Defibrillator

contd
Defibrillator
waveform
Monophasic waveforms deliver current of
one polarity
Monophasic damped sinusoidal returns to
zero gradually
Monophasic truncated exponential where
current is abruptly returned to baseline
• Biphasic waveforms: current travel toward the positive paddle and
then reverses back
• Reversing of polarity depolarizes all cells which is called as burping
response
• Classified into – biphasic truncated exponential waveform and
rectilinear biphasic waveform
• Biphasic waveforms are associated with fewer burns and less
myocardial damage
Energy level
For Sudden cardiac arrest
• Monophasic –single shock started at and repeated at 360J
• biphasic – single and repeated shock 200J
• Use maximum energy available in the machine
Current AHA recommendations are to attempt defibrillation with an
initial setting of 200-300J delivered energy, a second attempt at the
same energy level should be made if first attempt is unsuccessful
Paddle placement
Positions
• Anterior-lateral
• Anterior –posterior
• Anterior-left infrascapular
• Anterior-right infrascapular
• Anterior lateral position is more convenient
one –right of sternum below clavicle along the sternal angle (2nd or 3rd
intercostal space)
other- left 4th or 5th ICS in mid axillary line
• Paddles are placed along the long axis of the heart
• Anterior –posterior
One paddle over the pericardium and the other in left infrascapular
• AP placement is used for children with adult paddles
Position of electrodes in pregnant
patients
• One on right of sternum below the right clavicle
• Other left mid axillary line avoiding breast
Paddle size
• Adult- 10-13cm diameter
• Paediatric small paddles < 1yr
• Infant<10kgs- 4.5cm
• Children > 10kgs 8cm
• Small paddles concentrate current burn the chest
• Large paddles reduces current density
In pacemaker or ICD
paddles should not be placed directly on top of the pacemaker or ICD
paddles should be placed at least 12cm from the generator
90 degree to the ICD electrode
• Transthoracic cardioversion and defibrillation adversely affect the
pacemaker or icd due to electromagnetic interference
• This interference can be minimized by proper skin electrode
placement
• Paddles should not be placed in proximity to the device which is
usually in the left infraclavicular region
• In such cases Anterior-posterior position is preferred
Defibrillator with synchronizer
• For tachyarrhythmias other than ventricular fibrillation and pulseless
ventricular tachycardia the DC shock must be synchronized to the QRS
complex (called DC cardioversion)
• Because a shock falls during the vulnerable period (near the peak of T
wave) can induce VF
• The defibrillator have the ability to track the QRS and to stick a visible
marker on each one
• The same machine is used for both cardioversion and defibrillation,
SYNC button has to be selected before cardioversion otherwise it
functions as a defibrillator
Synchronized cardioversion
• Cardioversion is the electrical maneuver that delivers energy
synchronized to the large R waves or QRS complex
• It uses energy less than used for defibrillation in shockable sudden
cardiac arrest
• Avoids delivering shock during repolarization period( T waves on ecg)
Indications of cardioversion
• Atrial flutter
• Atrial fibrillation
• Re entrant SVT
• Mono morphic VT
• Polymorphic VT
• Wide complex tachycardia
Contraindications
• Digitalis induced dysrhythmias
• Junctional tachycardia or ectopics / multifocal atrial tachycardia
Energy recommended for
cardioversion
• Atrial flutter 50-100J (biphasic)
• Atrial fibrillation 120-200J (biphasic)
• Monomorphic VT 100J (biphasic)
• Paediatric recommendation; 0.5-1 j/kg upto 2J /kg
Elective cardioversion
• Sedation will be required for elective cardioversion if the patient is
awake as it is a painful and uncomfortable procedure
Pre procedure consideration
• History and physical examination
current medication including anticoagulation
• Fasting 6hrs
• Obtain 12 lead ecg
• Trans thoracic echo
• Shaving of site if necessary
• Check serum electrolytes and correct if deranged
• Assure O2 supply
• Digoxin should be withheld for 2 days
• Check consent
Steps
• Check environment at procedure site
• Turn on defibrillator
• Anaesthethic technique as required
• Apply electrodes
• Press SYNC
• Select energy
• 3 clear shout and look
• Deliver shock
Complications of cardioversion
• Systemic embolization
• Post shock cardiac arrhythmias
• Transient ST & T wave changes
• Aspiration in case of emergency cardioversion
Post procedure monitoring
• Record delivered energy and result
• Continuous ECG monitoring
• 12 lead ecg
• Inspect skin under the pad for burns
• If successful response check vitals, airway and consciousness
• If not successful check and reassess
Consider 9 C’s of cardioversion
• Consent
• Consult as needed
• Consider sedation
• Crash cart
• Confirm synchronization
• Confirm shock delivery
• Continuous monitoring
• Consider TEE
• Consider anticoagulant
Anticoagulation for cardioversion
Cardioversion of patients with atrial fibrillation has been reported to
be associated with risk of embolism of 1-7% if anticoagulation is not
administered
• if atrial fibrillation is present for atleast two days the patient should
be anticoagulated with warfarin for atleast 3 weeks before elective
cardioversion
• Anticoagulation be continued until normal sinus rhythm has been
maintained for 4 weeks
THANK YOU