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Defibrillators by Frank Weithoner
A defibrillator is used to stop uncoordinated heart beats of a massive heart attack by delivering a
controlled electric shock on the patient's chest.
— > Ventriculor Fibrillation
Electric Shock
The defibrillator is a portable device which runs on mains voltage and on internal battery. The unit
contains an adjustable high voltage source, an ECG, a printer for the ECG and the patient electrodes
(paddies). Modern defibrillators do a complete analyses of the patient's condition and set shock the
parameters automatically.
Defibrillators are used mostly in the operating room, emergency departments and intensive care units
(acu).
A defibrillator is not very common in developing countries. Either hospitals do not have a defibrillators or
the defibrillator does not work. The defibrillator is probably the device that is most commonly defective.
This is because the medical personnel are rarely trained properly on a defibrillator and they assume the
equipment is dangerous (which is not entirely wrong). And because the defibrillator is hardly used it is not
kept in operational condition.
Defibrillation
When the heart beats uncoordinated or too fast it cannot pump blood effectively any more. Cardiac output
and blood pressure fall to dangerous levels. This situation is life threatening and immediate action has to
be taken. Within a few minutes death or irreversible brain damage are otherwise the result.
Defibrillation is the treatment which can stop the abnormal heart rhythm by applying a strong, short
electric shock to the heart, The shock interrupts the uncontrolled activity of the heart cells, the cells get
depolarised and the abnormal heart rhythm stops. The heart then is able to control itself so that it beats
normally again
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‘The restart of the heart comes from the heart itself; a defibrillator can not start a heart which is not
beating. It only terminates the uncontrolled beating, It resets the heart.
A coordinated but too fast heart movement is called ventricular tachycardia
A.uncoordinated movement of the heart is called ventricular fibrillation.
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Normal ECG
Ventricular tachycardia
<
Ventricular fibrillation
Defibrillation is part of cai n (CPR) emergency procedure. It is applied
together with chest compression and artificial ventilation.
Defibrillator types
External defibrillators for clinical use are available as manual and synchronised defibrillators. Beside these
types there are fully automated defibrillators (AED) for non-clinical use and implanted defibrillators.
From a technical point of view external defibrillators are distinguished
between monophasic and biphasic defibrillators, which describes the waveform of the shock pulse. In
the developed world nowadays only biphasic defibrillators are found; in developing countries the older
monophasic version is still the most common type.
The internal ECG unit can also be used to trigger the shock pulse at the right moment. Such a
synchronised defibrillation is also called cardioversion.
Automated External Defibrillators (AED)
An AED is a small automatic controlled defibrillator. In contrast to a synchronised defibrillator in
cardioversion mode the AED also diagnoses the patient's condition and sets automatically all needed
parameter for the optimal shock.
<
A typical AED. It is small, lightweight and easy to use by everybody. The self-adhesive electrodes are
made in such a way that a correct position is always given.
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The user does not need AED equipment
training, only that the self-adhesive
pad has to be placed on the chest by
someone, and the equipment has to be
turned on. The equipment even gives
audible instructions to the operator.
In developed countries AEDs are found
in large public places, such as airports,
train stations and shopping centres. In
the developing world AEDs are hard to find
Usage
Defibrillators are potentially dangerous devices. Never contact the electrodes unless you
have confirmed that the defibrillator is completely discharged. Only trained personnel
may work with defibrillators.
Defibrillation is an emergency operation in addition to cardiopulmonary resuscitation (CPR) procedure. The
defibrillator may be operated by specially trained hospital personnel only. These trainings are held by
medics. It is not the task of the hospital technician to conduct user training for defibrillators. But the
technician can assist and can give technical information e.g. about how to conduct a self-test or charging
the internal batteries
In case of an emergency the first-aider undresses the upper body of the patient, turns on the defibrillator
and takes the paddles out of their holders. Then the operator applies conductive gel to the electrodes of
the paddles, distributes the gel evenly by rubbing the electrodes against each other and then places the
paddles on the chest of the patient.
The paddles will deliver an ECG signal on the internal monitor. On the base of the ECG the operator
decides whether or not defibrillation is needed and what energy level should be selected. The right energy
amount is then adjusted
With the paddles on the chest the operator charges up the defibrillator by pressing the charge button at
one of the paddles. This can take a few seconds. A beeping sound will appear when the capacitor is fully
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charged. In the meantime the operator makes sure that he/she is not touching the electrodes or the
Patient and that anybody else stays away from the patient. After doing so and shouting ‘Stand clear! the
operator presses the paddles firmly against the patient's chest and releases the charge by pressing the
‘two shock buttons of the paddles.
When the ECG shows a normal signal, the paddles can be put back into the holder. In the holder the
paddles get completely discharged and are now safe for cleaning
If the defibrillation was not successful the operator repeats the procedure, perhaps with a higher energy
setting.
