DEFIBRILLATION

&
CARDIOVERSION
Tipsy Antony
• Defibrillation.
• Indications
• Mechanism of defibrillation.
• Types of defibrillator
• Cardioversion
• Troubleshooting of defibrillator
• Complications of defibrillator
• AED
Defibrillation

Defibrillation is a process in which electronic device deliver

electric current to the heart to terminate lethal arrhythmias
and restore the normal heart rhythm.
How does defibrillator work?

• Conducting system of heart possess several

pacemakers – Sinoatrial (SA) node, Atria,
Atrioventricular (AV) node, Ventricles. 
• Sometimes, an event causes different pace maker cells
to start firing out of sequence. As a result, the heart
will start to contract in an uncoordinated fashion and
will fail to effectively pump blood.
• Defibrillator depolarizes a critical mass of the heart
muscle (most of the cells to fire at once), synchronize
them and allow SA node to takeover the pacemaker
function once again when the heart repolarizes.
Indications

1. Ventricular Fibrillation

2. Pulseless Ventricular Tachycardia

Why defibrillation of asystole is useless?

• Asystole means there is no electrical activity in the

myocytes i.e. non-functioning of cardiac pacemakers
rather than disorganized functioning of pacemakers.

• Electrical stimulation of heart activates or deactivates

ion pumps. But, if heart has been long deprived of
oxygen (hypoxia), necessary electrolytes, etc. –
electrical stimulation will not work.

• So, the primary cause for asystole must be sought and

treated to make the heart tissues excitable once again.
Types of defibrillator

External defibrillator

Internal defibrillator
External defibrillator
Electrodes placed externally
e.g. Portable defibrillator ,Wearable cardiac defibrillator
& Automated external defibrillator (AED).

Internal defibrillator
Electrodes placed directly in endocardium of the heart
e.g.Implantable cardioverter defibrillator(ICD).
Monophasic or Biphasic waveform
Defibrillators deliver energy using a monophasic or
biphasic waveform.
Conti…
• Monophasic defibrillators deliver energy in one
direction. Recommendations for monophasic
defibrillators include an initial shock at 360 joules.

• Biphasic defibrillators deliver energy in two

directions. It deliver successful shocks at lower
energies ,the first and any successive shocks
using 120 to 200 joules.
Conti…
The biphasic waveform is preferred over monophasic
waveform to defibrillate.

• Defibrillation more effective at low energy.

• Less trauma
• Less myocardial damage.
Energy selection in paediatrics as per
AHA
• 2j/kg- 4j/kg.
• Not to exceed above 10j/kg.
Paediatric paddle
Types of Defibrillator electrodes
Spoon shaped electrode
• Applied directly to the heart.
• In internal defibrillation, an initial dose of 20 joules is
recommended to avoid burn-like injury to the myocardium.
Care should be taken to avoid coronary vessels to prevent
vessel damage. Subsequent doses can be increased to a
maximum of 40 joules. Sterile internal pads must be used for
internal defibrillation and should be readily available during
any thoracotomy procedures
Conti
Paddle type electrode
• Applied against the chest wall
Conti
Pad type electrode
• Applied directly on chest wall
Position for Defibrillator electrodes
• Anterior-apical position
Conti
• Anterior-posterior position
• There are two accepted positions to optimize current
delivery to the heart:
• (1) Anteroapical – one pad/paddle is placed to the right of
the sternum just below the clavicle, and the other is
centred lateral to the normal cardiac apex in the anterior
or midaxillary line (V5–6)
• (2) Anteroposterior – the anterior pad/paddle is placed
over the precordium or apex, and the posterior pad/paddle
is placed on the back in the left or right infrascapular
region.
 Steps In Defibrillation
1.identify code blue, shout for help .gather crash cart
defibrillator and jelly
2. Power on the defibrillator, attach ECG leads and identify
the rhythm
3.Select energy- In adults biphasic 120-200 Joules;
monophasic 360 Joules (in children 2J/kg first shock, second
at 4J/kg, subsequent shocks ≥ 4J/kg not to exceed 10 J/kg or
adult dose)
4. Press charge button on paddle (or monitor)
• 5.Shout All clear! Ensure no one is touching the patient
including yourself. Keep oxygen away.)
• 6.Press the Shock button. Always face the patient when
pressing the shock button.
• 7. Resume CPR, beginning with chest compression for 5
cycles, then recheck rhythm
Conti…
• Ensure proper placement of electrodes on the chest.

• Apply pressure to the paddle and do not lean on

forward.
• Make sure there is no flowing oxygen source in
electrical field.

