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INSTRUMENT REPORT

ON

DEFIBRILLATOR

BY

JUNED SIDDIQUE

REMARK: ______________ SIGN. :


__________________

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HEARTSTART XL DEFIBRILLATOR

INTRODUCTION

• A Defibrillator is an instrument used for administering a high energy


shock wave to the heart during fibrillation, to is restore its normal
rhythm. The electric shock is given to the patient through large paddle
shaped electrodes pressed against the skin of the chest.

• In cardiac fibrillation, the main problem is that heart muscle fibres are
continuously stimulated by adjacent cells so that there is no
synchronized succession of events that follow the heart action. There
might be atrial fibrillation or ventricular fibrillation.

• Atrial fibrillation: The electrical signal in the upper chambers of the


heart is not organized and flowing rhythmically through the heart
muscle. It’s a very fast and irregular contraction of the atria. AF occurs
when the electrical signal begins in the different part of the atrium than
the sinoartial node or when the signal is conducted abnormally. When
this happens the electrical signal doesn’t travel through the normal
pathways in the atria, but instead may spread throughout the atria in a
fast and disorganized manner ,this causes the walls of the atria to
quiver very fast instead of beating normally.

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• As a result atria aren’t able to pump blood into the ventricle the way
they should.

Waveform of atrial fibrillation

• Ventricular fibrillation is a serious cardiac emergency and most


ominous arrhythmia. The uncoordinated movements of ventricular
walls of the heart may result from coronary occlusion, from electric
shock or from abnormalities of body chemistry. Because of this
irregular contraction of muscle fibers, ventricular pumping ceases,
blood is not ejected and there is steep fall of cardiac output. This might
prove fatal and death will occur if adequate steps are not taken
promptly. Therefore a strong, brief electrical current is passed across
the chest to stop ventricular fibrillation.

Fig 4.2 Waveform of ventricular fibrillation

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FEATURES

• Reliability and safety

Rugged mechanical design: The Heartstart Xl is built with high impact


plastic which has few openings and incorporate a rugged defibrillation
pads connector and battery interface.

Daily automatic self test: The Heartstart XL performs a daily test to ensure
it is ready to use when needed.

• Ease of use

Small and light: The biphasic waveform technology used in Heartstart XL


has allowed them to be small and light.

Voice prompts: Heartstart XL provides audible prompts that guide the user
through the device process.

Clear labeling and graphics: The Heartstart XL is designed enable fast


response by the user.

• Offers two modes of operation:

1. Automatic External Defibrillation (AED) Mode

2. Manual Mode 20

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• ECG monitoring can be accomplished in either mode using one of 2


methods:

1. ECG from the defib pads.

2. 3-lead ECG using separate monitoring electrodes.

• Powered by AC Power and a Rechargeable Sealed Lead Acid (SLA) battery.

• Provides non-invasive transcutaneous pacing.

• It automatically stores critical events, in its internal memory.

• Provides (SpO2) monitoring with a provision to set alarm limits.

PRINCIPLE OF OPERATION

The basic principle underlying applying the shock is that the charge is
stored on capacitor. Energy storage capacitor is charged at relatively slow
rate (in order of seconds) from AC line by means of step-up transformer and
rectified arrangement or from a battery and a DC-to-DC converter
arrangement, the energy stored in the capacitor is then delivered at a
relatively rapid rate (order of milliseconds) to the chest of the patient. For
effective defibrillation some shaping of the discharge current pulse is
adopted. The simplest arrangement involves the discharge of capacitor
energy through the patient’s own resistance, this results in exponential
discharge typical of an RC circuit. Rectangular and trapezoidal waveforms are
found effective and are employed in defibrillators design for clinical use. The
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basic circuit diagram of a defibrillator consists of a variable auto-transformer

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T1 which forms the primary of a high voltage transformer T2.The output


voltage if transformer is rectified by a diode rectifier and is connected to a
vacuum type high voltage change over-switch. In position A, the switch is
connected to one end of an oil-filled or electrolytic capacitor. In this position
capacitor charges to a voltage set by the positioning of the auto- transformer.
When the shock is delivered to the patient, a foot switch or a push button
mounted on the handle of the electrode is operated. The high voltage switch
changes over to position B and the capacitor is discharged across the heart
through the electrodes.

