again teaching our students the wrong information because

we think they are incapable of handling the right information or do we really

think that this will be of benefit to the patient in cardiac arrest?

If there is no benefit then why waste our time and energy in the treatment?

" Bledsoe, DO " wrote:

Most are healthy hearts. They fibrillate because of toxins, carbon

monoxide, electrical shock-things like that. Few have intrinsic heart

disease per se. Those that have congenital anomalies will die from failure.

BEB

_____

From: texasems-l [mailto:texasems-l ] On

Behalf Of Danny

Sent: Tuesday, January 30, 2007 3:53 PM

To: texasems-l

Subject: RE: CPR Question

So there is not a problem with damage to the nodes in a healthy pediatric

heart.

How many healthy pediatric patients go into V-Fib?

" Bledsoe, DO " <bbledsoe (AT) earthlink (DOT) <mailto:bbledsoe%40earthlink.net>

net> wrote:

Kids rarely die from V-fib and thus the cost of having duplicate pedi and

adult AEDs is cost-prohibitive. A pedi AED might be justified in a

pediatric ambulatory care clinic or a day care for special needs

kids-otherwise it will never be used. An adult AED is just as effective and

when the shock is administered to an otherwise health pediatric heart, the

heart can most likely tolerate the increased energy levels.

_____

From: texasems-l@yahoogro <mailto:texasems-l%40yahoogroups.com> ups.com

[mailto:texasems-l@yahoogro <mailto:texasems-l%40yahoogroups.com> ups.com]

On

Behalf Of Danny

Sent: Tuesday, January 30, 2007 3:14 PM

To: texasems-l

Subject: CPR Question

I have a question for the general learned and professional subscribers to

the list.

Who can explain the rationale behind the new CPR Guideline of using an adult

AED on a pediatric patient?

I understand it is a last resort but are we not burning the nodes when we

give them too much energy? Am I missing something?

Please help.

Danny L.

Owner/NREMT-P

PETSAR INC.

(Panhandle Emergency Training Services And Response)

Office

Fax

[Guest guest]

In a message dated 1/31/2007 2:13:20 P.M. Central Standard Time,

Grayson902@... writes:

I'm shocked, SHOCKED I tell you...

I'm assuming that was a Bi-phasic shock?

Louis N. Molino, Sr., CET

FF/NREMT-B/FSI/EMSI

Freelance Consultant/Trainer/Author/Journalist/Fire Protection Consultant

Buddhist philosopher at-large

LNMolino@...

(Cell Phone)

(Home Phone)

(IFW/TFW/FSS Office)

(IFW/TFW/FSS Fax)

" A Texan with a Jersey Attitude "

" Great minds discuss ideas; Average minds discuss events; Small minds

discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 - 1962)

The comments contained in this E-mail are the opinions of the author and the

author alone. I in no way ever intend to speak for any person or

organization that I am in any way whatsoever involved or associated with unless

I

specifically state that I am doing so. Further this E-mail is intended only for

its

stated recipient and may contain private and or confidential materials

retransmission is strictly prohibited unless placed in the public domain by the

original author.

[Guest guest]

That is exactly what the Life Pak 1000 Physio AED does. Since the defib is set

to defibrillate at 100,200,300 the Pedi pads through some sort of internal

mechanism reduces the defib levels to 50,75,86 automatically. However, these

pads cannot be utilized when we meet the volunteer and attach or Physio LP-12.

The pads must be changed out. I would guess that if we were to attach them and

shock at 100,200, or 300 the pads would function the same way. However, until I

know for sure we will change out the pads. The criteria for these pads is under

eight years old and under 55lbs. Other wise the adult pads are to be used. I

would welcome any discussion on this. I hope I have not misunderstood the thread

here.

Henry

Re: CPR Question

In a message dated 1/30/2007 3:31:44 PM Central Standard Time,

bbledsoe@... writes:

Kids rarely die from V-fib and thus the cost of having duplicate pedi and

adult AEDs is cost-prohibitive. A pedi AED might be justified in a

pediatric ambulatory care clinic or a day care for special needs

kids-otherwise it will never be used. An adult AED is just as effective and

when the shock is administered to an otherwise health pediatric heart, the

heart can most likely tolerate the increased energy levels.

what I'd like to see would be a set up where there would be two sets of pads

and one AED. apply the smaller set of pads (either for a pedi or a

small/frail adult), and the machine would be smart enough to limit the max

Joules

applied...

shouldn't be hard, but then again, with one of the major players going out

of the market at least for awhile, who knows?

ck

S. Krin, DO FAAFP

[Guest guest]

I don't know that I have anything more useful to add to the

discussion but I did want to make a couple of comments.

