Defibrillator

Definition

An electrical device used to counteract

fibrillation of the heart muscle and restore
normal heartbeat by applying a brief electric
shock
• Defibrillation consists of delivering a
therapeutic dose of electrical energy to the
affected heart with a device called a
defibrillator. This depolarizes a critical
mass of the heart muscle, terminates the
arrhythmia, and allows normal sinus rhythm
to be reestablished by the body's
natural pacemaker, in the sinoatrial node of
the heart.
• Defibrillators can be
• external,
• implanted
• transvenous,
• Subcutaneous
• Automated external defibrillators (AEDs)
 PURPOSES
Defibrillation is performed to correct life-
threatening arrhythmias of the heart
including
-ventricular fibrillation
-cardiac arrest.
It can also be used in non-life threatening
situations, atrial defibrillation can be used to
treat atrial fibrillation or flutter:
- To eradicate life-threatening ventricular
fibrillation or pulseless ventricular tachycardia.
2To restore cardiac output lost due to
dysrhythmias and reestablish tissue perfusion
and oxygenation.
• INDICATIONS:
• Ventricular arrhythmia (ventricular tachycardia or
ventricular fibrillation) and associated cardiac
arrest (unresponsive patient without a pulse)
•  
•  
• CONTRAINDICATIONS:
– Awake, responsive patients
– Any arrhythmias in a patient with a pulse
 MATERIALS:
• Defibrillator
• many different machines/models
• become familiar with equipment where you are practicing
• Paddles
• adult size (8-9cm diameter) for patient weight > 10 kg.
• pediatric size ( 2.2 cm diameter) for patient weight < 10 kg.
• Electrode pads
• Self – adhesive
• Conductive material
• Gel, paste or pads
 PROCEDURE/TECHNIQUE:
• Sudden death/cardiac arrest patients in VF or VT without a pulse
should be defibrillated as soon as possible (even before CPR,
medications or advanced airway procedures)
• Initiate CPR/ACLS protocols until defibrillator available
• Power on the defibrillator and select
“unsynchronized/defibrillation” mode
• Turn monitor selector to “paddles”
• Apply conductive materials (depends on what is available) before
paddle placement
• Apply defibrillator monitor cables, pads, or “quick-look” paddles to
patient in cardiac arrest to determine rhythm
• Paddle placement: 
– First (“sternum”) paddle:  to the right of the
upper sternum and below the clavicle
– Second (“apex”) paddle:  to the left of the
nipple in the midaxillary line, centered in
the 5th intercostal space
– Avoid placing both paddles next to one
another on the anterior chest wall
• Lead placement:
• “White-on-the-right” will help you to remember
the white electrode is placed on the right side
of the chest just below the right clavicle
• “Smoke over fire” will help you to remember
that the black lead is placed  on the left chest
just below the left clavicle, and the red lead is
placed in the left midaxillary line below the
expected  PMI of the heart
•  
• Electrode pad placement:
• Can be placed as described above for
paddles, or
• Anterior pad just to the left of the sternum,
and posterior pad on the patient’s back to
the left of the spine.  (This technique
“sandwiches” the heart between the pads)
• assess rhythm to confirm VF/VT:
• if you see a flatline, t rule out fine VF, if flatline remains (and you
have checked monitor, connections, and the patient) rotate paddles
90 degrees and re-assess rhythm to assure VF or (pulseless) VT
remains
• choose energy level and charge defibrillator (“charge” buttons may
be located on the paddles or on the machine itself)
• deliver shock(s) by simultaneously pressing the discharge buttons
located on the paddles (or on the monitor for electrode pads) after
ensuring “all clear” from the patient for equipment and providers
• re-assess patient, consider recommended medications, further
management
 
 Early defibrillation is
critical to survival
• VF -frequent rhythm witnessed in SCA

• Rx for VF is electrical defibrillation

• Probability of successful defibrillation diminishes

rapidly over time

• VF tends to deteriorate to asystole within a few

minutes
For every minute that passes between
collapse and defibrillation, survival rates
from witnessed VF SCA decrease 7% to 10%
if no CPR is provided

Ann Emerg Med. 1993;22:1652–1658

 3 actions that must occur
within the 1st moment of SCA
• Activation of the emergency medical services
(EMS) system

• Provision of CPR, and

• Operation of an AED

When 2 or more rescuers are present, activation of

EMS and initiation of CPR can occur simultaneously
 2 critical questions about
CPR+ defibrillation

• ? CPR should be provided before

defibrillation is attempted

• Number of shocks to be delivered in a

sequence before the rescuer resumes CPR
Shock First Vs CPR First
• Out-of-hospital witnessed arrest

• If AED is immediately available

• Use the AED as soon as possible.