When the defibrillator is not in use, it should be switched off but connected to mains. The batteries then
get recharged and kept charged up.
Paddle position
Successful defibrillation depends very much on how the paddles are placed on the patient's chest. The
medic must place the paddles according to the following rules:
The sternum electrode has to be placed on the right side of
the patient, below the clavicle. The apex electrode is placed
to the left side of the patient just below and to the left of the
pectoral muscle.
The electrodes must also not be mixed up because the
polarity of the pulse will otherwise be inverted.
In order to apply full energy, the contact resistance between
paddles and chest has to be as small as possible. Therefore
conductive gel is applied to the electrodes before they get Sternum
pressed to the patient's chest. For the same reason the
pressure has to be firm (about 10-15 kg force) so that
maximum contact surface Is given.
When the defibrillator is completely discharged the paddles 5 ‘
have to be cleaned with a mild soap solution or alcohol so that \
they are ready for use for the next time.
‘Apex
Cleaning by the user
Directly after usage the user should remove all residues of
conductive gel from the electrodes. Also once in a while the
housing, paddles and cables should be wiped clean with soapy water. Afterwards everything should be
wiped with a dry cloth,
Common problems during the usage
In developing countries user trainings on medical equipment in general are insufficient, bad or do not take
place. While a self-study by trial and error might work with simpler equipment it does not work with a
defibrillator. The defibrillator is known as a potentially dangerous device that delivers dangerous shocks,
and thus nobody wants to get close to it. Consequently nobody takes care of the defibrillator and the
internal battery never gets charged.
Additionally the defibrillator is handled as any other equipment in the hospital: It Is locked away when it is
ot in use, So it is not unusual when in an emergency ‘the man with the key' has to be found first.
Construction
‘The defibrillator is a portable but quite heavy equipment. Especially older types can weigh 10 kg. The
reason for this is a heavy internal lead-acid battery and an ECG monitor with an old fashion cathode ray
tube (CRT). Modern equipment uses smaller NiMH batteries, an LCD monitor and other energy saving
components. They are not as heavy and also a bit smaller.
‘Two holders for the two paddles are integrated in the plastic housing, The paddles are connected through
thick coiled cords with the equipment. The biggest knob on the front panel is the energy adjusting switch
Discharge energies between 2 and 360 J (monophasic) can be adjusted. A charge button which starts
charging the capacitor is also found at the front panel and additionally on one of the paddles. A beeping
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sound will appear when the capacitor is fully charged. Then the stored
energy can be released to the patient by pressing both discharge
buttons on the paddles at the same time. This series connection of
‘two switches is done for safety reasons. In monophasic defibrillators sone
the two discharge buttons control a big high-voltage relay which
switches the capacitor over from charge to discharge. In biphasic
defibrillators the relay is replaced by semiconductors, mostly
thyristors.
In cardioversion mode the two shock buttons do not control the relay
directly but trigger a circuit which analyses the ECG, waits for the
best moment and then releases the shock.
A defibrillator also includes an ECG which is displayed with a cathode
ray tube (CRT) or LCD monitor. Depending on the patient's heart
activity the operator decides if a defibrillation is needed and how high
the shock energy should be.
The ECG signal is picked up directly by the two paddles. Alternatively,
additional ECG electrodes can be connected.
A defibrillator also has an inbuilt printer which documents the
patient's ECG before, during and after defibrillation
A defibrillators is portable equipment and thus runs on rechargeable battery. Since the defibrillator has to
be ready for use at any time it has to be connected to mains whenever it is not in use in order to keep the
battery always fully charged.
Physical principle
‘The defibrillator delivers a controlled electric pulse of high energy through two paddles (electrodes) which
are placed on the patient's chest.
The treatment depends largely on the energy of the pulse. The energy is expressed in Joule (3) and is a
product of voltage V, current I and time t.
Energy must not be confused with power (V x 1)
‘The electric shock can reach 5 000 V at a current of about 20 A, These extreme high values are needed
because the pulse length is only a few milliseconds and per definition a defibrillator should be able to
deliver 360 J. But since maximum power is not always needed the output value can be set by the operator
to smaller energy values.
Wave forms
The defibrillator discharges the stored DC voltage of the capacitor across the body resistance. For a very
short time a very high current flows. Because of the low body resistance the capacitor discharges very
quickly.
In the simplest case a single high-voltage capacitor gets charged and discharged. The discharge current
then flows in one direction only. Defibrillators which operate on this working principle are
called monophasic defibrillators. The discharge energy of monophasic defibrillators depends on the
energy which was stored before in the capacitor. If a small amount of energy is wanted the capacitor is
charged up with only a small amount of energy, Assuming that the body resistance is always the same the
discharge energy amount corresponds to a certain charge voltage. In this case the energy control is
nothing else but a power supply with an adjustable output voltage
<
A typical 360 J discharge curve of a monophasic defibrillator connected to a 50 2 test load. The peak
voltage is reached after approximately 1.4 ms and lasts for 8 ms.