Thirty-five years ago, when professional EMS systems were beginning

to appear in this country and before the birth of the AHA's ACLS

program, various authorities recommended a 200 joule countershock for

all children and 60 to 100 joules in all infants.(1,2) These

recommendations were made in spite of the fact that animal studies at

the time suggested that detectable cellular and tissue damage

occurred within the myocardium at shock energies in that range.(3-5)

Other studies suggested that considerably less energy was effective

for defibrillation in a variety of non-human species.(5)

By the mid 70s, one researcher retrospectively evaluated the efficacy

of defibrillation energies of 2 J/kg in 27 children ranging from 3

days to 15 years of age. Of the 71 shocks administered to the

children in that study, 91% were successful within 10 J of the 2 J/kg

study energy.(6) Based on this one study with all its limitations,

the pediatric task force for the American Heart Association

recommended an initial energy setting of 2 J/kg for defibrillation

attempts in children with an increase to 4 J/kg in all subsequent

attempts. While other studies(7,8) and decades of experience have

demonstrated this energy setting to be effective, there are no

studies to date that have established the optimal energy setting for

pediatric defibrillation.

What I find interesting is that the original recommendation for

energy settings was based on short duration in-hospital ventricular

fibrillation in children. Could it be that this recommendation would

be ineffective or worse yet, harmful for the notoriously longer-

duration out-of-hospital pediatric ventricular fibrillation?

Researchers in Tucson retrospectively reviewed (lower level of

evidence) all cardiac arrests in children less than 13 years old for

about four and a-half years. Children in ventricular fibrillation

were shocked using a monophasic damped sinusoidal waveform at 2 J/kg

(±10 J).

Of the 13 children with documented VF, 11 were shocked a total of 14

times using a monophasic damped sinusoidal waveform at 2 J/kg (±10 J).

Seven of the 14 shocks terminated the VF (six to asystole, one to

pulseless electrical activity). Nine children (68%) died in the

emergency department and four (31%) in the pediatric intensive care

unit; none survived to hospital discharge.

This evaluation suggests that the 2 J/kg-4J/kg strategy taught since

I was a pup in Dr. Bledsoe's class may not be effective for out-of-

hospital pediatric ventricular fibrillation. Unfortunately, the

optimal pediatric defibrillation dose for prolonged VF has still not

been identified.

1. Swan HJC. Cardiac catheterization. In: Moss AJ, FH, eds.

Heart Disease in Infants, Children, and Adolescents. Baltimore, Md:

& Wilkins;1968:287.

2. Goldberg AH. Cardiopulmonary arrest. N Engl J Med. 1974;290:381-

385.

3. Gaba DM, Tainer NS. Myocardial damage following transthorasic

direct current countershock in newborn piglets. Pediatr Cardiol.

1982;2:281-288.

4. Dahl CF, Ewy GA, Warner ED, et al. Myocardial necrosis from

direct current countershock: effect of paddle electrode size and time

interval between discharge. Circulation. 1974;50:956-961.

5. Babbs CF, Tacker WA, VanVleet JF, et al. Therapeutic indices for

transchest defibrillator shocks; effective, damaging and lethal

electrical doses. Am Heart J. 1980;99:734-738.

6. Gutgesell HP, Tacker WA, Geddes LA, et al. Energy dose for

ventricular defibrillation in children. Pediatrics. 1976;58:989-901.

7. Mogayzel C, Quan L, Graves JR, et al. Out-of-hospital ventricular

fibrillation in children and adolescents: causes and outcomes. Ann

Emerg Med. 1995;25:484-491.

8. Atkins DL, Hartley LL, York DK. Accurate recognition and

effective treatment of ventricular fibrillation by automated external

defibrillators in adolescents. Pediatrics. 1998;101:393-397.

9. Berg MD et al. Pediatric defibrillation doses often fail to

terminate prolonged out-of-hospital ventricular fibrillation in

children. Resuscitation 67 (2005) 63–67.

Kenny Navarro

Science is the great antidote to the poison of enthusiasm and

superstition. - Adam (1723-1790) ish economist. The Wealth

of Nations, 1776.