Shock First Vs CPR First contd..

In hospital

CPR first
Out-of-hospital not witnessed SCA

5 cycles of CPR

Check the ECG rhythm

Defibrillation (Class IIb)

• One cycle of CPR consists of 30
compressions and 2 breaths

• When compressions are delivered at a rate

of about 100 per minute, 5 cycles of CPR
should take roughly 2 minutes
This recommendation regarding CPR prior to
attempted defibrillation is supported by 2
clinical studies

JAMA. 2003;289:1389 –1395

JAMA. 1999;281:1182–1188
1-shock Vs 3-shock sequence
• No published human studies

• Animal studies- 1 shock f/b CPR

• VF/ Pulseless VT- 1 shock f/b 5 # CPR

• Non shockable rhythm- CPR first

• 1st shock efficacy of Monophasic is lower than

biphasic shock
 Defibrillation waveforms
and energy levels
• The energy settings are designed to provide the
lowest effective energy needed to terminate VF

• Shock success -Termination of VF for at least 5

sec following the shock

• VF frequently recurs after successful shocks, but

this recurrence should not be equated with shock
failure
• Modern defibrillators are classified as
Monophasic
Biphasic

• Energy levels vary by type of device

• No specific waveform is associated with a higher

rate of return of spontaneous circulation (ROSC) or
rates of survival to hospital discharge after cardiac
arrest
 Monophasic waveform
Defibrillators
• Deliver current of one polarity

• 2 types

• The monophasic damped sinusoidal waveform

(MDS) returns to zero gradually

• Monophasic truncated exponential waveform (MTE)

current is abruptly returned to baseline (truncated)
to zero current flow
 Biphasic waveform
Defibrillators
• The optimal energy for termination rate
for VF has not been determined

• 200 J is safe and has equivalent or higher

efficacy for termination of VF than
monophasic waveform shocks of
equivalent or higher energy (Class IIa)
 Automated external
Defibrillators
• AEDs are sophisticated, reliable devices

• Use voice and visual prompts to guide lay

rescuers and healthcare providers to safely
defibrillate VF SCA
Lay Rescuer AED programs

• 1995 AHA recommended lay rescuer AED

programs to improve survival rates from out-of-
hospital SCA

• Studies of lay rescuer AED programs in airports,

& casinos have shown a survival rate of 41-74%
from out-of-hospital witnessed VF SCA when
immediate bystander CPR is provided and
defibrillation occurs within about 3 to 5 minutes
of collapse
 Electrode placement

• Right pad – Right Infraclavicular

• Left pad – Inf-lateral left chest, lateral to

the left breast

• Position the pad at least 1 inch (2.5 cm)

away from the implantable medical device
• Do not place pads directly on top of a
transdermal medication patch

• If the victim’s chest is covered with water

or the victim is extremely diaphoretic,
wipe the chest before attaching pads

• AEDs can be used when the victim is lying

on snow or ice

• If the victim has a hairy chest, remove

some hair
 Manual Defibrillation

• Both low-energy and high-energy biphasic

waveform shocks are effective

• Both escalating & non-escalating energy

defibrillators are available

• Insufficient data to recommend one over another

• Use device specific dose

• Biphasic- 150-200 J

• Monophasic- 360 J

• Although operator selects the shock

energy (in joules), it is the current flow (in
amperes) that actually depolarizes the
myocardium
 Transthoracic Impedance

• Human impedance is 70 to 80 Ω

• To reduce use conductive materials

• In O2 rich areas such as CCU’s arcing has

been known to cause fires
 Electrode size

• Min of 50 cm2

• 8-12 cm diameter

• Small electrode mat cause myocardial

necrosis
 Fire hazard
• In oxygen rich environment

• Self-adhesive minimize the risk of sparks

• Do not use medical gels or pastes with

poor electrical conductivity, such as
ultrasound gel
Synchronized cardioversion

• Shock delivery that is timed (synchronized) with

the QRS complex

• Avoids shock delivery during the relative

refractory portion of the cardiac cycle, when a
shock could produce VF

• Energy (shock dose) used for a synchronized

shock is lower than that used for unsynchronized
shocks (defibrillation)
• Synchronized cardioversion is recommended
to treat
• Unstable SVT
– d/t reentry
– atrial fibrillation
– atrial flutter
 SVT
• Monophasic energy for A Fib = 100-200 J
• A Flutter = 50-100 J
• If initial shock fails then increase dose in step
wise manner
• Optimal dose for biphasic waveforms not
established
• Success of terminating A fib with initial
dose = 85%
 Ventricular Tachycardia
• Pulseless VT is treated as VF
Thank You