Defib skillstation22122011edited

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


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


Importance of Early Defibrillation


Why Defibrillate?

• Does NOT equal to resuscitation outcome

• The goal is to RESTORE sinus rhythm


Shockable Rhythms

VF

VT


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


Automated External Defibrillators


Manual Defibrillators


Automated Implanted Cardioverter Defibrillator (AICD)


Types of Defibrillators by Waveform

• Monophasic

• Biphasic


MONOPHASIC

360J 54% - 63%*

* First-shock efficacy

360J 77% - 91%*


BIPHASIC

150-200J 86%—98%*

120-200J Up to 85% *

* First-shock efficacy


IMPORTANT POINTS DURING DEFIBRILLATION


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



• 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

√


Defibrillator Burn

• Correct use of coupling agent or defibrillator pads will prevent burns

http://images.google.com.my/imgres?imgurl=http://photos2.flickr.com/1692683_c408430116_m.jpg&imgrefurl=http://www.contractorpeon.com/blog/?m=200502&h=240&w=180&sz=5&hl=en&start=12&tbnid=FjOw_S3N5rVutM:&tbnh=110&tbnw=83&prev=/images?q=defibrillator&svnum=10&hl=en&lr=&sa=X



• Paddle force – 8kg in adult, 5kg in 1-8 year old children when

using adult paddles

• Paddle size – Minimum 150cm2, diameter 8-12cm



• 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







• 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



• One I clear, Two you clear, Three everybody clear

• Look back at monitor before shocking

• Paddles MUST be horizontal at all times!


What is wrong with this picture?


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


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


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


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


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


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


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

Health & Medicine

Defib skillstation22122011edited