Important points during defibrillation

1. DEFIBRILLATION

2. Cardiac Arrest Algorithm
D – danger
R – response
S – shout
A – airway
B – breathing
C – circulation
D – defibrillation

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

4. Importance of Early
Defibrillation

5. Why Defibrillate?
• Does NOT equal to resuscitation outcome
• The goal is to RESTORE sinus rhythm

6. Shockable Rhythms
VF
VT

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

8. Automated External
Defibrillators

9. Manual Defibrillators

10. Automated Implanted Cardioverter
Defibrillator (AICD)

11. Types of Defibrillators by
Waveform
• Monophasic
• Biphasic

12. MONOPHASIC
360J
54% - 63%*
* First-shock efficacy
360J
77% - 91%*

13. BIPHASIC
150-200J
86%—98%*
120-200J
Up to 85% *
* First-shock efficacy

14. IMPORTANT POINTS DURING
DEFIBRILLATION

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

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
√

17. Defibrillator Burn
• Correct use of coupling agent or defibrillator
pads will prevent burns

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

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

20. Important Points During
Defibrillation

21. Important Points During
Defibrillation

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 OxygenAdministration. 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 DefibrillationAttempt in a Neonate. Pediatrics 2003;112:677-679

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!

24. What is wrong with this picture?

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

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

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

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

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

30. References
1. American Heart Association CPR Guidelines
2020
2. Ibrahim WH. Recent advances and
controversies in adult cardiopulmonary
resuscitation. Postgrad Med J 2007;83:649-54

31. THANK YOU
ALS Subcommittee 2010
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