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‘A monophasic defibrillator provides shocks between
2.) and 360 J. The needed energy depends on the
capacity and the voltage across the capacitor. Or in
‘other words: The shock voltage can be calculated
when the energy is known and the capacity,
The energy is equal to half of the capacitance
multiplied by the voltage squared
If we want to apply a shock of 360 J by using a
capacitor of 35UF the capacitor has to be charged up
to approximately 4 540 V.
E="cxv? 360
4.540 V
va x 35 pF x V2
Modern defibrillators work differently. They do not use the discharge curve of the capacitor for the shock
but a truncated signal, The discharge curve is cut in order to get quick rise and fall edges. This cutting is
done by high-voltage thyristors.
Additionally a negative pulse is added to the output signal when the positive one has ended. This energy
Is provided by a second capacitor which is charged and discharged in reverse polarity. Also this pulse Is
shaped by thyristors which get switched on and off.
Because the energy now can not be determined anymore just by setting the charge voltage, the control
circuit gets more complex. Now the actual capacitor voltage is measured during discharge as well as the
real current through the patient. A microprocessor then calculates the effective energy and controls the
thyristors which switch the output signal.
This waveform is called biphasic. Biphasic defibrillators have a positive and a negative component. They
were invented because this waveform is considered to be more effective. Nowadays all new defibrillators
are biphasic. In developing countries were a lot of donated older equipment is used, the majority of
defibrillators are still monophasic.
<
A biphasic discharge curve.
The formerly discharge curves of two capacitors (one
for the positive and one for the negative part) is cut
into two pieces. The areas of the two parts correspond
to the set energy.
0 4 8 12 ms
Because the physiological efficiency of a biphasic defibrillator is better, less output energy is needed. As a
consequence the maximum setting of a biphasic defibrillator is typically just 200 J compare to 360 J of a
monophasic one, This decreases risk for the patient of burns and myocardial damage. For the defibrillator
it means that the power supply becomes smaller and the internal battery lighter. As the maximum voltage
gets smaller, the proof voltages of the components can be lower and the components get cheaper.
In biphasic defibrillators there is no patient relay any more. All the switching is done contact-less with
thyristors. They are faster, more precise and cheaper than the charge-discharge relay of a monophasic
defibrillator.
Cardioversion
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All defibrillators contain an ECG monitor for diagnosing the patient's condition before and after
defibrillation. But the ECG function can also be used for synchronising the discharge. This synchronised
mode of defibrillation is called cardioversion. The advantage of a controlled shock at the right time is,
that the defibrillation becomes more efficient by using less eneray.
When the defibrillator is set to cardioversion mode the user
still pushes the shock buttons but the defibrillator releases the Cardioversion
shock only when the defibrillator recognises the best moment.
This is 20 - 30 ms after the large R-peak of the QRS complex
has appeared. Another positive effect is that a shock during
repolarization period (T-wave) is also avoided.
The needed ECG signal is taken trough the paddles which act
as ECG electrodes. In addition all defibrillators have a
connector for external 3, 5 or 12-lead ECG electrodes.
Block diagram
The basic circuit of a defibrillator consists of a high voltage
power supply, a large capacitor as an energy storage, a relay
for switching over from charge to discharge, a control unit, an
ECG and the two paddles.
Ahigh voltage power supply HVPS starts to charge up the high voltage capacitor (typically 15 yF - 40 uF)
when the push button S1 is pushed.
The charge voltage depends on the position of the energy rotary switch S2. Usually energies between 2
and 360 J can be set. This corresponds with a charge voltage of between 300 V and 5 000 V.
Sternum
Apex
When the capacitor is fully charged it can be discharged by pressing push button S3. Then the high
voltage relay R switches over and connects the capacitor through the coil L and the paddles to the patient.
Due to the low impedance of the human body (50 @ - 150 Q) the capacitors discharge quickly. The coll
(typically 50 mH) is used to create a better physiologically waveform and to prolong the duration of
current flow (3 - 10 ms)
<
Capacitor in the back.
Front left: Relay.
Front right: Coil
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In addition to these basic functions the defibrillator
has some safety features. First, there is a circuit that
monitors the charge process and blocks the discharge
switch S3 when the capacitor is not fully charged. Also
3 is not just one switch but there are two in series,
‘one in each paddle. Also for safety reasons the
paddles get bypassed by an internal power resistor when returned to the holder. This ensures that the
capacitor is really discharged and the paddle electrodes are safe and can be touched.
<
The internal power resistor which discharges
the capacitor when the paddles are put back
into their holders.