In a defibrillator an enormous amount of voltage (approx. 4000V) is


initially applied to the patient. Although short duration pulses can affect
defibrillation, the high current required impairs the contractility of the
ventricles. This is overcome by inserting a current limiting inductor in series
with patient’s circuit. The inductor slows down the discharge from the
capacitor by the induced counter voltage, which gives output pulse a
physiologically favorable shape. The shape of the waveform of that appear
across electrodes depends on the value of the capacitor and inductor used in
the circuit.

The different types of waveforms used for defibrillation are:

• Monophasic Damped sine Waveform

• Biphasic Waveform

Monophasic Damped Sine Waveform

Most of the defibrillators are designed that uses DC types of waveform


known as Monophasic Damped Sine. The Monophasic Truncated
Exponential was used in early AED’s. Monophasic waveforms continue to
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be widely used in hospitals today. They use escalating high levels of


energy delivered in one direction through the patient’s heart. The
maximum energy setting for Monophasic Damped Sine is 360J.
Monophasic waveform always assumes that patient impedance is 50
ohms.

Fig 4.4 Monophasic waveform

Biphasic Waveform

In biphasic waveform energy I delivered in both the directions through


the patient’s heart that too at low energies. In M4735 HeartStart XL
defibrillator SMART Biphasic waveform technology has changed the way
defibrillation therapy is delivered.

Biphasic waveform

A clinician using monophasic defibrillator would typically


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shock a patient using escalating energy levels (200-300-600J), while using


SMART biphasic defibrillator shock recommended at 150J is given
consistently. As a result, there is a decrease in myocardial dysfunction to the
patient. Unlike the Monophasic Damped Sine Waveform, the SMART Biphasic
waveform measures the patient‘s impedance and adjust the waveform
accordingly prior to the delivery of shock.

The success of defibrillation correlates better with the amount of energy


stored in the capacitor than with the value of the voltage used, hence the
output of the DC defibrillator is calibrated in terms of watt-seconds or joules
as a measure of electrical energy stored in the capacitor.

Energy in watts seconds is equal to one half the capacitance in farads


multiplied by the voltage in volts squared, i.e. E=1/2C(V)2 .

The amount of energy that the defibrillator actually delivers to the patient
is of more relevance. This can be determining factor energy can be
estimated by assuming the value of a load resistance that is placed between
the electrodes and thus simulates the patient’s resistance.

MODES OF OPERATION

The two modes of operation for defibrillator are:

• Automatic External Defibrillation (AED) Mode

• Manual Mode

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In AED mode, the defibrillator analyzes the patient’s ECG and advices the
clinician whether or not to deliver a shock. Voice prompts guide you
through the defibrillation process by providing instructions and patient
information.

Voice prompts reinforced by messages that appear on the display.

Monitoring is available in AED mode through pads, 3-lead ECG monitoring


electrodes or optional 5-lead ECG monitoring electrodes.

The AED algorithm is not designed to handle erratic spike problems


caused by a properly or improperly functioning pacemaker.

An AED is to be used in the presence of a suspected cardiac arrest on


patients of at least 8 years of age that are:

• Unresponsive

• Not breathing

• Pulse less

An AED is not to be used on patients that exhibit one or any combinations of


the following:

• Responsiveness

• Spontaneous breathing

• Palpable pulse

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Overview of Automatic External


IF THE PATIENT IS Defibrillation (AED) Mode

UNRESPONSIVE

BREATHLESS

PULSELESS

ATTACH PADS

ROTATE ENERGY
SELECT KNOB TO AED
MODE

IF INSTRUCTED, PRESS ANALYZE

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SHOCK ADVISED NO SHOCK ADVISED
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At completion
CHECK PATIENT
PRESS SHOCK

Of shock
series
NO PULSE
PULSE

Within a shock series

PRESS VENTI-
PAUSE LATE

If rhythm monitoring on

 Manual Mode

In manual Mode, defibrillator turns control of defibrillation process over to


the user. The user accesses the patients ECG and selects the energy sitting
for the defibrillation if necessary. Monitoring is available in AED mode
through 3-lead ECG monitoring electrodes or optional 5-lead ECG monitoring
electrodes. There are no voice prompts. However, system and momentary
messages provide relevant information throughout the process. It is
important to be attentive to these messages. In manual mode, defibrillator is
always performed through paddles or pads.

Manual mode allows the user to perform synchronized cardio-version and


offers non-invasive pacing(optional).

