Clinical Skill Information Sheet

Manual Defibrillation

Aim
To safely and effectively defibrillate patients in cardiac arrest
Indications
Defibrillation is indicated in patients whom are unconscious with the heart rhythm of
ventricular fibrillation or pulseless ventricular tachycardia.
Background
A defibrillation shock when applied through the chest produces simultaneous
depolarisation of a mass of myocardial cells and may enable resumption of
organised electrical activity. Early defibrillation post cardiac arrest is proven to
greatly enhance a patient’s chances of survival. Defibrillation is an important skill to
be used effectively as part of resuscitation.

Defibrillation is particularly hazardous due to the above-mentioned depolarisation of

cells. Although this is beneficial to a patient in cardiac arrest, it is extremely
dangerous and potentially fatal for a bystander or paramedic. Defibrillation must only
be performed on unconscious patients in cardiac arrest. Conscious patients must
NOT be defibrillated regardless of their heart rhythm.

Bachelor of Paramedic Science

 Clinical Skill Information Sheet

Objective Rationale Action

Safety is the first priority 1. Use universal precautions. Always
in managing any patient. wear gloves and goggles when
Manage
attending to a patient.
safety
2. You may also want to consider wearing
a face mask and gown.
In order to effectively 1. Gain access to the patient’s chest by
defibrillate a patient in cutting off their upper clothing.
cardiac arrest, you must
ensure that they are 2. Position the defibrillation pads correctly
properly prepared. This on the patient. Ideally this involves
includes exposing and following the manufacturer’s
possibly shaving their instructions (found on the back of the
chest and applying the pads).
defibrillation pads in the
correct position.
Minimising transthoracic Adults – Use the anterior-lateral position.
impedance during One paddle or pad is placed on the mid-
defibrillation is essential. axillary line over the 6th left intercostal
Doing this will increase space on the left side of the body and the
trans-myocardial current other on the right parasternal area over
and increase the chance the 2nd intercostal space.
of delivering an effective
shock to the patient.
Chest hair has been
found to contribute
significantly to
Prepare the transthoracic
patient impedance.

There are specific

accepted variations of
pad placement based on
the flow of electrical
current and its effects on
the heart. Acceptable Small children – Use the anterior-lateral
alternate positions position. If using large pads as indicated
include; anterior- above, this involves sliding the pad which
posterior & apex – is usually placed on the left mid-axillary
posterior. In children, it line, up and over the middle of the anterior
may be necessary to chest and sliding the other pad, which is
use the anterior- usually on the right parasternal area, up
posterior pad and over the patient’s shoulder, and into
positioning. In large the middle of their back, between the
breasted individuals the scapulae.
left pad can be placed
lateral to or underneath
the left breast, to avoid
breast tissue.

Bachelor of Paramedic Science

 Clinical Skill Information Sheet

Objective Rationale Action

Early defibrillation has 1. As soon as the pads have been applied
been shown to improve dial up the correct joules for the patient.
outcomes for patients Adults – 200J - biphasic machine
suffering from cardiac Paediatrics – 4J/kg - biphasic machine
arrest. Consequently it
is our main aim to
ensure that we are 2. Then immediately verbalise the
doing all that we can to following instructions in a clear and
defibrillate a patient as loud voice:
soon as possible. - Compressions continue
- Everyone else clear
- Oxygen away
Defibrillators can be - Charging
dangerous if used
incorrectly and in the 3. Press charge on the defibrillator.
rush of a resuscitation Ensure you are watching the patient
attempt, it is easy to and ensuring that everyone (except for
become distracted and the person performing compressions)
make mistakes that can remains clear and not touching the
jeopardise the safety of patient in anyway (be careful to notice
those on scene. if they are indirectly touching the
Therefore, it is essential patient – ie, holding IV bags etc).
Immediately that the person
charge operating the
defibrillator defibrillator is constantly
providing clear
instructions to everyone
on scene and managing
their safety in regards to
the defibrillator.

