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UNDERSTANDING DEFIBRILLATION WAVEFORMS

Before we start, lets define a few terms:
Energy: Energy in a defibrillator is expressed in joules. A joule is the unit of work associated with one amp of
current passed through one ohm of resistance for one second.
When we express it in a formula, it is generally stated as follows:
Joules (Energy) = Voltage X Current X Time
Joules have become a surrogate for current in modern defibrillator language.
Current: Current is what actually defibrillates the heart. It is also expressed as Voltage/Impedance
(resistance).
Impedance: Resistance to Flow; there is resistance in the electrical circuit itself as well as in the patient. The
amount of impedance in a patient is difficult to determine as it relates to body mass, temperature, diaphoresis
quality of the contact with paddles or pads. Impedance is expressed in ohms.
Monophasic Waveforms: A type of defibrillation waveform where a shock is delivered to the heart from one
vector as shown below. It is shown graphically as current vs. time.
In this waveform, there is no ability to adjust for patient impedance, and it is generally recommended that all
monophasic defibrillators deliver 360J of energy in adult patients to insure maximum current is delivered in
the face of an inability to detect patient impedance.

Biphasic Waveforms: A type of defibrillation waveform where a shock is delivered to the heart via two
vectors. Biphasic waveforms were initially developed for use in implantable defibrillators and have since
become the standard in external defibrillators.
While all biphasic waveforms have been shown to allow termination of VF at lower current than monophasic
defibrillators, there are two types of waveforms used in external defibrillators. These are shown below.

Defibrillator manufacturers have approached biphasic defibrillation differently.

Both Physio Control and Philips use the biphasic truncated exponential (BTE) waveform originally developed
for internal defibrillators, though they use different energy settings with the waveform. Physio Control uses
what they term a high energy biphasic waveform, which they term ADAPTIV Biphasic. Physio Control
energy settings go up to 360 joules of energy and they essentially distribute the voltage and current available
over a wider range of energy settings. Additionally they vary the voltage and extend the duration of the shock
in higher impedance patients.
Therefore, with a Physio Control BTE Waveform, you might see the following differences in the waveform
when patient impedance differs:

Philips Medical also uses the biphasic truncated exponential waveform in their SMART Biphasic device, but in
this case, they distribute the voltage and current available over a more narrow range of energy with the
maximum current delivered at 200J, roughly equivalent to that delivered by the Physio Control device at 360J.
The Rectilinear Biphasic Waveform (RBW) is used by ZOLL Medical, and it differs from both of the BTE
waveform devices. ZOLL fixes voltage at the maximum and varies resistance in order to deliver constant
current across the broad range of patients. Like Philips, 200 Joules is the maximum setting on the defibrillator,
however this maximum represents more voltage on the capacitor than either Physio Control or Philips has
available. Additionally, the duration of the ZOLL RBE waveform is fixed at 10 msec based upon work by Gliner
et al.1 which indicates that the defibrillation threshold decreases with increasing time up to a point around 1012 msec, after which is begins to increase. As there is concern in the literature about the effects of current on
myocardial stunning, ZOLL chooses not to go beyond that threshold. 2
The ZOLL RBW defibrillator actually divides impedance into two components: equipment-based impedance
and patient-based impedance. Rather than adjusting the secondary variables, such as voltage and time, the
ZOLL RBW adjusts the equipment-based impedance, and adds or subtracts resistors in the equipment as
required to control for an essentially constant current during the course of the first phase.
For example, for a 200J energy setting, the ZOLL RBW charges the capacitor to the maximum voltage
regardless of patient impedance. In the case of a patient with 50 ohms of impedance, the defibrillator
controller adds ohms of resistance to effectively dampen the amount of current being delivered to the
patient. For a patient with 150 ohms of impedance, no equipment-based resistors are added, and the full
amount of current is delivered to the patient. In laboratory bench tests, at 200J, ZOLL delivered 27.8A peak
current and 24.0A average current to a 50 ohm resistor, and 14.8A peak current and 12.5A average current to
a 150 ohm resistor. At energy settings less than 200J, the difference between peak and average current is
even less, typically a maximum of 1A.

Note:
It is really not a good idea to try to compare manufacturers biphasic waveforms as each is appropriate for the
device in which it is found and none has been shown to be superior to others despite a number of clinical
trials.