DEFIBRILLATION

&
CARDIOVERSION

Ns. Retno Setyawati, M.Kep., Sp.KMB

 OVERVIEW

■ Defibrillation is non-synchronized
random administration of shock during
a cardiac cycle.
■ In 1956, Alternating Current (AC)
defibrillation was first introduced to treat
ventricular fibrillation in humans.
■ Later in 1962, Direct Current (DC)
defibrillation was introduced
 Description
■ Defibrillation is the treatment for immediately life-
threatening arrhythmias with which the patient does not
have a pulse, ie ventricular fibrillation (VF) or pulseless
ventricular tachycardia (VT), and ineffective depolarization
of the ventricles.

■ Cardioversion - is any process that aims to convert an

arrhythmia back to sinus rhythm. Electrical cardioversion is
used when the patient has a pulse but is either unstable,
or chemical cardioversion has failed or is unlikely to be
successful. These scenarios may be associated with chest
pain, pulmonary oedema, syncope or hypotension. It is also
used in less urgent cases - eg, atrial fibrillation (AF) - to try
to revert the rhythm back to sinus.
The heart rhythms associated with
cardiac arrest are divided in two
groups:
1. Shockable rhythms – ventricular
fibrillation and pulseless ventricular
tachycardia (VF/VT)
2. Non-shockable rhythms –
asystole and pulseless electrical
activity (PEA)
 UNRESPONSIVE?
!
Advanced Life Support! (ALS)
ALGORITHM OPEN+AIRWAY
LOOK+FOR+SIGNS+OF+LIFE

Summon+Help+if+Appropriate

CPR+30+:+2+
Until+defibrillator/monitor+attached

Assess+
Rhythm+

Shockable++ NonLShockable+
(VF/Pulseless!VT)! (PEA/Asystole)
During+CPR:+
!! Correct!reversible!
causes!
!! Check!electrode!
position!and!contact!
1+Shock++ !! Attempt/verify:!IV!
1505360!j!Biphasic!or! access,!airway!and!
oxygen!
360j!monophasic!
!! Give!uninterrupted!
compressions!when!
airway!secure!
!! Give!adrenaline!every!
355!min!
Immediately+resume+ !! Consider:! Immediately+resume+
CPR!30!:!2! •! Amiodarone! CPR!30!:!2!
For!2!minute! •! Atropine! For!2!minute!
!
 NON – SHOCKABLE RHYTHMS
■ This includes asystole and pulseless electrical activity (PEA)

Asystole

Pulseless Electrical Activity (PEA)

SHOCKABLE RHYTHMS

Ventricular fibrillation

Ventricular tachycardia
 Types of defibrillators
■ Automated external defibrillators (AEDs):
– These are useful, as their use does not require
special medical training.
– They are found in public places - eg, offices,
airports, train stations, shopping centres.
– They analyse the heart rhythm and then charge
and deliver a shock if appropriate.
– However, they cannot be overridden manually
and can take 10-20 seconds to determine
arrhythmias.
– Unsurprisingly ease of use and speed of use are
important factors for success.
Cont…
■ Semi-automated AEDs:
– These are similar to AEDs but can be
overridden and usually have an ECG
display.
– They tend to be used by paramedics.
– They also have the ability to pace.

■ Standard defibrillators with monitor - may

be monophasic or biphasic.

■ Transvenous or implanted defibrillators.

DEFIBRILLATOR
■ Defibrillators deliver a brief electric shock to the heart,
which enables the heart's natural pacemaker to regain
control and establish a productive heart rhythm.
■ The defibrillator is an electronic device that includes
defibrillator paddles and electrocardiogram monitoring.
■ During external defibrillation, the paddles are placed on
the patient's chest with a conducting gel ensuring good
contact with the skin.
■ Two types of defibrillators are in use today for external
cardioversion and defibrillation: a monophasic
sinusoidal waveform (positive sine wave) and a biphasic
truncated waveform.
DEFIBRILLATION - indications

■ Defibrillation is indicated when

ventricular fibrillation (VF) or
ventricular tachycardia (VT) has not
spontaneously converted to an
organized rhythm.
■ Ventricular fibrillation and ventricular
tachycardia are rarely spontaneously
reversible and are not compatible with
life.
 Paddle size, shape and
position
■ The optimum electrode size is ± 13 cm in diameter in
adults, 8-10 cm in children and 4.5-5 cm in infants.
■ Paddle position influences current flow through the
myocardium. One electrode should be placed below the
outer half of the right clavicle and the other just outside the
usual position of the cardiac apex (V4-5 position).
■ Anterior-posterior (one paddle over the precordium and the
other on the back just behind the heart) electrode
placement may be recommended in patients with
implanted defibrillators or pacemakers.
■ 4 positions (anterior-apex, anterior-posterior, anterior–left
infrascapular, anterior–right infrascapular)
 Energy Selection For Defibrillation Or
Cardioversion
Atrial fibrillation energy requirements are as follows:
■ 200 Joules for monophasic devices
■ 120-200 Joules for biphasic devices
Atrial flutter energy requirements are as follows:
■ 100 Joules for monophasic devices
■ 50-100 Joules for biphasic devices
Ventricular tachycardia with pulse energy requirements are
as follows:
■ 200 Joules for monophasic devices
■ 100 Joules for biphasic devices
Ventricular fibrillation or pulseless ventricular tachycardia
energy requirements are as follows:
■ 360 Joules for monomorphic devices
■ 120-200 Joules for biphasic devices
 Energy levels for defibrillation

■ Monophasic - the cardiopulmonary

resuscitation (CPR) algorithm
recommends single shocks started at
and repeated at 360 J.

