DEFIBRILLATION          ALS Subcommittee 2010
Cardiac Arrest AlgorithmD – dangerR – responseS – shoutA – airwayB – breathingC – circulation            D – defibrillatio...
Importance of Early                   Defibrillation• To give the victim the best chance of survival, 3  actions must occu...
Importance of Early   Defibrillation                      ALS Subcommittee 2010
Why Defibrillate?• Does NOT equal to resuscitation outcome• The goal is to RESTORE sinus rhythm                           ...
Shockable RhythmsVFVT                         ALS Subcommittee 2010
Definition of Defibrillation• Defined as the termination of VF for at least  5s after the shock  – an electrophysiological...
Automated External   Defibrillators                     ALS Subcommittee 2010
Manual Defibrillators                        ALS Subcommittee 2010
Automated Implanted Cardioverter      Defibrillator (AICD)                           ALS Subcommittee 2010
Types of Defibrillators by                    Waveform• Monophasic• Biphasic                                     ALS Subco...
MONOPHASIC 360J                                  360J77% - 91%*                            54% - 63%*             * First-...
BIPHASIC150-200J                            120-200J86%—98%*                            Up to 85% *           * First-shoc...
IMPORTANT POINTS DURING     DEFIBRILLATION                   ALS Subcommittee 2010
Important Points During                      Defibrillation•   Hairy chest•   Wet chest•   Breasts•   Patches            W...
Important Points During                   Defibrillation• Coupling agent   – NO ARCING!!       R. S. Hummel 3rd, J. P. Orn...
Defibrillator Burn• Correct use of coupling agent or defibrillator  pads will prevent burns                ALS Subcommitte...
Important Points During                 Defibrillation• Paddle force   – 8kg in adult, 5kg in 1-8 year old children when  ...
Important Points During                   Defibrillation• Paddle position   1. Sternal - apical   2. Biaxillary   3. Right...
Important Points During    Defibrillation                          ALS Subcommittee 2010
Important Points During    Defibrillation                      ALS Subcommittee 2010
Important Points During                       Defibrillation• Fire   May be ignited by sparks from poorly applied     defi...
Important Points During               Defibrillation• One I clear, Two you clear, Three everybody  clear• Look back at mon...
What is wrong with this picture?                            ALS Subcommittee 2010
How to defibrillate ?                 stop look go1. Attach electrodes to patient’s chest2. Turn defibrillator on – select...
Synchronised Cardioversion• For rhythms with an organised QRS complex and  perfusing i.e. with a pulse but haemodynamicall...
Defibrillation + CPR• Early defibrillation is critical to survival from  sudden cardiac arrest because:  1. The most frequ...
If Flatline…• Always double check that it IS a flatline  – Check other leads  – Check attachment of leads  – Increase the ...
SUMMARY• Definition• Types of defibrillator• Tips for defibrillation   –   Hairy chest   –   Wet chest   –   Breast   –   ...
References1. American Heart Association CPR Guidelines Nov   20102. European Resuscitation Council Guidelines for   Resusc...
THANK YOUNATIONAL COMMITTEE ON RESUSCITATION TRAINING  SUBCOMMITEE FOR ADVANCED LIFE SUPPORT           Dr Tan Cheng Cheng...
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Defib skillstation22122011edited

  1. 1. DEFIBRILLATION ALS Subcommittee 2010
  2. 2. Cardiac Arrest AlgorithmD – dangerR – responseS – shoutA – airwayB – breathingC – circulation D – defibrillation ALS Subcommittee 2010
  3. 3. Importance of Early Defibrillation• To give the victim the best chance of survival, 3 actions must occur within the first moments of a cardiac arrest: 1) Activation of the emergency medical services 2) Provision of CPR 3) Operation of a defibrillator AHA guidelines 2010.Section 6.Electrical therapies ALS Subcommittee 2010
  4. 4. Importance of Early Defibrillation ALS Subcommittee 2010
  5. 5. Why Defibrillate?• Does NOT equal to resuscitation outcome• The goal is to RESTORE sinus rhythm ALS Subcommittee 2010
  6. 6. Shockable RhythmsVFVT ALS Subcommittee 2010
  7. 7. Definition of Defibrillation• Defined as the termination of VF for at least 5s after the shock – an electrophysiological event that occurs 30- 50ms after shock delivery; the heart is stunned and hopefully the SA Node will take over ALS Subcommittee 2010
  8. 8. Automated External Defibrillators ALS Subcommittee 2010
  9. 9. Manual Defibrillators ALS Subcommittee 2010
  10. 10. Automated Implanted Cardioverter Defibrillator (AICD) ALS Subcommittee 2010
  11. 11. Types of Defibrillators by Waveform• Monophasic• Biphasic ALS Subcommittee 2010
