Chapter 9: Defibrillation

Question 1

How quickly after onset of VF or pulseless VT does cerebral hypoxic injury begin?

Answer 1

Within 3 minutes

Question 2

In absence of bystander CPR, how much does mortality rate increase for every minute between collapse and attempted defibrillation?

Answer 2

7-10%

Question 3

Do short interruptions in chest compressions (to assess rhythm and give rescue breaths) impact success of defibrillation?

Answer 3

Yes!

Associated with myocardial dysfunction and reduced survival

Pre-shock pause should also be minimised

Question 4

When bystander CPR is given, how much does mortality rate increase for every minute between collapse and attempted defibrillation?

Answer 4

3-4%

Question 6

How is successful defibrillation defined?

Answer 6

Absence of VF/pVT 5s after shock delivery

Ultimate goal is ROSC

Question 7

What factors impact defibrillation success?

Answer 7

Transthoracic impedance:

• good contact with pads
• clean and dry area
• shave off hair

Electrode position - best to be over area in fibrillation

Question 8

What other electrode positions are acceptable for defibrillation?

Answer 8

Antero-posterior - left precordium and inf. to left scapula

Postero-lateral - mid axillary line and inf. to right scapula

Bi-axillary

Patients with implantable pacemakers/defib’s - must place 10-15cm away from these

Question 9

What should you do first CPR or defibrillation?

Answer 9

If unwitnessed cardiac arrest, begin CPR immediately while defib is being set up

Once defibrillator on, dont delay, attempt ASAP

Question 10

What should you do if a cardiac arrest is witnessed (and VF/pVT)?

Answer 10

Confirm rhythm

Give 3 successive shocks

Check for rhythm change and if appropriate pulse and signs of ROSC

Question 11

What shock energy should be used?

Answer 11

First at minimum of 150J

Based on manufacturers guidance - if don’t know then maximum shock energy for all

Question 12

What safety checks are key when defibrillating?

Answer 12

• Ensure no-one is touching the body
• Wipe water away from patient chest before
• Don’t hold IV infusion equipment or patients trolley during delivery
• Oxygen safety

Question 13

How should oxygen be used safely during defibrillation?

Answer 13

• Take off any mask or nasal cannula and place >1m away
• Can leave ventilation bag connected to tracheal tube or supraglottic airway
• If pt on ventilator - leave ventilator tubing unless preventing CPR –> ventilation bag and switch off ventilator. Patients in critical care unit may be dependent of PEEP so try leave connected to ventilator

Question 14

How is defibrillation modified in children?

Answer 14

> 8yo - same as adult

1-8 yo - special paediatric electrodes or can use adult but ensure don’t overlap

<1 can use AED if no other option

Question 15

What is the shock synchronised with in synchronised cardioversion?

Answer 15

R wave - this avoid relative refractory period so minimises risk of inducing VF

VF/pVT don’t require this

Question 16

If synchronised cardioversion fails, what should you do?

Answer 16

Choose a different lead or adjust amplitude

Question 17

Can implantable ICD’s give a shock?

Answer 17

Yes at 40 or 80J

It gives these shocks without warning and number of shocks depends on the device

Can deactivate defibrillation capability by placing ring magnet over ICD - doesn’t disable pacemaker

Question 18

Should you defibrillate a patient if they have an ICD?

Answer 18

Yes if the ICD has not delivered a shock or if it has failed to terminate the arrhythmia

Question 19

What is the maximum energy needed for internal defibrillators?

Answer 19

50J

Typically deliver between 10-20J

Question 20

Evidence for defib shocking levels

Answer 20

No evidence whether to increase voltage or stay at same voltage but likely increase.

Question 21

How to do synchronised cardioversion

Answer 21

Can use same defibs
Used for atrial or ventricular tachyarrhythmias -

Have to synchronize it with the R wave of an ECG.

Question 22

Where to place pads if patient has pacemaker/defib

Answer 22

Anterior and posterior on left side.