Procedure for Defibrillation

This procedure is for use by nurses who have attained certification in the delegated act of defibrillation.

Defibrillation is the application of a controlled electrical shock to terminate ventricular fibrill or pulseless ventricular tachycardia. The shock is delivered through the chest wall in an atte to completely depolarize the myocardium and provide an opportunity for the SA node to tak over (ACLS). The longer that the myocardium is in VF or VT, the more damage that is done, t less chance there is of survival. The ONLY effective treatment is defibrillation. The probabili successful defibrillation diminishes rapidly over time.

NOTE: nurses in the ICU are NOT certified to perform cardioversion; please refer to the cardioversi procedure For further information on delegated acts, please refer to the hospital policy: Certification of Staff in the Performance of Delegated Controlled Acts

Procedure

Rationale

1. Identify VF/pulseless VT on the monitor--check the patient, check the leads and confirm pulselessness. If arrest was witnessed, give precordial thump.

Precordial thump may produc enough energy to terminate V given early in VF.

2. Lay pt flat and initiate CPR. Ask a colleague to get the crash cart. NOTE: if pt is on a specialty bed, place the bed on "max inflate" 3.. Plug in the crash cart. Connect the gray cable with the silver jack end on the defibrillator to the bedside monitor (silver round outlet above the recorder) to obtain ECG information from the monitor.

Bed surface must be made h for CPR to be effective.

Connecting the crash cart to monitor means that you DO N have to put more ECG electro on the pt to obtain an ECG signal.

4. Apply gel pads ( if using paddles) or pacing/defib electrodes(Zoll pro-padz).

Pacing/defib electrodes have advantage of saving time if a in and out of a VF --don't hav

If applying gel pads:

waste time applying pads the next time the pt goes into VF they are already on.

place one pad on upper chest below the right clavicle place second pad below the left nipple at the midaxillary line (see picture below)

If applying pacing/defib electrodes:

place the round pad on the anterior chest, in between the left nipple and the sternum with the top of the pad level with the top of the nipple (see package for placement) --NOTE: if continuous 12 lead monitoring is being done, it is recommended that the V leads be removed so that the electrode can be properly placed place the rectangular pad on the back behind the front pad (see picture on the package) press pads firmly to the edges to remove air pockets remove the cable from the paddles and attach it to the pacing/defib electrodes

The breast tissue has a highe resistance and therefore shou be avoided. In theory since th resistance is higher it will take more energy to either conver rhythm or get capture.

Placement right over the nipp tends to be rather painful and should be avoided.

Arcing may occur if shock is delivered near an ECG electr

Place gel pads or electrodes at least 2 cm away from electrodes and 10 cm away from a pacemaker generator 5. Prepare the machine for defibrillation:

turn the selector knob to "defib" setting(see below). The energy level defaults to 120 joules.

The Zoll defibrillators are biphasic; this means that the machine delivers current that

flows in one direction for a specified duration then revers the current to flow in the othe direction. Significantly lower energy levels are required wi biphasic defibrillators. 6a) If using gel pads and paddles:

Apply the paddles to the chest on the gel pads, ensuring that the paddles are not in contact with ECG electrodes or wires. Charge the defibrillator by pressing "charge" button on the machine itself;alternatively, the person with the paddles can press the "charge" button on the side of the apex(right) paddle. A distinctive charge ready tone sounds and "DEFIB 120J READY" message will be displayed Hold the paddles firmly to the chest with 25-30 lbs of pressure ensure there is no contact with metal and that all personnel are away from the bed call "all clear--I'm shocking on 3--1, 2, 3 " discharge the shock by simultaneously and firmly depressing the red buttons on both paddles; hold the buttons for 2 seconds .The shock should be delivered at the end of exhalation keep the paddles on the chest

Firm pressure is required to ensure good contact with the chest.

Air filled lungs decrease elect conduction.

Keep the paddles on the ches that you are ready to give another shock if necessary.

6b) if using pacing/defib electrodes:

Charge the defibrillator by pressing "charge" button on the machine. A distinctive charge ready tone sounds and "DEFIB 120J READY" message will be displayed ensure that all personnel are away from the bed call "all clear--I'm shocking on 3--1, 2, 3 " discharge the shock by pressing the "shock" button on the machine

7. Immediately charge the defibrillator to 150 J by pressing the up arrow on the display ; if VF still present, shock again as

150 is the next energy level o the biphasic defibrillator.

above.

Rapid, stacked shocks decre thoracic impedance and impr the chances of successful conversion of VF.

8. Immediately charge the defibrillator to 200 J by pressing the up arrow on the display; if VF still present, shock again as above.

200J is the next energy level a biphasic defibrillator.

9. If VF persists, start CPR and follow ACLS protocol. Continue to monitor rhythm.

10. Document defibrillation on the cardiac arrest record.

11. Assess skin for burns. 12. Provide information and reassurance to patient and family .

References

1. American Heart Association. (2000)Guidelines 2000 for cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 6: advanced cardiovascular life support: 7D. The American H in collaboration with the International Liaison Committee on Resuscitation.Circulation, August 22; 1 suppl). 2. Zoll defibrillator M series Operators manual Developed By : Rachelle McCready, Clinical Educator, Critical Care, ICU-UC Date: July 2004

Disclaimer

Contact: Rachelle M E-mail rachelle.mccready@lh