Defibrillators

Use & How

Dr.Imran
 Definition

Defibrillator is a device that deliver a

therapeutic dose of electrical energy (electric
shock) to the affected heart (fibrillated heart or
other shockable rhythm) to force the heart to
produce more normal cardiac rhythm.
 History
First demonstrated on dogs in 1899 by Jean-Louis Prvost & Frederic
Batelli, two physiologists from University of Geneva, Switzerland.

The first use on a human was in 1947 by Claude Beck,

professor of surgery at Case Western Reserve University.

Transthoracic defibrillation was first used in humans using

alternating current (AC)

Bernard Lown and his coworkers introduced direct current

(DC) defibrillators into clinical practice.
 Defibrillator

Does not re-start the heart.

Stops all electrical activity.
If heart is still viable its natural pace maker will take over.
It is an emergency life saving procedure.
Probability decreases with time.

Mechanism
Current depolarizes the myocardium.
Induces asystole temporarily.
Allows SA node to take over coz its the first to repolarize.
 Indications

- Pulse-less polymorphic VT/VF.

- When unsure weather monomorphic or

polymorphic VT in a un-stable patient.
 Non Shockable rhythms

- Asystole

- Pulse less electrical activity (PEA)

 Defibrillator

Loss of synchronization in heart is called as

fibrillation.

Types of fibrillation

Atrial fibrillation

Ventricular fibrillation
 Need for a Defibrillator
Defibrillation is the definitive treatment for the life threatening
cardiac arrhythmias ventricular fibrillation and pulseless
ventricular tachycardia

Ventricular fibrillation results from:

-Coronary occlusion
-Electrical shock
-Abnormalities of body chemistry

This irregular contraction of the muscle fibers causes non

effectively blood pumping and that results in a steep fall of cardiac
output.
 Ventricular fibrillation
Ventricular fibrillation can be converted into a more efficient rhythm
by applying high energy shock to the heart.

This causes all muscle fibers to contract simultaneously, which may

then respond to normal physiological pacemaking pulses

Restoration of normal rhythm in fibrillating heart as achieved by direct current shock (arrow)
across the chest wall. The horizontal line after the shock shows that the cardiograph was blocked
or disconnected for its protection during the period of shock4
This recommendation regarding CPR prior
to attempted defibrillation is supported by
2 clinical studies

JAMA. 2003;289:1389 1395

JAMA. 1999;281:11821188
 AC DEFIBRILLATION

Applying a brief(.25 to 1 sec) burst of 60 HZ ac at an

intensity of around 6 A.

This application of an electrical shock to resynchronize

the heart is sometimes called counter shock.

If the patient does not respond, the burst is repeated

until defibrillation occurs. this method is known as ac
defibrillation.
 Disadvantage of using ac Defibrillator

It is cannot be successfully used to correct atrial

fibrillation.

Successive attempts to correct ventricular fibrillation are

often required.

Attempts to correct atrial fibrillation by this method often

result more serious ventricular fibrillation.
 DC Defibrillation
In this method a capacitor is charged to a high dc voltage and
then rapidly discharged.

The amount of energy discharged by the capacitor may range

between 2 to 400joules with peak value of current 20A.

A corrective shock of 750-800 volts is applied within a tenth of a

second .
CIRCUIT OF DC DEFIBRILLATOR
 PRINCIPLE OF DEFIBRILLATOR

Energy storage capacitor is charged at relatively slow

rate from AC line.

Energy stored in capacitor is then delivered at a

relatively rapid rate to chest of the patient.

Simple arrangement involve the discharge of capacitor

energy through the patients own resistance.
 Cont..
The discharge resistance which the patient represents is
roughly a ohmic resistance of 50 100 ohms for a typical
electrode size of 80cm2.

The particular wave form is called Lown wave form.

The pulse width of this waveform is 10ms.

 Types of Defibrillators

1. Manual external defibrillator

2. Manual internal defibrillator

3. Semi-Automated External Defibrillator

4. Automated external defibrillator (AED)

5. Implantable cardioverter-defibrillator (ICD)

{automatic internal cardiac defibrillator (AICD)}

6. Wearable cardiac defibrillator

 Manual external defibrillator

Electrodes placed directly around the heart area of chest.

Higher Voltage required than internal defibrillator.

Classified as -

Monophasic

Biphasic
 Monophasic waveform Defibrillators
Deliver current of one polarity.

