Following defibrillation, you must immediately

recommence CPR, the emphasis being on good quality

chest compressions. There is often a delay in getting an
ECG trace, and the initial cardiac cycles after defibrillation may not be associated with a pulse. Reassess only
after 2 minutes of CPR.

CPR
The strong emphasis is on good quality CPR. Early
attainment of a definitive airway and continuous uninterrupted chest compressions are vital. The latest
Resuscitation Council (UK) guidelines (2010) suggest
that chest compression should continue even during
charging of the defibrillation paddles, and halt for as
little a time as possible to deliver assess the rhythm and
deliver the shock.

Correct placement of the paddles is illustrated in

Figure 69.3. One paddle is placed to the right of the
sternum, below the clavicle, the other in the left midaxillary line in the V6 position. If the patient has a
permanent pacemaker, the paddles must be placed at
least 15cm away from any part of it or it may malfunction, or burn and cause tissue damage.

Selecting the correct energy value is important for

good effective resuscitation. Most defibrillators are
biphasic as this is less damaging to the tissues. A smaller
amount of energy is required because the current
travels in two directions, thereby traversing the myocardium twice. The initial setting for biphasic defibrillators
is usually 150200J for the initial shock, and then 150
360J for all subsequent shocks. Older monophasic defibrillators may be present as well, and these are usually
set at 360J for all shocks.

If the initial rhythm is pulseless electrical activity

(PEA), also termed electromechanical dissociation, or
asystole, no shock is required. Uninterrupted CPR
should continue, and the patient should be reassessed
every 2 minutes.
In many cardiac arrest situations, you will switch
cycles between algorithms, some cycles being shockable, others being non-shockable.

Key drugs
Adrenaline 1mg intravenously should be given every
35 minutes, i.e. every other cycle after two cycles have
been completed. It usually comes in a prepacked 10mL
syringe, with a strength of 1:10,000; 1mg adrenaline is
equivalent to all 10mL of this preparation.
Atropine 3mg intravenously should be given once
only, if there is PEA with a heart rate of <60/min or
asystole.
If patient has hyperkalaemia, hypocalcaemia or
hypermagnesaemia, 10mL 10% calcium chloride over
10 minutes may be helpful.
Amiodarone could be considered for VF or pulseless
VT.
In torsade des pointes, magnesium sulphate is
important.

Hints and tips for the exam

These have been largely covered above.
Know the algorithms. Following them precisely will
secure a pass.
Keep it simple and organised.
If in doubt, think back to the beginning.