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ALS Subcommittee 2010
DEFIBRILLATION
ALS Subcommittee 2010 ALS Subcommittee 2010
Cardiac Arrest Algorithm
D – danger
R – response
S – shout
A – airway
B – breathing
C – circulation
D – defibrillation
ALS Subcommittee 2010 ALS Subcommittee 2010
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 ALS Subcommittee 2010
Importance of Early Defibrillation
ALS Subcommittee 2010 ALS Subcommittee 2010
Why Defibrillate?
• Does NOT equal to resuscitation outcome
• The goal is to RESTORE sinus rhythm
ALS Subcommittee 2010
Shockable Rhythms
VF
VT
ALS Subcommittee 2010 ALS Subcommittee 2010
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 ALS Subcommittee 2010
Automated External Defibrillators
ALS Subcommittee 2010 ALS Subcommittee 2010
Manual Defibrillators
ALS Subcommittee 2010 ALS Subcommittee 2010
Automated Implanted Cardioverter Defibrillator (AICD)
ALS Subcommittee 2010 ALS Subcommittee 2010
Types of Defibrillators by Waveform
• Monophasic
• Biphasic
ALS Subcommittee 2010
MONOPHASIC
360J 54% - 63%*
* First-shock efficacy
360J 77% - 91%*
ALS Subcommittee 2010 ALS Subcommittee 2010
BIPHASIC
150-200J 86%—98%*
120-200J Up to 85% *
* First-shock efficacy
ALS Subcommittee 2010
IMPORTANT POINTS DURING DEFIBRILLATION
ALS Subcommittee 2010 ALS Subcommittee 2010
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 ALS Subcommittee 2010
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 ALS Subcommittee 2010
Defibrillator Burn
• Correct use of coupling agent or defibrillator pads will prevent burns
ALS Subcommittee 2010 ALS Subcommittee 2010
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 ALS Subcommittee 2010
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 ALS Subcommittee 2010
Important Points During Defibrillation
ALS Subcommittee 2010 ALS Subcommittee 2010
Important Points During Defibrillation
ALS Subcommittee 2010 ALS Subcommittee 2010
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 ALS Subcommittee 2010
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
What is wrong with this picture?
ALS Subcommittee 2010 ALS Subcommittee 2010
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 ALS Subcommittee 2010
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 ALS Subcommittee 2010
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 ALS Subcommittee 2010
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 ALS Subcommittee 2010
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 ALS Subcommittee 2010
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 ALS Subcommittee 2010
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
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