With an improved circuit design the defibrillator can measure the real energy which is given to the
patient. The shock voltage (at the capacitor) is monitored by the voltage divider Ri, R2 and the patient
current during the shock is measured with the modified coil L. The output coil now has a secondary
winding which delivers a voltage which corresponds to the current through the patient. Both
measurements get to a microcontroller in the control unit. Together with the shock time the
microcontroller calculates the energy and switches off relay R when the preset energy amount is
delivered.
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Control
Modern biphasic defibrillators need a second capacitor in order to create the negative part of the output
signal. Additionally the typical discharge curve of the capacitors are shaped in order to improve the
effectiveness.
In practice the two discharge curve are cut and put together.
This is achieved by fast switching power thyristors or
MOSFETS, They also switch over the capacitors from charging
to discharging.
Together with a voltage and current monitoring circuit and the
possibility of trimming the discharge curve, the delivered ,
energy can now be precisely delivered to the patient.
The following simplified circuit diagram shows how thyristors
are used to trim the signal and to charge and discharge the
‘two capacitors. :
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ov Th
° : af
oF ions
ze ,
The
Capacitor C1 gets charged up when Thy! is switched through. C2 is charged when Thy2 is switched. When
the capacitors are fully charged (voltage divider R1/R2 is not shown here) they can now get discharged.
First C1 delivers the positive parts of the signal. This happens when Thy3 is switched and the sternum
electrode is connected to positive terminal of C1, and Thyé6 is controlled and connects the negative
terminal of C1 to the apex electrode. When the right energy amount is delivered the two thyristors switch
off and at the same time thy4 and thyS are switched on. Then the negative potential of C2 gets to the
sternum via thy4 and the positive potential to the apex paddle via thy5. When the preset energy is
reached the thyristors are switched off. The result is a biphasic signal with steep signal edges.
Power supply
‘The power supply in a defibrillator is a combination of three different power supplies. They all work as
switch mode power supplies (SMPS). One delivers all needed low voltages for the control electronics, one
delivers the high voltage DC for charging the capacitor and one charges the internal battery.
While two of the power supplies work
as common step-down switch mode
power supplies, the one for charging
the capacitor is a step-up power
supply. Depending on what energy is
set, the voltage can reach
approximately 5 000V. Such a high
voltage needs extraordinary safety
measures and an excellent design.
Also all components around the
capacitor (relay, coil...) have to be
heavy duty components which are able
to withstand these high voltages and
high currents. Contacts and conductors
are generously dimensioned and well
insulated to prevent voltage flashover.
Blank connections are sealed with
plastic or silicon. This also applies to the PCB, The conductor tracks have to be protected against contact
and flashovers.
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Paddles
Due to the high current through the paddles and the low contact resistance which is needed to let this
high current flow, the electrodes of the two paddles must have a certain size.
Also, they have to be well insulated and built that way, the operator can not touch the electrodes
accidentally while applying the shock.
In practice the paddles are massive plastic handles with an electrode surface with the size of a smart
phone. The paddles are connected through a rugged spiral cable with the defibrillator. For defibrillating
children smaller paddles are available or suitable adapters are already integrated in the paddles.
Each paddle has a shock release button which have to be pressed at the same time, Also a charge button
is usually integrated in one of the paddles.
<
For safety reasons both paddles have
discharge buttons (orange) which have to be
pressed at the same time. One paddle also
provides a charge button (yellow) and a
contro! LED which lights up when the capacitor
is fully charged.
To ensure a good connection and to minimise the electrical resistance the user has to apply conductive gel
on the electrodes before placing the paddles on the patient's chest, Skin resistance can be several kilo
ohms with dry skin but with gel it drops to a few ten ohms. If no gel is used serious burns can occur. Still,
even with gel the paddles have be pressed firmly on the patient chest. Therefore a pressure of 10-15 kg is.
necessary.
During surgical operations special internal electrodes can be used. They do not have rugged handles
and no integrated shock buttons. The surface of the electrodes are much smaller because the current
Which is used for defibrillating the heart directly is also much smaller.
<
Electrodes for internal use. They do not have
switches and are autoclaveable.
For clinical use self-adhesive pad electrodes are used instead of paddles. These pads are stuck on the
patient as a precaution when the patient is at risk of arrhythmia. The electrodes will remained connected
to the defibrillator and in case of an emergency the system is immediately ready for use. Self-adhesive
electrodes are safer for the operator, as they minimise the risk for the operator coming into contact with
the patient when the shock is delivered.
Self-adhesive pads are also used in conjunction with an automated external defibrillators (AED).
Adhesive electrodes are disposable items and can not be reused, They also have an expiration date.
Expired electrodes should not be used because the adhesive also acts as a conductive gel and it looses its
properties overtime, As a result serious burns may occur.
