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DEFIBRILLATOR

1. Introduction

Defibrillator is a process in which electronic device sends an electric shop to the


heart to stop an extremely Rapid irregular Heartbeat and restore the normal heart
rhythm. Defibrillation is a common treatment for life threatening cardiac
dysrhythmia ventricular fibrillation and pulseless ventricular tachycardia.

2. Definition

Defibrillator is a device that delivers a therapeutic dose of electrical energy


(electrical shock) to the affected heart fever related hot or other shockable
Rhythm to force the heart to produce more normal cardiac rhythm.

3. Objective

 Define defibrillation
 Describe need and history of defibrillation
 Describe the principle and mechanism of defibrillation
 Types and classes of defibrillator

4. Purpose of defibrillation

Defibrillation is performed to correct life threatening fibrillation of the heart


which could result in cardiac arrest. It should be performed immediately after
identifying that the patient is experiencing a cardiac emergency has no pulse and
is unresponsive.

5. Principle of defibrillator
 Energy is storage a 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 involved the discharge of capacitor energy through
the patient's on resistance.
 The discharge resistance which the patient represents as purely ohmic
resistance of 5 to 100Ω approximately for a typical electrode size of 80
cm2
 This particular waveform figure is called lower wave form.
 The pulse width of this waveform is generally 10ms.

6. Mechanism of defibrillator

 Fibrillation cause the heart to stop pumping blood leading to brain


damage
 Defibrillator deliver a brief electric shock to the heart which enables the
heart natural pacemaker to regain control and establish a normal heart
rhythm.

7. Steps of defibrillation

 Give 2 min CPR before analysis


 Power on ADE
 Attach electrode pad
 Check rhythm
 Clear
 Give shock (120 – 200 J)
 Resume CPR for 2 minutes before analysis cardiac Rhythm again
 Consider giving vasopressor / anti arrhythmias derive subsequent shock

8. Types of defibrillators

1. Manual external defibrillator


2. Manual internal defibrillator
3. Semi-automated external defibrillator
4. Automated external defibrillator (AED)
5. Implantable cardioverters defibrillators (Automated internal cardiac
defibrillator)
6. Wearable cardiac defibrillator

A. Manual external defibrillator

Electrode placed directly around the heart area of chest higher voltage required
then internal defibrillator.

B. Manual internal defibrillator

 Just like normal defibrillator


 Electric charge is usually formed in by internal pedals in closed or direct
contact with the heart.
 These devices are mainly used in operating theatre where the chest can be
opened or being treated by a surgeon.

C. Semi-automated external defibrillator

 Carries features of both full manual as well as automated units of


defibrillator.
 Has a ECG display and manual override in it.
 Generally used by paramedics and emergency medicine techniques.

D. Implantable cardioverter defibrillator (ICD) Automated internal


cardiac defibrillator (AICD)
 An implanted device that detects and terminates life-threatening episodes
of VF / VT in high-risk patients.

E. Wearable cardiac defibrillator


 Life vest
Automated external defibrillator

 AED is portable type of external defibrillator that automatically diagnosis


the ventricular fibrillation in a patient.
 Automatic refers to the ability to autonomously analyze the patient
condition.
 AED is provided with self adhesive electrodes instead of hard held
paddles.

Paddle placement

4 positions

 Anterior lateral most convenient


 Anterior posterior
 Anterior left intra scapular
 Interior right interscapular

Anterior lateral position

 On right of sternum below clavicle (2nd & 3rd ICS) other left 4th or 5th ICS
mid axillary line.
 Reversing paddle markings “sternum and apex” does not affect
defibrillation
 Paddles placed along axis of heart
 AP placement used in children with adult paddles

Paddle size

Adult : large Paddles, 10-30 cm diameter

Pedriatic : small paddles <1 yr

Infant <10kg- 4.5 cm

Children > 10kgs - 8 cm


Monitoring

 Monitoring that patient stay in converted rhythm


 Keep patient well oxygenated
 Check serum K+ & Mg+ levels
 Maintain acid base balance
 Get 12 lead ECG after procedure
 Check for chest pain and access.
 Get CPK and troponin done
 Access patient’s skin