Using strong hand

gestures is also helpful
when trying to ensure
that everyone is clear
and safe. By moving
your hand around and
over / above the patient
to physically block
people from being too
close, you will make it
clear that everyone must
be away from the
patient.

Bachelor of Paramedic Science

 Clinical Skill Information Sheet

Objective Rationale Action

Knowing the patient’s 1. When the defibrillator is fully charged, it
underlying heart rhythm will alarm. This is your cue to say the
is important when following in a clear and loud voice:
undertaking a - Compressions cease
resuscitation and it is - Compressor stand clear
crucial when making the (The compressor should respond to you
decision whether to by putting both of their hands up in the air
defibrillate or not.
Interpret and declaring ‘I’m safe’ whilst making eye
heart contact with you).
rhythm The length of the pre-
shock pause (the
2. Turn to the machine and analyse the
interval between heart rhythm. In a loud, clear voice say:
stopping chest
compressions and - Confirm rhythm is – VF, VT, Asystole
delivering a shock) is etc
inversely proportional to (Someone else in the resus should then
the chance of successful respond with ‘confirming VF/VT/Asystole
defibrillation. etc).
Once the heart rhythm  If the heart rhythm is VF or VT:
has been analysed, you 1. SAY in a loud, clear voice:
then need to decide - All clear, shocking
whether to continue with 2. PRESS the shock button (double
defibrillation or disarm check that everyone is still clear
the charge. prior to pressing the button).

Defibrillation works by  If the heart rhythm is asystole:

depolarising the 1. SAY in a loud, clear voice:
myocardial cells in order
- Disarming machine
for them to commence
functioning in an 2. PRESS the disarm button.
organised manner.
Deliver the Consequently, we only  If the heart rhythm is anything other
shock or defibrillate ventricular than VF, VT or asystole:
disarm fibrillation (VF) and 1. SAY in a loud, clear voice:
pulseless ventricular - Disarming machine
tachycardia (VT). 2. PRESS the disarm button.

We don’t want to
defibrillate anyone with
a pulse, as this would be
counterproductive and
potentially result in them
losing that pulse.
Additionally, we don’t
want to defibrillate a
patient with pulseless
electrical activity (PEA)

Bachelor of Paramedic Science

 Clinical Skill Information Sheet

Objective Rationale Action

(other than VF or VT) as
we want to support the
myocardial cells to be
able to become
organised enough to
produce an output
(pulse) and we do this
through compressions
and medications.

Finally, we don’t need to

unnecessarily defibrillate
those that don’t have
any myocardial electrical
activity (asystole) as it is
dangerous and will
potentially cause further
damage to the already
injured heart cells.

Contrary to most
television programs and
common lay-person
belief, defibrillation
doesn’t start the heart
beating, it in fact stops
disorganised electrical
activity in the heart, in
the hope that the heart
will intrinsically
recommence an
organised heart rhythm.
After a defibrillation or  If a shock was delivered due to a
negative pulse check, heart rhythm of VF or VT:
the resuscitation attempt 1. Immediately resume CPR directing
enters another cycle and the compressor to continue
the whole process compressions by saying in a loud,
begins again. clear voice:
- compressions continue
Resume
compressions
Remember, the
overriding factor is that  If the machine was disarmed due to a
continuous heart rhythm of asystole:
compressions need to 1. Immediately resume CPR directing
occur in order to give the compressor to continue
the patient the best compressions by saying in a loud,
possible chance at a clear voice:
positive outcome. - compressions continue

Bachelor of Paramedic Science

 Clinical Skill Information Sheet

Objective Rationale Action

 If the machine was disarmed due to a
heart rhythm of anything other than
VF, VT or asystole:
1. Immediately check for a pulse.

2. (a) If you palpate a pulse, initiate

Post Resuscitation Care.
(b) If no palpable pulse,
immediately resume CPR directing
the compressor to continue
compressions by saying in a loud,
clear voice:
- compressions continue

Bachelor of Paramedic Science