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Myths
Often in a TV series a patient is seen with a ‘flat-line’ ECG
signal and medics bring the patient back to life with @
defibrillator. This unfortunately works only in TV and not in
real life.
A defibrillator can stop uncoordinated heart beatings like
ventricular fibrillation and ventricular tachycardia, but it can
not start a heart which does not beat anymore. Only
continuing CPR (Cardiopulmonary Resuscitation), a
combination of chess compression with artificial ventilation
can help.
Also often in movies operators are seen which rub the
paddies together rapidly before placing the paddles. Rapid
movements are useless. Rubbing does not charge the
capacitor. The paddles are only rubbed together gently to
spread the conductive gel on the electrodes.
Installation
The defibrillator should be placed where everybody in the hospital has free
and fast excess and on the other hand the equipment is not in the way.
‘A.wall socket should be near by where the defibrillator can be connected
when it is not in use so that the batteries are always charged.
Also, there should be space for ECG cables, conductive gel and a roll of
spare printer paper.
Additionally, signs should be fixed on the hospital walls showing where the
next defibrillator is located.
In developing countries a few more considerations should be made.
a Again, there should be really free and fast access to the defibrillator. Defibrillator
It makes no sense to lock up the defibrillator when in case of an
‘emergency the person with the key has to be found.
= The wall socket should be exclusively for the defibrillator and not
be used for other purposes. This applies in particular for mobile phone
chargers. It is a not a bad idea to colour mark the wall socket and label it.
The wall socket should have no switch as is common with the UK wall socket type.
= A bottle of conductive gel should be placed close to the defibrillator or better attached to
the equipment in that way that it can not disappear.
= Ifthe instruction are not clearly shown on the defibrillator a quick start guide should be
attached to the wall close to the defibrillator. This guide does not replace a proper user
training but it might help when defibrillators of different manufacturers are available in
the hospital.
When the defibrillator has to be used without an internal battery the following should be regarded (only in
exceptional cases)
a Make sure that the defibrillator really works without the internal battery.
a The power plug and all wall sockets in the department must have the same standard
All wall sockets must function and have connection to the back-up system, Note that
maybe not all wall sockets get power from a generator in case of a power cut,
a The power cord should be long enough. If this is a problem replace the cable against a
longer one, Do not leave an extension cable with the defibrillator. It will disappear
one day.
Repair
A defibrillator is a potentially dangerous device. It runs with very high voltages and
even when it is switched off the capacitor may keep its charge. Only trained technicians
should maintain and repair defibrillators.
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‘There is hardly any other medical equipment found in developing countries which is more often not
operational than the defibrillator. Reason for this is not a sophisticated and sensitive technology. In fact a
defibrillator is a quite robust and reliable equipment. In fact, almost all problems with defibrillators are
due to problems with their internal batteries. They are either weak, defective or simply missing
Before working on an open defibrillator make sure the capacitor is discharged. Generally, the paddies only
have to be in their holders and the defibrillator have to be switched on (just switched on - not charged
up). The correct discharge procedure is explained in the service manual of the defibrillator.
When the repair is finished a complete maintenance according to the PPM procedure should be done.
Special tools and measurement equipment
For the repair and maintenance of a defibrillator standard tools including a good multimeter with capacitor
testing is needed. In case of repairs on the SMPS a component tester including an ESR meter is helpful
For performing calibration and a performance tests a calibrated defibrillator analyser is needed. Since this
is an expensive measurement equipment which is not often used, it is hardly found in hospital workshops
in developing countries.
For hospital workshops in countries with limited resources which can not afford a defibrillator analyser a
simple load resistor would be already helpful. With such a load resistor a function test and a battery
performance tests can be made.
Tip! Building a defibrillator test load
Defibrillator testing requires an external load resistor is needed. The resistor simulates
the body resistance of the patient. Such a dummy load is in principle just @ power
resistor of 50 2, Because the output power of the defibrillator is extremely high, the
resistor therefore has to be big. The exact power dissipation is difficult to calculate
because the discharge time is very short. Commercial defibrillator analysers however
contain 2 80 W - 120 W resistor.
With such a power dissipation the resistor does not get very hot even after several
discharges. Half the wattage would be also fine, when only a few discharges with
maximum energy are made.
Unfortunately such a big resistor is not easy to get. But instead of using one big
resistor, a combination of several resistors in series or in parallel can be an option. In
fact, the series connection is the ideal configuration because the voltages across the
resistors get smaller as more resistors are used. This is important because resistors
with 2 proof voltage of 5 000 V and more are not easy to find, But when 5 resistors of
the same value are connected in series the proof voltage of a single resistor has ‘only’
to be 1 000 V at 360 J.
The solution for a test load could be: 5 x 10 @ resistors in series, each 17 W. 11 W
types are also fine when they are mounted between two metal sheets which act as heat
sinks.
