Clinical paperDo clinical examination gloves provide adequate electrical insulation for safe hands-on defibrillation? I: Resistive properties of nitrile gloves☆
Introduction
The quality of external chest compression during a resuscitation attempt is crucial to successful defibrillation, admission to hospital alive and survival to hospital discharge. Four factors indicate the quality of external chest compression; adequate compression rate, adequate depth of compression, complete chest recoil and a high compression fraction (percentage of time during which chest compression is being delivered). Chest compression fraction is a key determinant of subsequent survival in patients with a shockable rhythm1 and current resuscitation guidelines therefore emphasise the need to minimise interruptions to chest compressions during CPR.2
Interruptions to chest compressions are surprisingly common and when they do occur, are often of considerable duration. Studies have demonstrated typical no-flow times of 24–63%.3, 4, 5, 6 Common reasons for interruption to CPR include the need to secure the airway and subsequently ventilate the patient, assessing the rhythm or performing a pulse check, and the need to defibrillate.7 Interruptions relating to defibrillation occur as the rescuer stands clear for the rhythm check and then subsequent shock delivery. The associated pre-shock pause closely relates to the success of the ensuing defibrillation, with pauses longer than 10 s adversely impacting on defibrillation success.8
Interruptions to CPR in order to defibrillate are aimed at ensuring the safety of rescuers and avoiding an inadvertent shock from the electrical discharge of the defibrillator; typically as much as 3000 V for biphasic defibrillators and 5000 V for older monophasic defibrillators.9 When used for clinical purposes, accidental electrical contact during defibrillation generally results in no more than the sensation of a shock or mild burns which nevertheless would be unacceptable to rescuers.10 However, with a current of approximately 20 mA being required to trigger a sensory stimulus, the safe threshold of 1 mA set by international safety standards is clearly being exceeded by a considerable margin.
Being able to safely perform hands-on defibrillation would make a significant contribution to minimising no-flow time and potentially contribute to improvements in survival. Several studies have brought us closer to understanding whether this is ever likely to be a safe option. Examination of leakage current during simulated defibrillation11 led to the suggestion that “chest compressions may be safely continued through defibrillation provided self-adhesive pad electrodes are used and gloves are worn”12 and more recently, animal studies have concluded that hands-on defibrillation can be safely performed but acknowledged that further clinical studies are needed before implementation into daily practice,13 although this has been disputed.14, 15, 16 More recently, 8.5% of paramedics wearing nitrile gloves undertaking intentional hands-on defibrillation reported the sensation of an electric shock,17 suggesting that recommendations regarding the safety of hands-on defibrillation are premature.
We have previously reviewed aspects of electrical safety during defibrillation and discussed the use of clinical gloves to provide an electrical barrier.9 Suggestions that clinical examination gloves provide adequate electrical resistance to safely isolate the rescuer from harmful voltages have three assumptions; that the gloves are intact, that the material from which the gloves are manufactured provides adequate resistance to current flow and that the material is able to withstand voltages of appropriate magnitude. All three requirements must be met for the rescuer to be safely isolated from the defibrillator.
Even when used for relatively delicate surgical procedures, surgical gloves, which tend to be of better quality than non-sterile examination gloves, are regularly damaged and no longer provide a barrier to fluids.18 Clinical examination gloves are generally thinner and are only designed to provide a physical barrier to blood and secretions. They have been shown to be poor at providing a barrier to fluids when used for critical care procedures,19 and when subject to friction,20 but their suitability to act as an electrical barrier is unknown. A variety of methods may be used to determine electrical integrity of the glove, the simplest being visual inspection. However, whilst gross tears may be evident visually, the glove may be compromised in more subtle ways that are either difficult to identify or invisible to the naked eye. Measurement of electrical resistance across the glove allows detection of these more subtle defects and allows an estimation of its ability to act as an electrically resistive barrier to defibrillation current.
We therefore examined the ability of commonly used clinical examination gloves to meet two of these three assumptions; namely whether the material from which the gloves are manufactured provides adequate resistance to current flow and whether gloves remain intact having endured the physical rigours of cardiopulmonary resuscitation.
Section snippets
Methods
Clinical examination gloves worn by members of hospital cardiac arrest teams were collected immediately following termination of the resuscitation care. Gloves were labelled according to whether they had been used to perform external chest compressions during the resuscitation attempt (the clinical (CPR) group) or worn by a member of the team not actively carrying out chest compressions (the clinical (non-CPR) group). Fresh, in-date, unused gloves were obtained from the same glove batch numbers
Results
A total of 40 new, unused gloves were tested for electrical resistance. Results were compared with 28 clinical (non-CPR) gloves worn by members of the resuscitation team but not used to perform external chest compressions and 128 clinical (CPR) gloves worn by members of the resuscitation team used to perform external chest compressions. Visual inspection revealed three gloves with visible tears (one new unused glove, one from the clinical (CPR) group, and one from the clinical (non-CPR) group).
Discussion
This study demonstrates that the electrical resistance of standard nitrile gloves, a common glove type used for clinical procedures, reduces when worn and reduces still further when used to perform chest compressions. Additionally, some gloves may have macroscopic tears even when new, rendering them completely permeable to electrical current. Whilst a gross tear clearly compromises electrical insulation and therefore increases risk to the rescuer, the more subtle impact of a reduction of
Conflict of interest statement
No author has any conflict of interest with the contents of this study.
Acknowledgement
The authors are grateful to David Johnson, Steve Clitheroe and Brad Olden for their assistance with developing the measurement apparatus.
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2013.03.011.