  12. 12. MONOPHASIC 360J 360J77% - 91%* 54% - 63%* * First-shock efficacy ALS Subcommittee 2010
  13. 13. BIPHASIC150-200J 120-200J86%—98%* Up to 85% * * First-shock efficacy ALS Subcommittee 2010
  14. 14. IMPORTANT POINTS DURING DEFIBRILLATION ALS Subcommittee 2010
  15. 15. Important Points During Defibrillation• Hairy chest• Wet chest• Breasts• Patches Wrenn, K. The hazards of defibrillation through nitroglycerin patches. Ann Emerg Med 1990; 19(11): 1327-8• AICD / pacemaker ALS Subcommittee 2010
  16. 16. Important Points During Defibrillation• Coupling agent – NO ARCING!! R. S. Hummel 3rd, J. P. Ornato, S. M. Weinberg and A. M. Clarke. Spark-generating properties of electrode gels used during defibrillation. A potential fire hazard. JAMA November 25, 1988; 260: 20 √ ALS Subcommittee 2010
  17. 17. Defibrillator Burn• Correct use of coupling agent or defibrillator pads will prevent burns ALS Subcommittee 2010
  18. 18. Important Points During Defibrillation• Paddle force – 8kg in adult, 5kg in 1-8 year old children when using adult paddles• Paddle size – Minimum 150cm2, diameter 8-12cm ALS Subcommittee 2010
  19. 19. Important Points During Defibrillation• Paddle position 1. Sternal - apical 2. Biaxillary 3. Right or left upper back – apical 4. Antero-posterior especially in atrial arrhythmias• All 4 positions are equally effective in shock success Deakin CD, Sado DM, Petley GW, Clewlow F. Is the orientation of the apical defibrillation paddle of importance during manual external defibrillation? Resuscitation 2003;56:15—8 ALS Subcommittee 2010
  20. 20. Important Points During Defibrillation ALS Subcommittee 2010
  21. 21. Important Points During Defibrillation ALS Subcommittee 2010
  22. 22. Important Points During Defibrillation• Fire May be ignited by sparks from poorly applied defibrillator paddles in the presence of an oxygen-enriched atmosphere Miller, P. H. Potential fire hazard in defibrillation. JAMA 1972;221(2): 192. Early report of fire hazard during defibrillation Fires from Defibrillation during Oxygen Administration. Hazard. Health Devices Jul 1994;23(7):307-8 Robertshaw, H. and G. McAnulty. Ambient oxygen concentrations during simulated cardiopulmonary resuscitation. Anaesthesia 1998;53(7): 634-7 Theodorou et al. Fire Attributable to a Defibrillation Attempt in a Neonate. Pediatrics 2003;112:677-679 ALS Subcommittee 2010
  23. 23. Important Points During Defibrillation• One I clear, Two you clear, Three everybody clear• Look back at monitor before shocking• Paddles MUST be horizontal at all times! ALS Subcommittee 2010
  24. 24. What is wrong with this picture? ALS Subcommittee 2010
  25. 25. How to defibrillate ? stop look go1. Attach electrodes to patient’s chest2. Turn defibrillator on – select leads3. Analyse the rhythm ?shockable4. Apply coupling agent or pads to patient’s chest5. Select energy level6. Apply paddles to chest7. Charge the paddles8. The “Clear” chant9. Check monitor again10.Discharge shock and return paddles to machine ALS Subcommittee 2010
  26. 26. Synchronised Cardioversion• For rhythms with an organised QRS complex and perfusing i.e. with a pulse but haemodynamically unstable – Shock delivery timed with the QRS complex • Low-energy shock of 50-200J• Indications: Supraventricular tachycardia Atrial flutter Atrial fibrillation Unstable monomorphic VT• Not effective in junctional tachycardia or multifocal atrial tachycardia ALS Subcommittee 2010
  27. 27. Defibrillation + CPR• Early defibrillation is critical to survival from sudden cardiac arrest because: 1. The most frequent initial rhythm in sudden cardiac arrest is VF 2. Rx for VF is defibrillation 3. Probability for successful defibrillation diminishes with time 4. VF tends to deteriorate to asystole within a few minutes ALS Subcommittee 2010
  28. 28. If Flatline…• Always double check that it IS a flatline – Check other leads – Check attachment of leads – Increase the size of rhythm to rule out fine ventricular fibrillation ALS Subcommittee 2010
  29. 29. SUMMARY• Definition• Types of defibrillator• Tips for defibrillation – Hairy chest – Wet chest – Breast – Patches – AICD / pacemaker – Coupling agent – Paddle force, paddle size, paddle position – Fire ALS Subcommittee 2010
  30. 30. References1. American Heart Association CPR Guidelines Nov 20102. European Resuscitation Council Guidelines for Resuscitation 20103. Ibrahim WH. Recent advances and controversies in adult cardiopulmonary resuscitation. Postgrad Med J 2007;83:649-54 ALS Subcommittee 2010
  31. 31. THANK YOUNATIONAL COMMITTEE ON RESUSCITATION TRAINING SUBCOMMITEE FOR ADVANCED LIFE SUPPORT  Dr Tan Cheng Cheng  Dr Luah Lean Wah  Dr Ismail Tan bin Mohd Ali Tan  Dr Wan Nasrudin bin Wan Ismail  Dr Chong Yoon Sin  Dr Priya Gill  Dr Ridzuan bin Dato’ Mohd Isa  Dr Thohiroh binti Abdul Razak  Dr Adi bin Osman ALS Subcommittee 2010
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