For calibration and serious testing such load resistor does not help much because we
still can not measure the output power. But for a function test, using the defibrillator's
Joule display and for testing the battery such a test load is enough.
Typical technical problems
Battery
The biggest problem with defibrillators is the internal battery. These rechargeable batteries have to be
always charged even if the defibrillator is not used. If this does not happen the battery loses its charge
due to self-discharge and once dropping under the discharge cut-off voltage the battery gets damaged.
That is why defibrillators and other rechargeable equipment always have to be connected to mains. Due to
lack of user training on medical equipment (and missing responsibilities) in developing countries most
equipment with internal batteries suffer defective batteries,
As most defibrillators are of older type, we usually find sealed lead-acid (gel) batteries and sometimes
even very old nickel-cadmium (NiCd) batteries. Newer defibrillators run on nickel metal hydride (NiMH) or
lithium-ion (Li-ion) cells. AEDs usually work with lithium batteries and thus are not rechargeable.
The state of the batteries can be checked by doing a series of discharges as described in
the | Manual performance test. Special attention should be given when an older defibrillator still runs on
nickel-cadmium batteries (NiCd). NiCd batteries are sensitive to partially discharges and incomplete and
irregular charging. They need regular discharging and charging, otherwise they rapidly loose capacity
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(memory effect). Because of these drawbacks NiCd batteries are not suitable any more for medical
equipment these days and should always be replaced with nickel metal hydride (NiMH) batteries.
In developing counties defibrillators run mostly on lead-acid (gel) batteries. Theses batteries are more
robust than NiCd batteries but even with these batteries the manufacturers suggest replacement every
two years. Therefore batteries of defibrillators have a label which shows the date of last exchange. When
you replace a battery please do not forget to note the date of replacement on the battery.
Battery replacement every other year is not realistic in developing countries. Instead a regular
performance test can be done, so that the battery is only replaced when it gets significantly weaker,
In general, batteries should be replaced only with the same type and size (Ah). If this is not possible or
not wanted (in case of NiCd batteries) make sure that the end-of-charge voltage of the battery is similar.
If the battery voltages (nominal and end-of-charge voltage) are different the new battery would not get
fully charged or gets overcharged.
The charging characteristics of NiCd and NiMH are similar and a NiCd battery can be exchanged with a
modern NIMH battery. But a lead-acid battery behaves differently during charging and can only be
replaced by another lead-acid battery. After replacing a battery always do a | Manual performance test.
If you plan to run a defibrillator without the internal battery because a spare is not available, please note
that a defibrillator without a battery might work but the time for charging the capacitor can take much
longer.
Capacitor
Even when the paddles are in their holders and the
capacitor should be discharged, discharge the
capacitor manually before working on it. Use a
discharge-cable, a cable with a small load resistor.
When the capacitor is discharged it can be tested
using a quality multimeter, Such a high-voltage
capacitor has a capacity of 15-100 uF. The proof
voltage is about 2 000 V (biphasic) and up to 5 000 V
(monophasic).
When a capacitor has to be replaced because of
capacity loss it is very unlikely to find a spare in the
next electronic shop. Because of their gigantic proof
voltage they are only found in defibrillators. But if you
can get another broken defibrillator it might contain an
identical one. Especially with older monophasic
defibrillators that often work with a 35 uF type. And if
the capacity is the same, also the proof voltage will be
the same because they all work with the same energy
at the same load.
Power supply
The power supply unit of a defibrillator consists of different independent power supplies for different
purposes. They are all designed as switch-mode power supplies (SMPS)
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Power Supply
ECG Monitor
Coil
Capacitor
First, there is a standard power supply which supplies all electronic stages. It is a common design and
delivers low voltages (e.g. 5 V, 12 V) for all electronic stages.
Then there is the high-voltage power supply which delivers the charge voltage for the capacitor(s). This
time the SMPS is a step-up type, meaning the output voltage is higher than the input voltage. This also
means that the components have much higher proof voltages (2 000 - 5 000 V)
The last SMPS is the battery charger which delivers the charge current for the internal battery. It also
monitors the state of charge.
Due to the life-threatening voltages and for shielding reasons, the power supply is completely covered by
a metal housing.
Before working on the power supply make sure that the shock capacitor is completely discharged. Only
then the power supply can be opened. But keep in mind that the mains filter capacitors of the power
supply are remain charged. Discharge them all by a discharge cable.
Problems with SMPS in medical equipment can happen but are not very common. The components are of
much better quality and e.g, the leaking capacitors in consumer electronics are rarely used. Problems with
power transistors and MOS-FETs are more likely to arise. More about SMPSs and their repair in the SMPS
chapter. (— Switched-Mode Power Supplies)
Paddles
‘The function of the paddles can be checked by doing a
test run in self-test mode or with an external
defibrillator tester. When the paddles do not work
properly or just infrequently, do not forget to inspect
the spiral cable and the plug and socket. When in
doubt the cable and the connection can be checked
with an ohm-meter. The resistance should be no more
than 0.15 2.