[Guest guest]

>>By the mid 70s, one researcher retrospectively evaluated the efficacy

of defibrillation energies of 2 J/kg in 27 children ranging from 3

days to 15 years of age. Of the 71 shocks administered to the

children in that study, 91% were successful within 10 J of the 2 J/kg

study energy.(6) Based on this one study with all its limitations,

the pediatric task force for the American Heart Association

recommended an initial energy setting of 2 J/kg for defibrillation

attempts in children with an increase to 4 J/kg in all subsequent

attempts.<<

Kenny, are you saying that AHA has in the past based major recommendations on

retrospective studies involving a tiny study group of patients?

I'm shocked, SHOCKED I tell you...

--

Grayson, CCEMT-P, etc.

MEDIC Training Solutions

http://www.medictrainingsolutions.com/

[Guest guest]

In a message dated 1/31/2007 7:28:18 P.M. Central Standard Time,

ewalsh@... writes:

The correct bi phasic shock is

SHOCKED DEKCOHS

or it could be

_ /SHOCKED\_

\DEKCOHS/

Ed Walsh LP

Ah Ya got me Ed was just thinking too fast I guess and like driving it gets

you in trouble.

Louis N. Molino, Sr., CET

FF/NREMT-B/FSI/EMSI

Freelance Consultant/Trainer/Author/Journalist/Fire Protection Consultant

Buddhist philosopher at-large

LNMolino@...

(Cell Phone)

(Home Phone)

(IFW/TFW/FSS Office)

(IFW/TFW/FSS Fax)

" A Texan with a Jersey Attitude "

" Great minds discuss ideas; Average minds discuss events; Small minds

discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 - 1962)

The comments contained in this E-mail are the opinions of the author and the

author alone. I in no way ever intend to speak for any person or

organization that I am in any way whatsoever involved or associated with unless

I

specifically state that I am doing so. Further this E-mail is intended only for

its

stated recipient and may contain private and or confidential materials

retransmission is strictly prohibited unless placed in the public domain by the

original author.

[Guest guest]

The reduced conversion and survival rates of long-term VF patients leads

us to the other recommendation from 2005 for adults, mainly that after

several minutes

of hypoxia the heart is less responsive to defibrillation, period. Hence

the recommendation to give CPR first for these patients, at least in the

adults.

=Steve=

Kenny Navarro wrote:

> I don't know that I have anything more useful to add to the

> discussion but I did want to make a couple of comments.

>

> Thirty-five years ago, when professional EMS systems were beginning

> to appear in this country and before the birth of the AHA's ACLS

> program, various authorities recommended a 200 joule countershock for

> all children and 60 to 100 joules in all infants.(1,2) These

> recommendations were made in spite of the fact that animal studies at

> the time suggested that detectable cellular and tissue damage

> occurred within the myocardium at shock energies in that range.(3-5)

> Other studies suggested that considerably less energy was effective

> for defibrillation in a variety of non-human species.(5)

>

> By the mid 70s, one researcher retrospectively evaluated the efficacy

> of defibrillation energies of 2 J/kg in 27 children ranging from 3

> days to 15 years of age. Of the 71 shocks administered to the

> children in that study, 91% were successful within 10 J of the 2 J/kg

> study energy.(6) Based on this one study with all its limitations,

> the pediatric task force for the American Heart Association

> recommended an initial energy setting of 2 J/kg for defibrillation

> attempts in children with an increase to 4 J/kg in all subsequent

> attempts. While other studies(7,8) and decades of experience have

> demonstrated this energy setting to be effective, there are no

> studies to date that have established the optimal energy setting for

> pediatric defibrillation.

>

> What I find interesting is that the original recommendation for

> energy settings was based on short duration in-hospital ventricular

> fibrillation in children. Could it be that this recommendation would

> be ineffective or worse yet, harmful for the notoriously longer-

> duration out-of-hospital pediatric ventricular fibrillation?

>

> Researchers in Tucson retrospectively reviewed (lower level of

> evidence) all cardiac arrests in children less than 13 years old for

> about four and a-half years. Children in ventricular fibrillation

> were shocked using a monophasic damped sinusoidal waveform at 2 J/kg

> (±10 J).

>

> Of the 13 children with documented VF, 11 were shocked a total of 14

> times using a monophasic damped sinusoidal waveform at 2 J/kg (±10 J).