• Synchronized Cardio version:


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Synchronized Cardio version involves delivering a shock that is


synchronized to the R wave of the ECG. The defibrillator is responsible for
detecting the R wave of the ECG and placing markers on the printed strip and
on the display to indicate the timing of the proposed cardio version shock.
The specific point on the R wave is selected to avoid the heart to enter into
ventricular fibrillation

• Non-invasive pacing:

It provides non-invasive transcutaneous pacing by delivering a


monophasic, electrical stimulus to the heart. This stimulus is intended to
cause cardiac depolarization and myocardial contraction. It is used for
treating with symptomatic bradycardia, if performed early. Paced pulses are
delivered through multifunction defibrillator electrode pads, applied to the
patients bare chest. It can deliver paced pulses in either demand mode or
fixed mode. Use demand mode pacing whenever possible. Observing the
patient closely while pacing is very important. In demand mode, the pacer
delivers paced pulses when the patient’s heart rate is lower than the selected
pacing rate.

FRONT PANEL AND DISPLAY

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Front Panel of Defibrillator

The HeartStart XL Defibrillator has various controls and corresponding soft


keys for the functions to be performed. There are softkeys for using pacer
mode, for printing event summary, increasing and decreasing ECG size and
volume used for voice prompts which guides through defibrillation process
when AED mode is used. The monitor displays various alarms limits, selected
lead and the different elements that appear while using AED mode or Manual
mode.

The front panel consists of defibrillation controls, audiovisual controls,


monitoring controls, print controls and Manual as well as AED mode controls
and display layout when used in AED or Manual mode. There is patient cable
connector, data card and battery input on the front side.

FRONT PANEL DESCRIPTION:


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Defibrillation Control:

It consists of energy select knob and a set of softkeys that perform


the fuction displayed as a label above each button. These controls
assist in both AED and manual mode defibrillation.

Audiovisual Controls:

Adjusts the volume of voice prompts and the QRS beeper.

Adjusts the size of the ECG waveform displayed, printed, and


stored. Processing and simultaneously generously a 1mV calibration
pulse.

Monitoring Controls:

It consists of set of softkeys monitoring functionality. These


functions are displayed in the softkeys label below each button.
Monitoring softkeys also control heart rate and SpO2 alarms, and
selection of the ECG source to monitor.

Print Control:

Print Controls performs the function shown on each button. The print
controls from are:

Prints ECG data, defibrillation events. And marked


Strip
events real-time or with a 6 second delay. Press to
start printing; press again to stop printing.
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Summa Prints the event summary. Printing may be stopped


ry by pressing the Summary or Strip button.

Inserts a timed stamped annotation in the Event


Mark
summary. It may be configured to print an annotated
ECG strip when pressed.

Manual Mode Controls:

It provides access to manual defibrillation and synchronized


cardioversion and optional pacing functionality. Synchronized
cardioversion and pacing controls only function when manual mode is
enabled. It consists of energy select knob and pacing controls, which
are described as follows.

Energy select knob: it is used to enable both manual mode and AED
mode. The AED On position activates AED mode. Manual On enables
Manual mode, synchronized cardioversion and pacing.

Button below the display (far left) that enables


synchronized cardioversion when first pressed in
manual mode; disables synchronized cardioversion
when pressed again.

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Activates the pacing functions buttons, allowing to


Pacer
visualize the buttons below to define pacing rate,
mode, and current output. Also turns off the pacer
function when pressed a second time.

Rate
Adjust the pacing rate.

Start/S
Starts pacing, delivers pacer pulses when first
top
pressed; stops Pacing when pressed again.

Mode
Selects Demand or Fixed Mode for pacing.

Output
Adjusts the current output for pacing.

Display Layout

The elements that are displayed on the screen when AED or manual
mode is selected are almost same except few which are explained
as follows. 20

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AED Mode

Displays shows heart rate and its alarm, the ECG lead which is
selected, oxygen saturation (SpO2) value and its alarm, pleth bar
and pulse rate derived from pulse oximetery, ECG of the patient,
number of shocks delivered to the patient, incident timer shows the
elapsed time since the HeartStart XL was turned on.

The defibrillation softkeys when AED mode is selected (pause,


analyze and shock). User message areas accompany voice prompts
to guide through the defibrillation process. System and Momentary
messages provide status information, offer recommendation and
alerts to conditions that require attention. System message remains
on the display until the condition that generated the message no
longer exists. Momentary message is temporary and appears on the
display for a minimum of 3 seconds.

Manual Mode

The information that is displayed is same for manual mode also


except for the defibrillation softkeys. There is display which shows
that synchronization is on or off. The defibrillation softkeys in
manual mode are sync on/off, charge and shock.