Printer
In developing countries it is not uncommon that
internal printers are not used simply due to missing
printer paper. In fact the printer itself rarely has 2
technical problem,
The printer in a defibrillator is generally a thermal
printer. That means that it does not use ink and thus
does not have a printer head which can get clogged or dried up. That is why they are so robust.
The printer head consists of small heating elements which are controlled by a microprocessors while a
thermal-sensitive paper is moved by a rubber roll under the printer head. Whenever a heating element is
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controlled it blackens the paper.
The drawback of thermal printers is the thermal paper itself. Thermal paper is often difficult to get,
especially for older equipment.
After long use it can happen that dust and paper fibres accumulate on the printer head and the print out
gets difficult to read. Then the print head can be cleaned with a cotton swab and a drop of alcohol. Also
the rubber roller should be wiped off with alcohol in order to ensure the paper feed
TIP! Thermal paper is also used at supermarket checkouts and for ticket machines.
It is not a bad idea to check if these locally available paper rolls perhaps also fit the
defibrillator printer.
Planned preventive maintenance (PPM)
Since the battery is the weakest component of the defibrillator, checking the state of the battery is,
recommended in addition to the a normal function test.
Please remember that a defibrillators is a lifesaving device for an emergency situation. When doing PPM
on a defibrillator make sure that a spare defibrillator is available and functioning.
For the same reason it is also not advisable doing PPM of all defibrillators the same day. Also note that for
a battery capacity test the battery has to be discharged and again recharged which can take 24 hours.
Planned preventive maintenance on defibrillators should be done twice a year and after every repair.
Inspection from the outside
Defibrillator housing and paddles should not be damaged.
Power cord, mains plug and strain relief should be firmly connected and not damaged.
a Paddles should be clean and should not show pitting, corrosion and residues of conductive
gel
= Coiled cables of the paddles should be in good condition and not damaged. Unplug the
paddle connector. The contacts must be clean.
Printer should be in good condition. No signs of wear and tear on drive gear and rollers.
Accessories (defibrillator gel, ECG electrodes) should be available at the location of the
defibrillator, Also the wall socket should functioning properly.
Inspection from the inside
«Take off the defibrillator housing
= Remove dust if necessary.
= Check for corrosion of the metal parts. All cables are tightly connected.
= Check the electronic components for burns, breaks and capacitors for deformation and
leakages.
Search the solder side of the board for cold soldering points and loose connections.
Check all fuses. No fuse must be bypassed.
Function check
Close the defibrillator and connect it to mains, The battery charge LED should come on.
Safety function check
= Turn the energy select switch to 20 J. Make sure that paddles are placed in their holder.
Press charge button.
= With the paddles in their holders, press Apex shock button. Defibrillator must not
discharge.
= With the paddles in their holders, press Sternum shock button. Defibrillator must not
discharge.
Press both shock buttons. Defibrillator should discharge now. The internal printer should
print the test result.
ECG function check
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Connect an ECG tester and check if the ECG is displayed
Check the ECG alarm functions. There should be alarms when the heart rate is too low or
too high (e.g. 40 and 120)
= Print out the ECG, It has to be good print quality.
Cardioversion test
= Place paddles on the defibrillator analyser. Switch to sync (cardioversion) mode. Turn the
energy select switch to 20 J. Press charge button.
= Press both shock buttons. Defibrillator must not discharge.
= Turn on the ECG simulator of the analyser. Press both shock buttons, Defibrillator should
discharge now.
Automated self-test
Most defibrillators provide an automated self-test function. During a self-test the defibrillator gets charged
up and a controlled discharge follows. The process is monitored, the energy measured and the result
displayed on the monitor or can be printed out. How this test exactly works and what tests are covered is
explained in the user manual.
It is possible that the performance of the battery is not tested during this self-test. Sometimes another
menu item has to be selected to check also the battery performance. Check the user or service manual for
more information.
Some manufacturers recommend a weekly self-test and in many hospital in the developed world the self-
test has to be done even on a daily base. In many hospitals in the developing countries the defibrillator is
rarely or never used. Thus hardly anyone knows the self-test function. Discuss this topic with the
responsible doctors and offer instruction in how to perform the self-test.
Manual performance test
‘The self-test is done with reduced energy and thus is not a performance test. Only a test under real
conditions can give information about the performance of the defibrillator and its internal battery. For such
a performance test a defibrillator analyser is needed
<
For safety reasons both paddles have
discharge buttons (orange) which have
to be pressed at the same time. One
paddle also provides a charge button
(yellow) and a contro! LED which lights
up when the capacitor is fully charged.
