Overcoming Obstacles to Effective AED Pad Adhesion in Emergency Cardiac Care

The stated complaint was, “Dad has cold hands.” As a result, the call came out as a Basic Life Support 2 -- in my district, this means that an aid unit with two EMT Basics alone would respond. My partners and I, on the ALS car, jumped the call only because it was mere blocks from our station.

On the quick drive over, we speculated about our patient. Had he held a refrigerated soda can too long? Did he always have poor circulation and chilly fingertips? It was a balmy summer day, so an extended period outside was unlikely to be the culprit.

Upon arriving, we clambered out with the monitor and code box in hand. We were directed to the bathroom, where the Dad in question was slumped over on the toilet.

He had stone gray and profusely sweaty skin, all the more apparent due to his complete lack of clothes. He did not look up or react in any way when three strangers in duty boots joined him where he, in more ideal circumstances, should have had privacy. He breathed slightly fast but still with a sufficient tidal volume. He held his head up and protected his airway, though doing that much was a struggle.

The problem became apparent as soon as I pressed my fingertips into his wrist to feel his heartbeat. It was about 25. It was irregular, and thready, and was not perfusing his brain and nor providing service to other vital organs either.

Since it could offer no useful insights here, I didn’t prioritize taking blood pressure. Though ACLS Guidelines are clear about this situation, I didn’t try to get an IV or push Atropine, either.

I applied the pacing pads, set the monitor to a rate of 70, and carefully cranked up the milliamps. Briefly, it worked. The patient didn’t speak or make eye contact, but his skin became a more natural pink. His breathing slowed, too, but not greatly.

After I applied the pacing pads, we scooped him onto the gurney and rushed him out to the rig. One of the EMTs from the aid unit summoned another Medic unit. Meanwhile, I worked to get a line through the patient’s scarred, pockmarked arms. Then my EMT partner drew my attention to a problem: the pads weren’t sticking.

He was sweating so profusely that dabbing at his chest with gauze barely helped. A fresh set of pads didn’t work any better. Ultimately, wearing three pairs of gloves, an EMT tried to manually hold the pads in place on his chest.

As it turned out, pacing had been his last link to life and it was now too late. He coded, which to be fair was a likely end to any version of that scenario. We tried for forty minutes and couldn’t get him back.

At the time, I thought we’d done everything that we could with the tools that we had. But I would learn months later, was not entirely accurate.

An Ongoing Challenge

A few months later, we were awoken at 3 am to a report of a 44-year-old male who was complaining of difficulty speaking between words.

When my team arrived on that scene, the patient was out on his lawn, soaked with sweat, and wheezing loudly. His heart rate and blood pressure were normal. He had no cardiac history of any kind. His shortness of breath had come on abruptly.

Here, I made a mistake. His end-tidal readings were high, but because of his blood pressure, lack of cardiac history, and the sudden onset of symptoms, I thought he was experiencing respiratory wheezing rather than cardiac. I administered epinephrine, working on a presumptive diagnosis of anaphylaxis due to his age, history, and the reported suddenness of his shortness of breath.

Luckily, I’d also put him on a CPAP to both address his high end-tidal readings and cover my bases.

I couldn’t even get enough pads for a 4-lead to stick to his soaked skin that replaced any liquid as soon as we wiped it off. If I’d been able to attach the 12, I definitely would have appreciated his STEMI. But I couldn’t and so I didn’t and as a result, to quote my medical director, I “flogged his already-struggling heart with repeated epinephrine doses.”

Iodine Wipes as the Solution

There are electrodes made specially for diaphoretic patients. If your agency has the budget for those and regularly stocks them on ALS rigs, make use of them. But, in my area, no providers carry specialized electrodes for excessively damp patients. I wasn’t able to find AED and monitor pads for Lifepak users that are specially designed to attach to very wet skin.

However, there is a solution to this problem that does not involve any leadership signing off on supply sheets. And that solution is iodine wipes.

To use them on sweaty or profusely diaphoretic patients, you need to first, remove any problematic hair from the areas of the chest you will be applying either AED pads or electrodes.

Then, take out your iodine wipes. Specifically, you need the wipes that are inundated with brown liquid, not clear. At our agency, we keep them with our intraosseous drills. Wipe the areas you need to affix equipment to thoroughly with the iodine.

Next, wipe the area with an alcohol wipe. Just your standard wipe soaked through with rubbing alcohol, often located with your IV or glucometer supplies. Don’t do this as thoroughly as the iodine. Just a few swipes will do.

Attach the pads or electrodes as quickly as possible after you’ve applied the alcohol.

Bask in the magic.

I couldn’t find any primary literature on this technique, so I can’t speak to its broader scope or any documented evidence of its success. Still, I can speak to my personal experience: I’ve had wonderful results. I’ve walked up to a scene where providers are scowling down at a wet, gray man and fretting about their lack of 12 leads. Then, three Iodine wipes and two minutes later changed that scene to one where we’re looking down at an obvious lateral STEMI and can notify our nearest cath lab promptly.

It works. I’m based out of a rural area so I don’t work as many codes as my urban counterparts, but I do have an unusually good ROSC rate. It’s plausible that this is luck, especially since I have been blessed with genuinely reversible arrests, including hypoglycemic and hyperkalemic cases this year alone. Still, I think the fact that I can always attach pads tightly to the patient’s chest could also be a factor.

As always in medicine, a large controlled study of this technique would be ideal. 

But, as is also often the case, I’m not sure when or if such data is going to become available. So, while we wait for those studies especially since this involves only utilizing disinfectants we already use, I think this technique should be taught to all providers and consistently used. This bit of troubleshooting is especially critical because pads and electrodes do more good and offer more accurate readings when they’re attached to the patient.  If the patient was my loved one, I’d want them slathered in iodine and then dabbed with alcohol, even if there is currently a lack of double-blind studies. It’s possible that could make all the difference.