■ Biphasic - the CPR algorithm

recommends shocks initially of 150-200 J
and subsequent shocks of 150-360 J.
Differences between monophasic and
biphasic systems
■ In monophasic systems, the current travels only in one
direction - from one paddle to the other.
■ In biphasic systems, the current travels towards the positive
paddle and then reverses and goes back; this occurs several
times.
■ Biphasic shocks deliver one cycle every 10 milliseconds and
they are associated with fewer burns and less myocardial
damage.
■ With monophasic shocks, the rate of first shock success in
cardiac arrests due to a shockable rhythm is only 60%,
whereas with biphasic shocks, this increases to 90%.
■ However, this efficacy of biphasic defibrillators over
monophasic defibrillators has not been consistently reported
Treatment Recommendation
■ Newer defibrillators deliver energy in biphasic
waveforms. Biphasic waveform defibrillators
deliver a more consistent magnitude of
current. They tend to successfully terminate
arrhythmias at lower energies than
monophasic waveform defibrillators.
■ There is insufficient evidence to recommend
any specific biphasic waveform. In the
absence of biphasic defibrillators,
monophasic defibrillators are acceptable.
Step for Defibrillation of Shockable Rhythms
 Steps of Defibrillation
■ Stand at the patient's left side.
■ Thurn on the defibrillator unit.
■ Set the display to the "quick- look" paddles.
■ Remove any fluid materiaIs on the chest wall
(conductive jelly, saline, sweat, urine, water), as they
can form a bridge between the paddIes and result in
arcing and thermal burns to the thorax. AIso remove
any nitroglycerin patches or ointments from the
patient's torso.
■ Ensure that there are no open oxygen sources that
could ignite when the unit is discharged.
 Cont…
■ Grasp the left paddle (sternum) with the left hand and
the right paddle (apex) with the right hand. This is the
anterolateral paddle position.
■ Apply the paddles and observe the patient's cardiac
rhythm.
■ Set the energy level
■ Charge the paddles
■ Ensure that nurses and other assistans are not
touching the patients or the stretcher
■ Deliver the charge by simultaneously pressing the
discharge buttons on each paddle.
■ Observe the monitor and reevaluate the patient's
cardiac rhythm and start ALS
DEFIBRILLATION -
contraindications

There are few contraindications to

defibrillation
■ The main contraindication is in a patient
who has made it clear that he or she does
not wish to be resuscitated
■ Defibrillation should not be used for
arrhythmias other than ventricular
tachycardia or ventricular fibrillation.
Complications
Thermal and electrical burns - Skin burns may
result, the severity of which increases depending
on the energy level utilized and the number of
shocks delivered.
Care must be taken to avoid contact between the
ECG monitor leads and the paddIes, or of the
paddIes with each other, as sparks or fire may
result.
Burns can be minimized by utilizing electrically
conductive contact media and firmly applying the
paddles to the patient.
 CARDIOVERSION
(direct current (DC) shock )
■ Synchronized cardioversion is shock delivery
that is timed (synchronized) with the QRS
complex. This synchronization avoids shock
delivery during the relative refractory portion of
the cardiac cycle, when a shock could produce
VF.
■ Synchronized cardioversion is used to terminate
both supraventricular and ventricular
tachycardias and is usually an elective
procedure, although it should be performed
urgently if the patient is hemodynamically
unstable.
Cont…
■ The energy (shock dose) used for a
synchronized shock is lower than that
used for unsynchronized shocks
(defibrillation).
■ These low-energy shocks should always
be delivered as synchronized shocks
because if they are delivered as
unsynchronized shocks they are likely to
induce VF.
Atrial fibrillation with a controlled ventricular response
Technique
■ Initial energy level for cardioversion is typically
50 to 100 J and varies with different
arrhythmias. If the first shock is unsuccessful,
energy level is increased for subsequent
shocks.
■ The machine must be synchronized to the
QRS complex for cardioversion. Most
machines put a bright dot or similar marker
on the QRS complex when in the “synch”
mode
Indication
(atrioventricular
nodal reentrant tachycardia [AVNRT] and
atrioventricular reentrant tachycardia [AVRT])

(types I and II)

with pulse
■ Any patient with reentrant tachycardia with
narrow or wide QRS complex (ventricular rate
>150 bpm) who is unstable (eg, ischemic chest
pain, acute , hypotension,
acute altered mental status, signs of shock)
 Contraindications
■ Digitalis toxicity–associated tachycardia, sinus tachycardia
caused by various clinical conditions, and multifocal atrial
tachycardia.
■ Patients with are at risk for developing clots
in the left atrium, predisposing them to increased stroke
risk, patients who are not anticoagulated should not
undergo cardioversion without a transesophageal echo that
can assess the presence of a left atrial thrombus.
■ Synchronized cardioversion should also not be used to treat
VF, since the cardioverter may not sense a QRS wave and
may therefore fail to deliver a shock.
■ Synchronized cardioversion is also not appropriate for the
treatment of pulseless VT or polymorphic (irregular) VT,
since these require high-energy, unsynchronized shocks (ie,
defibrillation doses). In addition, cardioversion is not
effective for the treatment of junctional tachycardia.