Current travels in one direction through the patients heart from one
paddle to another.

2 types :-
The monophasic damped sinusoidal waveform (MDS) returns to
zero gradually

Monophasic truncated exponential waveform (MTE) current is

abruptly returned to baseline (truncated) to zero current flow
MDS v/s MTE wave form
 Biphasic waveform Defibrillators

Current travels towards the +ve paddle & then reverses back.

Reversing of polarity, depolarizes all cells called burping

response.

Classified into
Biphasic truncated exponential waveform (BTE)
Rectilinear biphasic waveform (RLB)

RLB is better than BTE.

Biphasic truncated exponential waveform (BTE)
v/s
Rectilinear biphasic waveform (RLB)

RBL BTE
 Advantages of Biphasic over Monophasic
Less power Less trauma Less battery.

Defibrillation more effective at low energy.

Fewer burns.

Less myocardial damage.

1st shock success rate in cardiac arrest due to shockable

rhythm
Monophasic 60%
Biphasic increases to 90%
 Manual internal defibrillator

Just like normal defilbrillator.

Electric charge is usually pumped in by internal

paddles in close or direct contact with the heart.

These devices are mainly used in operating theatres,

where the chest can be opened or being treated by a
surgeon
 Semi-Automated External Defibrillator

Carries features of both full-manuated as well as

automated units of defibrillator.

Has an ECG display and manual override in it.

Generally used by paramedics and emergency medicine

technicians.
Implantable cardioverter-defibrillator (ICD)
{automatic internal cardiac defibrillator (AICD)}

A implanted device that detacts and terminats life threatning

episodes of VF / VT in high risk patients.
 Wearable cardiac defibrillator

- Life vest
 AUTOMATIC EXTERNAL
DEFIBRILLATOR

AED is a portable type of external defibrillator that

automatically diagnoses the ventricular fibrillation in a patient.

Automatic refers to the ability to autonomously analyze the patient's

condition.

AED is provided with self-adhesive electrodes instead of hand held

paddles.
 Automated external defibrillator (AED) cont
Use does not require special medical training.
Found in public places offices, airport, shopping mall.

The electrodes transmit information about the person's heart rhythm to a

controller in the AED.

The controller examines the electrical output from the heart and determine if
the patient is in a shockable rhythm or not and whether shock is needed.

The AED uses voice / visual prompts to tell user when to give the shock,
and the electrodes deliver it.
 Paddle placement

4 Positions ----
Anterior-lateral > most convenient
Anterior-posterior
Anterior-left infrascapular
Anterior-right infrascapular

Anterior-lateral position ----

one right of sternum below clavicle (2nd & 3rd ICS)
other left 4th or 5th ICS mid axillary line

Reversing paddle markings sternum & apex does not affect defibrillation

Paddles placed along axis of heart.

AP- placement used in children with adult paddles.
Position of electrodes in pregnant patients :-

-One on right of sternum below the right clivcle

-Other left mid-axillary line avoiding breast

Paddle Size
- Adult large paddles
10-13 cm diameter

- Pediatric small paddles <1yr

Infant <10kgs 4.5cm
Children >10kgs 8cm
 Steps of Defibrillation
Give 2min CPR before analysis.

Power on ADE

Attach electrode pad.

Check rhythm.

CLEAR.

Give shock(120-200J)

Resume CPR for 2mins before analysis cardiac rhythm again.

Consider giving vasopressors / anti-arrhythmics during subsequent

shock.
 Defibrillation Success

Termination of VF into an organized rhythm or

asystole for atleast 5secs after shock.
Regardless of haemodynamic response

Start with
150-200J Bisphasic truncated waveform
120J Rectilinear biphasic waveform
 Monitoring

Monitor that patient stay in converted rhythm.

Keep patient well oxygenated.(SPO2 >98%)

Check serum K+ & Mg+ levels.

Maintain acid base balance.

Get 12 lead ECG after procedure.

Check for chest pain & access.

Get CPK & Troponin done.

Access patients skin.

 Efficacy of Defibrillation

Trans thoracic resistance is the major factor :

Which depends upon

Chest width & configuration

Ventilatory phase
Electrode skin interface
Electrode position
Electrode size
Force of electrode application
Energy level
Time between & no. of shocks
Factors to consider during defibrillation

1) Duration of VF

- the longer VF lasts, the harder it is to cure

- the quicker the batter
- shock early, shock often
- likelihood of resuscitation decrease by 7-10% with every
passing minute (Ann Emerg Med. 1993;22:16521658 )
2) Myocardial environment / condition

Hypoxia, acidosis, hypothermia, electrolyte imbalance,

drug toxicity impede conversion.