REAR PANEL

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Fig 4.7 Rear Panel

Connecting To Power:

Ac power and the M4735A battery power the Heartstart XL.

Printer:

To take printouts of required medical parameters,such as strip prints of


required ECG Lead.

ECG Connector:

To connect 3-5 ECG Lead patient cable

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SpO2 Connector:

To connect SpO2 patient cable

ECG Out(Sync) Jack:

To connect pads and external and internal paddles.

The patient cable connector from ECG Out is used to connect:

• External paddles

• Pads cable patient used for multifunction defibrillator


pads

AC Power:

The required AC power is 230V.

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BLOCK DIAGRAM OF HEARTSTART XL


DEFIBRILLATOR

HIGH VOLT HIGH VOLT STATUS


POWER
CAPACITOR CHARGER BATTERY INDICATOR
SUPPLY

ON
/O
FF

SWITCHING/ISOLATIO
N

SHOCK
APEX STERNUM

SHOCK LED

ECG FRONT END


CONTROL BOARD
APEX STERNUM
BEEPER
REAL TIME CLOCK 20

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DATA CARD
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SPEAKER

MICROPHONE

IR PORT

TEMPERATURE
SENSOR

BLOCK DIAGRAM DESCRIPTION

Control Board

The control board holds the main processor and all of the circuitry
required to control the real time functions of the defibrillator. The real
time control provides the signals needed to sample the ECG and voice
data onto data card, send data to display and play the voice prompts
on the speaker, turn on various tones, charge the high voltage
capacitor and deliver the shock to patient. In addition, the processor on
the control board runs all of the data processing for analysis system.

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Patient Circuit

This circuitry includes all components needed to deliver the


defibrillator waveform to the patient. The large amount of energy
stored in the battery is low voltage that is not effective for defibrillator
shock. In order for the patient to be defined, enough energy for one
shock must be transferred to the high voltage capacitor at a voltage
high enough to make defibrillator waveform effective. This voltage is
maintained on the capacitor until the shock is delivered, ensuring that
the device is ready to deliver a shock of 150J to the patient. When the
shock button is pressed, the HV capacitor is disconnected from the HV
charger circuit and connected to patient throughout the electrode
pads. The switching circuitry then allows the current to flow in one
direction pad to pad through the patient, and then reverses the
direction of flow for a preset period of time. The direction of current
through the patient is based on the measured impedance. It is bi-
directional flow of current that forms the SMART BIPHASIC waveform.

User Interface

The user interface consists of the main LCD display, the on/off button,
the shock button, the connector light, shock button light, the beeper,
and the speaker and status indicator.

In normal operation, text prompts are displayed on main LCD and voice
prompts are provided through the speaker. These prompts guide the
rescuer in the use of the device and give warnings such as low battery,
to call the user’s attention to certain parts of the device that may need
attention. The connector light blinks when the unit is turned on to
draw attention. the voice prompt and display guides the user in
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connecting the defibrillation pads to the AED and the AED advices a
shock and charges, the shock button light blinks to guide the user to
the shock button and to indicate that it is ready to deliver a shock to
the patient. The beeper is also provided to draw user’s attention
indicating either that the device is ready for delivering a shock or the
battery is low and needs to be replaced.

Battery

The power source for defibrillator is a 12 V, 2Ah battery pack. The


battery packs are rechargeable.

Power Supply

The power supply is used to convert the battery voltage to various


voltages needed to supply the electronics within the defibrillator.

ECG Front End

The front end amplifies and filters the ECG signal input from electrodes
and feeds this signal into A/D converter the sampling rate for A/D
converter is 200 Hz and this digital data is fed into the control board to
be used by analysis system and stored onto the data card.

Recording

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When the AED is turned on and the pads are applied to the patient, the
AED continuously records the ECG and the event summary onto the
data card if installed. The AED can also record all the audio information
from the event through the microphone. The ECG and audio
information can later be reviewed using event review data
management software.

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APPLICATION

• The M4735A HeartStart XL Defibrillator is for use in hospital in


basic life support, advanced cardiac life support or defibrillation.

• When operating as a semi-automatic external defibrillator in


AED Mode, it is suitable for use by medical personnel trained in basic
life support for use that includes use of an AED.

• When operating as a defibrillator/monitor in Manual Mode, it is


suitable for use by healthcare professionals trained in advanced
cardiac life support.

