Electrical therapies

Automated
external defibrillators - AED,
defibrillation, cardioversion and
pacing
 Defibrillation is the passage across the myocardium
of an electrical current of sufficient magnitude
to depolarise a critical mass of myocardium and
enable restoration of coordinated electrical activity.
Defibrillation is defined as the termination of
fibrillation or , the absence of ventricular
fibrillation/ventricular tachycardia (VF/VT)
at 5 s after shock delivery; however, the goal of
attempted defibrillation is to restore spontaneous
circulation.
Normal sinus rhythm
 Normal sinus rhythm
 * each P wave is followed by a
QRS
 * P waves normal for the
subject

* P wave rate 60 - 100 bpm with
<10% variation
 rate <60 = sinus bradycardia

rate >100 = sinus tachycardia
 variation >10% = sinus
arrhythmia
 P wawes

Normal P waves height < 2.5
mm in lead II width duration <
0.11 s in lead II
 normal PR interval 0.12 to 0.20 s
(3 - 5 small squares)

normal atrial depolarization,
 for short PR segment consider
Wolff-Parkinson-White syndrome or
Lown-Ganong-Levine syndrome
(other causes - Duchenne muscular
dystrophy, type II glycogen storage
disease (Pompe's), HOCM)
for long PR interval see first degree
heart block and 'trifasicular' block
normal QRS complex
 corresponds to the
depolarization of the right
and left ventricles.
 < 0.12 s duration (3 small
squares)
 for abnormally wide QRS
consider right or left bundle
branch block, ventricular rhythm,
hyperkalaemia, etc.

no pathological Q waves
 no evidence of left or right
ventricular hypertrophy

Normal QT interval = 0.42 s.
 Causes of long QT interval:

myocardial infarction,
myocarditis, diffuse myocardial
disease

hypocalcaemia, hypothyrodism
 subarachnoid haemorrhage,
intracerebral haemorrhage

drugs (e.g. sotalol,amiodarone)
 Normal ST segment It has a duration of 0.08 to 0.12 sec, connects the
QRS complex and the T wave . No elevation or depression

causes of elevation include acute MI (e.g. anterior, inferior), left bundle
branch block, normal variants (e.g. athletic heart, high-take off), acute
pericarditis

causes of depression include myocardial ischaemia, digoxin effect,
ventricular hypertrophy, acute posterior MI, pulmonary embolus, left bundle
branch block

Normal T wave (represents the repolarization of the ventricles)

causes of tall T waves include hyperkalaemia, hyperacute myocardial
infarction and left bundle branch block

causes of small, flattened or inverted T waves are numerous and include
ischaemia, hyperventilation, anxiety, drinking iced water, drugs (e.g.
digoxin), pericarditis, intraventricular conduction delay and electrolyte
disturbance
Sinus tachycardia
Ventricular tachycardia
Ventricular fibrilation
 Automated external defibrillators

(1) Make sure you, the victim, and any bystanders are safe.
(2) If the victim is unresponsive and not breathing normally, send
someone for the AED and to call for an ambulance.
(3) Start CPR according to the guidelines for BLS.
(4) As soon as the defibrillator arrives switch on the defibrillator and
attach the electrode pads. If more than one rescuer is present, CPR
should be continued while this is carried out
• follow the spoken/visual directions
• ensure that nobody touches the victim while the AED is analysing the
rhythm
 Automated external defibrillators

5a If a shock is indicated
• ensure that nobody touches the victim • push shock button as directed
(fully automatic AEDs will deliver the shock automatically)
• continue as directed by the voice/visual prompts
5b If no shock indicated
• immediately resume CPR, using a ratio of 30 compressions to 2 rescue
breaths
• continue as directed by the voice/visual prompts
6 Continue to follow the AED prompts until
• qualified help arrives and takes over
• the victim starts to breathe normally
• you become exhausted
 Automated external defibrillators

Automated external defibrillators are sophisticated, reliable computerised

devices that use voice and visual prompts to guide lay rescuers and
healthcare professionals to safely attempt defibrillation in cardiac arrest
victims .
Automated external defibrillators have microprocessors that analyse several
features of the ECG, including frequency and amplitude.
They are extremely accurate in rhythm analysis.
 Automated external defibrillators

Safe use of oxygen during defibrillation

In an oxygen-enriched atmosphere, sparking from poorly applied defibrillator
paddles can cause a fire.
-Take off any oxygen mask or nasal cannulae and place them at least 1m away
from the patient’s chest.
-Leave the ventilation bag connected to the tracheal
tube or other airway adjunct OR disconnect any bag-valve device from the
tracheal tube and remove it at least 1 m from pacient chest.
If the patient is connected to a ventilator, leave the ventilator tubing (breathing
circuit) connected to the tracheal tube
Minimise the risk of sparks during defibrillation.
 Automated external defibrillators

CPR versus defibrillation as the initial treatment

Recent evidence has suggested that a period of CPR before
defibrillation may be beneficial after prolonged collapse.
It is reasonable for EMS personnel to give a period of about 2
min of CPR (i.e., about five cycles at 30:2) before
defibrillation in patients with prolonged collapse (>5 min).
Laypeople and first responders using AEDS should deliver the
shock as soon as possible.
 Energy level

The recommended initial energy level for the first shock using a
monophasic defibrillator is 360 J. With monophasic
defibrillators, if the initial shock has been unsuccessful at 360 J,
second and subsequent shocks should all be delivered at 360 J.
The initial biphasic defibrillator shock energy should be at least
150 J , afther that 200 J .
If a shockable rhythm (recurrent ventricular fibrillation) recurs
after successful defibrillation , give the next shock with the
energy level that had previously been successful.
In children case – optimal energy level is 4J/kg (25kg=100J) mono
or biphasic defibrillator
 Cardioversion
If electrical cardioversion is used to convert atrial or ventricular
tachyarrhythmias, the shock must be synchronised to occur with the R
wave : VF can be induced if a shock is delivered during the relative
refractory portion of the cardiac cycle.
Synchronisation can be difficult in VT because of the wide-complex and
variable forms of ventricular arrhythmia. If synchronisation fails, give
unsynchronised shocks to the unstable patient in VT to avoid
prolonged delay in restoring sinus rhythm. Ventricular fibrillation or
pulseless VT requires unsynchronised shocks. Conscious patients must
be anaesthetised or sedated before attempting synchronised
cardioversion!
 Precordial thump and Pacing

A precordial thump is most likely to be successful in converting

VT to sinus rhythm. Successful treatment of VF by precordial
thump is much less likely. Consider giving a single precordial
thump when cardiac arrest is confirmed rapidly after a
witnessed, sudden collapse and a defibrillator is not
immediately to hand.Using the ulnar edge of a tightly clenched
fist, a sharp impact is delivered to the lower half of the sternum
from a height of about 20 cm, followed by immediate retraction
of the fist, which createsan impulse-like stimulus.
Consider pacing in patients with symptomatic bradycardia .