2. Cardiac Arrest Algorithm
D – danger
R – response
S – shout
A – airway
B – breathing
C – circulation
D – defibrillation
ALS Subcommittee 2010
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
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
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. 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. Defibrillator Burn
• Correct use of coupling agent or defibrillator
pads will prevent burns ALS Subcommittee 2010
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. 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
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. 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. What is wrong with this picture?
ALS Subcommittee 2010
25. How to defibrillate ?
stop look go
1. Attach electrodes to patient’s chest
2. Turn defibrillator on – select leads
3. Analyse the rhythm ?shockable
4. Apply coupling agent or pads to patient’s chest
5. Select energy level
6. Apply paddles to chest
7. Charge the paddles
8. The “Clear” chant
9. Check monitor again
10.Discharge shock and return paddles to machine
ALS Subcommittee 2010
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. 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. 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. 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. References
1. American Heart Association CPR Guidelines Nov
2010
2. European Resuscitation Council Guidelines for
Resuscitation 2010
3. Ibrahim WH. Recent advances and
controversies in adult cardiopulmonary
resuscitation. Postgrad Med J 2007;83:649-54
ALS Subcommittee 2010
31. THANK YOU
NATIONAL 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