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SAFETY PRECAUTIONS

• Use multifunction defibrillator pads prior to their expiration date.


Discard pads after use. Do not reuse it.

• Use only 3-wire AC power cords with 3-pronged


grounded plugs.

• Avoid touching of multifunction defib pads with each


other .Contact with metal objects may cause electrical arcing and
patient skin burns during defib and may divert current away from the
heart.

• During defib air pockets between skin and pads may


cause patient skin burns. To help prevent air pockets, make sure the
pads completely adhere to the skin.

• Do not use the equipment in a flammable or oxygen-rich


atmosphere.

• Avoid connecting the patient to many devices at once.


Leakage current may exceed.

• Do not discharge the defibrillator with the paddles


shorted together.

• Electromagnetic compatibility with surrounding device


should be assessed prior to using the defibrillator.

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CLEANING THE UNIT

Cleaning the HeartStart XL

• Isopropyl alcohol (70% in water)

• Mild soap and water

• Chlorine bleach (3% in water)

• Compounds such as Lysol (10% in water)

• When cleaning be sure to avoid pouring fluids on the device and do


not allow fluid to penetrate the exterior surface of the device.

Cleaning the printer head

If the printout is light then clean the printer head to remove any
build up paper residue.

Cleaning the external and internal paddles

Clean the electrode surface and handle with standard hospital


solution. Do not use enzymatic or ammonia based cleaners. Use
a small , soft brush with cleaning solution to clean any
contamination from electrode surface and edge.

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Cleaning the pads cable

• Clean using any of the following:

• 2% gluteraldehyde solution (such as cidex)

• Sodium hypochoride

Cleaning the ECG cable

Wiping with any one of the following may clean the ECG cable

2% gluteraldehyde solution (such as cidex)

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TECHNICAL SPECIFICATIONS

Separate specifications are given for defibrillator, ECG monitoring, SpO2


monitoring, display, printer, battery, etc. they are listed as follows:-

Charge Time:

Less than 3 seconds to 200 Joules with a new, fully charged M3516A SLA
battery pack at 25oC. Less than 15 seconds to 200 Joules when powered
by AC with no battery installed.

Patient Impedance Range:

25 to 180 Ohms.

Manual Output Energy (Delivered):

2, 3, 5, 7, 10, 20, 30, 50, 70, 100, 150,200 Joules.

AED Mode:

• AED Energy Profile: Fixed Energy (150 Joules).

• AED Shock Series: 1, 2, 3, or 4 shocks per series.

• Shock Series Timer: off, 30, 60, 90, 120, 150, 180, or 210 seconds.

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ECG Monitoring:

• Heart Rate Display: Digital readout on display from 15 to300bpm,with


an accuracy of ±10%.

• Heart Rate Alarms: Configurable pairs of low and high heart rate alarm
limits : 30 to 100, 60 to 140, 90 to 160, and 120 to 200 bpm.

• Hands Free Defibrillation: Patient Cable Length: 7 ft. (2.13 m).

• ECG Cable Length: 12 ft. (3.7 m).

• ECG Size: 2.5, 5, 10, 20, 40 mm/mV.

Display:

• Size: 115 mm x 86 mm.

• Type: EL – Electroluminescent.

• Resolution: 320 x 240 pixels.

• Sweep Speed: 25 mm/s nominal (stationary trace; sweeping erase


bar).

• Viewing Time: 4 seconds.

Battery:

• Type: 2 Ah, 12V, rechargeable, Sealed Lead Acid (SLA).

• Dimensions: 61.7 mm (H) x 23.9 mm (W) x 182 mm (D).

• Weight: 1.4 lb. (0.65 kg).

• Charge Time: Approximately 15 hours total to 100%.

• Capacity: >100 minutes ECG monitoring.


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• Battery Storage: Should not be stored above 40°C for extended


periods

of time.

Thermal Array Printer:

• Speed: 25 mm/s with an accuracy of ±5%.

• Paper Size: 50 mm by 30 m (100 ft.).

Internal Event Summary:

The internal Event Summary stores up to 300 events and up to 50


waveforms.

Temperature:

0° to 55°C operating, -20°C to 70°C storage.

AC Line Powered:

100-240 VAC, 50/60 Hz, .4A max (unit off), 1.5A max (while charging ).

Battery Powered:

12 V Rechargeable, SLA.

Dimensions:

19 cm (H) x 37.6 c cm (W) x 34.6 cm (L).

Weight:
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6kg, including battery and one roll of paper.

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