>

> Seven of the 14 shocks terminated the VF (six to asystole, one to

> pulseless electrical activity). Nine children (68%) died in the

> emergency department and four (31%) in the pediatric intensive care

> unit; none survived to hospital discharge.

>

> This evaluation suggests that the 2 J/kg-4J/kg strategy taught since

> I was a pup in Dr. Bledsoe's class may not be effective for out-of-

> hospital pediatric ventricular fibrillation. Unfortunately, the

> optimal pediatric defibrillation dose for prolonged VF has still not

> been identified.

>

>

> 1. Swan HJC. Cardiac catheterization. In: Moss AJ, FH, eds.

> Heart Disease in Infants, Children, and Adolescents. Baltimore, Md:

> & Wilkins;1968:287.

> 2. Goldberg AH. Cardiopulmonary arrest. N Engl J Med. 1974;290:381-

> 385.

> 3. Gaba DM, Tainer NS. Myocardial damage following transthorasic

> direct current countershock in newborn piglets. Pediatr Cardiol.

> 1982;2:281-288.

> 4. Dahl CF, Ewy GA, Warner ED, et al. Myocardial necrosis from

> direct current countershock: effect of paddle electrode size and time

> interval between discharge. Circulation. 1974;50:956-961.

> 5. Babbs CF, Tacker WA, VanVleet JF, et al. Therapeutic indices for

> transchest defibrillator shocks; effective, damaging and lethal

> electrical doses. Am Heart J. 1980;99:734-738.

> 6. Gutgesell HP, Tacker WA, Geddes LA, et al. Energy dose for

> ventricular defibrillation in children. Pediatrics. 1976;58:989-901.

> 7. Mogayzel C, Quan L, Graves JR, et al. Out-of-hospital ventricular

> fibrillation in children and adolescents: causes and outcomes. Ann

> Emerg Med. 1995;25:484-491.

> 8. Atkins DL, Hartley LL, York DK. Accurate recognition and

> effective treatment of ventricular fibrillation by automated external

> defibrillators in adolescents. Pediatrics. 1998;101:393-397.

> 9. Berg MD et al. Pediatric defibrillation doses often fail to

> terminate prolonged out-of-hospital ventricular fibrillation in

> children. Resuscitation 67 (2005) 63–67.

>

> Kenny Navarro

>

>

> Science is the great antidote to the poison of enthusiasm and

> superstition. - Adam (1723-1790) ish economist. The Wealth

> of Nations, 1776.

>

>

>

>

>

[Guest guest]

The correct bi phasic shock is

SHOCKED DEKCOHS

or it could be

_ /SHOCKED\_

\DEKCOHS/

Ed Walsh LP

lnmolino@... wrote:

>

>

>

> In a message dated 1/31/2007 2:13:20 P.M. Central Standard Time,

> Grayson902@... <mailto:Grayson902%40aol.com> writes:

>

> I'm shocked, SHOCKED I tell you...

>

> I'm assuming that was a Bi-phasic shock?

>

> Louis N. Molino, Sr., CET

> FF/NREMT-B/FSI/EMSI

> Freelance Consultant/Trainer/Author/Journalist/Fire Protection Consultant

> Buddhist philosopher at-large

> LNMolino@... <mailto:LNMolino%40aol.com>

>

> (Cell Phone)

> (Home Phone)

> (IFW/TFW/FSS Office)

> (IFW/TFW/FSS Fax)

>

> " A Texan with a Jersey Attitude "

>

> " Great minds discuss ideas; Average minds discuss events; Small minds

> discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 - 1962)

>

> The comments contained in this E-mail are the opinions of the author

> and the

> author alone. I in no way ever intend to speak for any person or

> organization that I am in any way whatsoever involved or associated

> with unless I

> specifically state that I am doing so. Further this E-mail is intended

> only for its

> stated recipient and may contain private and or confidential materials

> retransmission is strictly prohibited unless placed in the public

> domain by the

> original author.

>

>

[Guest guest]

In a message dated 1/31/2007 7:29:51 P.M. Central Standard Time,

ewalsh@... writes:

The correct bi phasic shock is

SHOCKED DEKCOHS

or it could be

_ /SHOCKED\_

\DEKCOHS/

Clever Ed, very clever...

Grayson, CCEMT-P, etc.

_www.medictrainingsolutions.com_ (http://www.medictrainingsolutions.com/)

MEDIC Training Solutions