Performance test with a defibrillator analyser. The analyser measures the energy of the shock and can also
create different types of ECG signals including tachycardia and fibrillation.
A typical manual performance test covers a charge up test, an output energy measurement and a battery
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test. In practise you run the defibrillator on battery power and do a series of charging and discharging
while you observe the charge time and the discharge energy. The idea is that the battery should last a
number of charges/discharges without @ reduced output power or increased charge time
a Make sure the internal battery is fully charged. In case of a doubt charge the defibrillator for 24 hours
before you start.
Connect a defibrillator analyser. Select 360 J
Charge the capacitor. The charge time should be no longer than 15 s.
Deliver a shock. The analyser displays the delivered energy. It should be not less than 306 J (-15%).
Repeat charging and discharging 10 times. Make sure that the test load does not get overheated.
The charge time should never be longer than 15 s and the output power never less than 306 J.
When a defibrillator has problems delivering 10 discharges the battery is weak (25-50 discharges can be
expected with a new battery). The battery will not last for much longer and the defibrillator will no longer
work reliably. The battery should be replaced.
Capacitor test
Once the capacitor is charged up it should not loose its charge too quickly. This can be checked as
followed:
= Connect a defibrillator analyser. Select 360 J.
= Charge up the defibrillator but do not release a shock.
= Wait 1 minute and then discharge. The output energy should not be less than
85% of the set value.
Paddle continuity
All patient cables and the wires inside defibrillator cables can break or tear off at the connection points,
Also the pins in the plug can get corroded. For this reason a continuity check of paddles should be done
during every maintenance. The continuity is measured with an ohmmeter (milli-ohmmeter, good
multimeter) between the paddle surface and the corresponding pin of the connector. The resistance should
not exceed 0.15 2. Wiggle the cable, especially close to the the paddle and the plug and observe the
ohmmeter,
Calibration
‘An adjustment of the output energy is needed
when the measurement result of a connected
defibrillator analyser differs by more than
15%, That means for example, when the
output eneray at 360 J is less than 306 }
It is important that the measurement is done
with an external and calibrated analyser. The
energy display of the defibrillator is not
relevant,
Adjustment procedure differ from
manufacturer to manufacturer. Sometimes it
has to be done through the equipment
software and sometimes it needs manual
adjustment on the PCB, The correct procedure
is described in the service manual.
Cleaning by the technician
= Clean the housing, paddles and cables. Use soapy water. Wipe with a cloth and let
everything dry.
= Remove all residues of conductive gel from the electrodes. The surface must be
completely clean and shiny. If soapy water does not help try it with polishing paste. Avoid
abrasive products. The surface must not be scratched.
De-dust the interior if necessary.
Clean the printer unit. Take out the paper roll and check for dust and paper residues.
De-dust the printer if needed. Clean the printer head and rubber rollers with alcohol and
cotton swaps.
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Electrical safety test
The last step of the maintenance procedure is the electrical safety test, The defibrillator should be
connected to a electrical safety tester now and the following tests performed. The measurements can also
be done manually step-by-step according to the procedure explained in the Electrical safety test
procedures chapter.
Ground resistance
‘The ground resistance is measured between the grounding pin of the power cord and exposed metal on
the chassis, It should be less than 0.5 Q.
Earth leakage current
The earth leakage current is the current through the ground wire to earth.
‘The measurements are made when the defibrillator is switched on, in normal and reverse polarity. The
current should not exceed 500 WA.
Then the same measurements should be made in single fault condition (SFC) when neutral is open, also in
on and off mode in normal and reverse connection. The current should not exceed 1 000 HA.
Chassis leakage current
The chassis leakage current is measured from chassis to ground with the PE connection of the defibrillator
temporarily open
The measurements are made when the defibrillator is switched on, in normal and reverse polarity. The
leakage current should not exceed 100 UA.
‘Then the same measurements should be made in single fault condition (SFC) when neutral is open, also in
on and off mode in normal and reverse connection. The current should not exceed 500 yA
Patient leakage test
The patient leakage current is measured between the paddles and ground. The two paddles should be
measured separately.
‘The defibrillator has to be switched on and measurements should be done with normal mains polarity and
in reverse. The current should not exceed 10 UA.
Then the same measurements should be made in single fault condition (SFC) with open neutral and also
with open PE, also in on and off mode in normal and reverse connection. The leakage current should not
exceed 50 WA
Manufacturers
Important manufacturer of defibrillators are:
Cardiac Science, GE, HP, Nihon-Kohden, Philips, Physio-Control, Schiller, Welch Allyn, Zoll
Further literature
On Wikipedia you can find further articles about these topics:
Defibrillation
Automated external defibrillator
Cardiac arrest
Ventricular fibrillation
Ventricular tachycardia
Cardioversion
Cardiopulmonary resuscitation
ry (electricity)
‘Switched-mode pawer supply
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