• State firmly “ I CLEAR, YOU CLEAR, ALL CLEAR”

and deliver shock.
• If VF persists, increase the joule and follow the steps
as before.
Troubleshooting
• Attach the external and internal paddles if the
monitor reads, "No paddles.“

• Check to ensure that the leads are securely

attached if the monitor reads, "No leads.“

• Connect the unit to AC power if the message

reads, "Low battery."
Conti
• Verify that the Energy Select control settings are
correct if the defibrillator does not charge.

• Close the recorder door and the paper roll if the

monitor message reads, "Check recorder”.
Nursing Responsibilities
• Check the battery of defibrillator and plug to
charge in each duty shift.

• Keep equipment's and resuscitation cart ready .

Daily look for replacement of required articles
and medications in the cart.

• Ensure placement of electrodes /paddles.

Conti…
• Ensure that defibrillator is set on asynchronous mode.

• Ensure that appropriate jelly is applied before delivering

the shock.

• Oxygen delivery devices are at least 1 m away from the

patient during electric countershock.
 Conti
• Ensure no one is touching the patient during the
delivery of shock to patient.

• Monitor and record the vitals before, during and

after the procedure.

• Obtain the ECG strip.

 After Care of Defibrillator
• If further defibrillation is unnecessary, discharge the
machine by turning it off.

• Once the machine is discharged, clean the paddles and

make sure to remove all conductive jelly.

• Disinfect the defibrillator with Bacillol solution.

• Keep the defibrillator over a dry non insulating surface.

• Connect charger to plug and keep it ready for next time.

Cardioversion
A synchronized circuit in the defibrillator delivers a
shock that is programmed to occur on the R wave
of the QRS complex of the ECG.

Indication
• Ventricular tachydysrhythmias (e.g., VT with a
pulse)
• Supraventricular tachydysrhythmias (e.g., atrial
fibrillation with a rapid ventricular response).
Current European Society of Cardiology and AHA guidelines
suggest the following initial energy selection for specific
arrhythmias
Steps
Cardioversion is the same as for defibrillation with
the following exceptions-

• If synchronized cardioversion is done on a non-

emergency basis , the patient is sedated (e.g., IV
midazolam ) before the procedure.

• Press the Sync button.

• Set the small joule and charge the capacitors.

Steps

• If the patient becomes pulseless or the rhythm changes to

VF, turn the synchronizer switch off and perform
defibrillation.
Nurses Role
• Consent form
• Strict attention to maintaining the patient’s airway is
critical
• Emergency articles
Complications
• Skin burns from the defibrillator paddles are the
most common complication of defibrillation.

• Other risks include injury to the heart muscle.

AED (Automated External Defibrillator)
• Indication

• It is used to provide defibrillation by layperson or healthcare provider.

The device analyzes the heart rhythm and identifies the rhythm if it is
shockable or not.
Equipment required
AED, self-adhesive multifunction defibrillation pads
•

•  
FOR PEADIATRIC PATIENTS
•  If small pads are not available, adult pads can be used in the
anterior-posterior position. It is important to ensure that the
pads do not touch. The pads cannot be cut to fit the patient
either. A delay in defibrillation for lack of infant pads or low
voltage defibrillator is not recommended. A shock with adult
pads/defibrillator at adult dose is better than not delivering a
shock at all. 
Procedure

• 1. Power ON the AED. (some devices power on when the

case or lid is opened)
• 2. Follow AED voice prompts ( written in green):

 Attach pads to patient’s bare chest (adult pads are

applied on a person ≥ 8 years of age) Peel off the backing

of the pads and then attach the adhesive pads on bare
chest, the pad placement is depicted as a picture on the
pads itself. Attach AED connecting cable to the AED
device.
 Analysing rhythm (stop CPR, clear victim, allow the AED to

analyse rhythm)
 It may say shock advised, charging followed by stay clear

and deliver shock, press the flashing button.

 Make sure no one including you is touching the patient when

you press the shock button.

• 3. Resume CPR (5cycles or 2 min) after delivering the shock or in

case no shock is advised by AED.

• Figure: Use of Automated External Defibrillator (AED)
• can we deliver shock to a patient with pacemaker or ICD?
References
• Brunner & Suddarth’s; Textbook of Medical Surgical
Nursing; 13th Edition; vol.2,2014; Published by Woulters
Kulwer (India)Pvt Ltd New Delhi
• Lewis SL, Driksen SR, Heitkemper MM.Lewis's medical
surgical nursing: assessment and management of clinical
problems. 2nd ed. Vol.2.New Delhi: Elsevier; 2015.
• Jacob A, Rekha R, Jadhav, sonali .Cilinical nursing
procedures: the art of nursing practice 3rd ed.jaypee
brothers medical publishers.page no. 370-373.
• NELS procedure manual
•
THANK YOU