Factors to consider during defibrillation

1. Duration of VF
 The longer VF lasts the harder it is to cure
 The quicker the better
 Shock early shock often
 Likelihood of resuscitation decrease by 7 to 10% with every passing
minute

2. Myocardial environment slash condition

Hypoxia, acidosis, hyperthermia, electrolyte imbalance drug toxicity impede


conversion

3. Heart size body type

Pediatric requirement lower than adult

4. Use largest size paddles


 Completely chest without pedals lowerly each other
 In paediatric minimum of 3 cm distance between pads

Note:

Small Paddles : concentrate the current bum heart

Large paddles : reduces current density


5. Previous counter shock
 Repeat shock lower resistance
 Give one shop at a time and then continue CPR
 Subsequent shop either equal or higher energy

6. Paddle size

7. Paddle placement
 In pacemaker/ ICD at least 12 cm from general 90 degree to AICD
electrode avoid placing bets directly over no delay in defibrillation.

8. Paddles skin interface


 Only gel should be used (ECG gelly)
 Cream, paste, saline pads
 Gel decrease resistance to the flow of current
 Never use alcohol

9. Paddle contact pressure


 Firm pressure of 25 Pounds
 In child <10kgs – 3 kg pressure
 In large children > 10kgs – 5kg pressure
 Deflate lung, shortens the path of current
 Do not loosen paddles they slip

CARDIOVERSION

Cardioversion is the delivery of energy that synchronized to the large R waves


or QRS complex.

 It uses energy less that that used for defibrillation in shockable SCA
 Avoid delivery shock during repolarization period (T wave on ECG)

Indications

 Atrial flutter
 Atrial fibrillation
 Wide complex tachycardia of uncertain type
Contra indications

 Digitalis induced dysrhythmias


 Refractory to cardioversion
 May precipitate to more serious ventricular dysrhythmias
 Juctional tachycardia or ectopics/ multifocal atrial tachycardia
 Automatic foci not reverted by cardioversion

Cardioversion

Dose/ Details

Synchronized Cardioversion

Initial recommended doses

 Narrow regular : 50-100 J


 Narrow regular : 120-200J
 Wide regular : 100 J
 Wide irregular : defibrillation dose (not synchronized)

Cardioversion can be elective or Emergency

Elective Cardioversion

Preprocedure consideration

 History and physical examination (neurological)


 Concurrent illness
 Current medication including anticoagulation
 Fasting 6hrs
 Correct electrolyte imbalance
 Obtain 12 lead ECG
 Digoxin to be withheld for 48 hrs
 Continue other medications
 Transthoracic Echo or TEE
Cardioversion Anesthetic Drugs

IV sedation : Proprofol, Etomidate, Thiopentone, Benzodiazepines

Etomidate : Haemodynamically mor4e stable myoclonus 40%


interference with ECG Interpretation

Steps

 Check environment at procedure site


 Turn on defibrillator
 Anesthetic technique as required
 Apply electrodes
 Press sync control
 Select application energy level
 ‘3’ shout and shock
 Deliver shock

Post Procedure monitoring

 Record delivery energy and result


 Continuous ECG monitoring
 12 Lead ECG
 If successful response check for peripheral pulses, BP, airway patency and
LOC.
 Inspect skin under the pads
 If not successful, check and reassess.

Complications of Cardioversion

 Systemic embolization
 Post shock cardiac arrhythmias
 Asystole
 Heart block
 Atrial / ventricular ectopias
 Ventricular tachy arrhythmias
 Translucent ST & T wave changes
Risks in Defibrillation

 Skin burns form the defibrillation paddles are the most common
complication of defibrillation
 Other risks include injury to the heart muscle, abnormal heart rhythms and
blood clots.
BIBLIOGRAPHY

1) Willis A Tacker “External Defibrillators” in Biomedical Engineering


Handbook, J. Bronzino , CRC Press, 1995.

2) En.wikipedia.org/wiki/ defibrillation

3) http://www.slideworld.org/viewslides.aspx/defibrillator

4) Brunner & Sudharth’s Textbook of Medical Surgical Nursing.

5) Basavanthappa BT, Essential of Medical Surgical Nursing, Published by


Jaypee- 567.