DO NOT DELAY SHOCK trying to correct these problems.

3) Heart size / Body type

Pediatric requirement lower than adult

2J /kg initial shock
4J /kg repeat shock
Higher dose (upto 10J/kg)
Or adult maximum dose

Direct size / energy relationship in adults unknown

4) Use largest size paddles

- completely contact chest without paddles touching each

other
- In pediatric minimum of 3cm distance between pads.

NOTE :-
- Small paddles : concentrate current, burn heart.
- Large paddles : reduces current density
5) Previous counter shock

- repeated shocks lower resistance

- give one shock at a time & then continue CPR
- subesquent shock either equal or higher energy

6) Paddle size
( as discussed before)
7) Paddle placement
- In pacemaker / ICD
atleast 12cm from generator
90 degree to AICD electrode
avoid placing pads directly over
no delay in defibrillation

- for other as described before.

8) Paddles Skin interface

- only gel should be used (ECG gelly)

- cream, paste, saline pads etc.- not recommended
- gel decreases resistance to the flow of current
- never use alcohol

9) Paddle contact pressure

- firm pressure of 25 pounds

- in child <10kgs --- 3kg pressure
- in large children >10kgs --- 5kg pressure
- deflate lung, shortens the path of current
- do not lean on paddles : they slip
 CARDIOVERSION

Cardioversion is the delivery of energy that is

synchronized to the large R waves or QRS complex.

It uses energy less than that used for defibrillation in

shockable SCA

Avoids delivering shock during repolarization period (T

wave on ECG)
 Indications

- Atrial flutter

- Atrial fibrillation

- Re entry SVT

- Mono morphic VT

- Poly morphic VT

- Wide complex tachycardia of uncertain type

 Contraindications

- Digitalis induced dysrythmias

- refractory to cardioversion
- may precipitate to more serious ventricular dysarythmias

- Junctional tachycardia or ectopics / multifocal atrial

tachycardia
- automatic foci not reverted by cardioversion
CARDIOVERSION
 Cardioversion can be
Elective or Emergency
 Elective Cardioversion

> Pre procedure conciderations

- History & physical examination (neurological)
- Concurrent illness
- Current medication including anticoagulation
- Fasting 6hrs
- Correct electrolyte imbalance
- Obtain 12 lead ECG
- Shaving at site if nessacery
- Digoxin to be withheld for 48hrs
- Continue other medications
- Transthoracic Echo or TEE
 Cardioversion Anaesthetic Technique

Cardioversion is almost always performed under induction or sedation

(short-acting agent such as midazolam)

exceptions : if patient is hemodynamically unstable or if

cardiovascular collapse is imminent

- Amnesia / Sedation / GA may be required

- Premedication Midazolam 1 to 2 mg

- Pre oxygenation

- Airway maintained & supported

 Cardioversion Anaesthetic Drugs

-- IV sedation Propofol, Etomidate, Thiopentone,

Benzodiazepines

-- Etomidate
haemodynamically more stable
myoclonus 40%- interferes with ECG interpretation

-- Propofol
hypotension (boluses)
slow induction can attenuate this drop
 Steps
- Check environment at procedure site

- Turn on defibrillator

- Anaesthetic technique as required

- Apply electrodes

- Press SYNC control

- Select applicationenergy level

- 3 clear shout & look

- Deliver shock
 Post Procedure Monitoring
- Record delivery energy & result

- Continuous ECG monitoring

- 12 lead ECG

- If successful response
check for peripheral pulses, BP, Airway patency & LOC

- Inspect skin under the padds

- If not successful, check & reassess

 Complications of Cardioversion

- Systemic embolization

- Post shock cardiac arythmias

asystole
heart block
atrial / ventricular ectopics
ventricular tachyarrythmias

- Trasient ST & T wave changes

 Cardioversion Defibrillation
Elective planned procedure Emergency life saving procedure
Synchronized shock Un-synchronized shock

Low energy shock High energy shock

There can be some delay No delay, immediate

Anti-coagulation needed No anti-coagulation needed

Less damage to myocardium More damage to myocardium

Used in most of the arrhythmias Used in VT / VF

except VT /VF