Naszariah Mohd Noor

Lecturer
Medical Engineering Technology Section
UniKL BMI
Sem 1P 2015
 Cardiac Defibrillators
Ventricular fibrillation is life-threatening
Ventricular fibrillation (v-fib for short) is the most
serious cardiac rhythm

disturbance. The lower

chambers quiver and the

heart can't pump any blood,

causing cardiac arrest.

The heart's electrical activity becomes disordered.
When this happens, the heart's lower (pumping)
chambers contract in a rapid, unsynchronized way.
(The ventricles "fibrillate" rather than beat.) The
heart pumps little or no blood.
This is reflected in the ECG, which demonstrates
coarse irregular undulations without QRS-complexes.
The cause of fibrillation is the establishment of
multiple re-entry loops usually involving diseased
heart muscle. In this arrhythmia the contraction of
the ventricular muscle is also irregular and is
ineffective at pumping blood.
The lack of blood circulation leads to almost immediate
loss of consciousness and death within minutes. Collapse
and sudden cardiac arrest follows -- this is a medical
emergency!

The ventricular fibrillation may be stopped with an

external defibrillator pulse and appropriate medication.
Defibrillation is the most effective treatment for
ventricular fibrillation. The success of resuscitation of
patients with ventricular fibrillation relates to how
fast electrical defibrillation can be applied. The longer
the duration of fibrillation, the greater the
deterioration of the myocardium related to hypoxia
as a fibrillating heart consumes a very large amount
of oxygen. The chance of successful defibrillation is
also reduced with the length of time fibrillating.
 Defibrillation
Defibrillation is a technique used in emergency medicine
to terminate ventricular fibrillation or pulseless
ventricular tachycardia.

It uses an electrical shock to reset the electrical state of

the heart so that it may beat to a rhythm controlled by its
own natural pacemaker cells.
It is not effective for asystole (complete cessation of
cardiac activity, more commonly known as "flatline") and
pulseless electrical activity (PEA).

The purpose of defibrillation of ventricular arrhythmias is

to apply a controlled electrical shock to the heart, which
leads to depolarization of the entire electrical conduction
system of the heart.
When the heart repolarizes, the normal electrical
conduction may assert itself, in which case the ventricular
arrhythmia is terminated.

However, if not enough energy is used for defibrillation,

the heart may not be completely depolarized, in which
case the ventricular tachycardia or fibrillation may not be
terminated.
 Purpose of Defibrillation

Defibrillation is performed to correct life-threatening

fibrillations of heart, which could rest in cardiac
arrest. It should be performed immediately after
identifying that the patient is experiencing a cardiac
emergency.
 Defibrillators

The defibrillator is a device that delivers electric shock to the

heart muscle undergoing a fatal arrhythmia.

Electric shock can be used to reestablish normal activity

Four basic types of Defibrillators

1. AC Defibrillator

2. DC Defibrillator
 Defibrillators
Before 1960 were AC model

This machine applied 5 to 6A of 60 Hz across the patient’s

chest for 250 to 1000ms.

The success rate for AC defibrillator was rather low.

Since 1960, several different dc defibrillators have been
devised.

This machines store a dc charge that can be delivered to the

patient.

The different between dc types in the wave shape of the

charge delivered to the patient
 DC types

1- Lown

2- Monopulse

3- Tapered (dc) delay

4- Trapezoidal wave
 Lown

- The current will rise very rapidly to about 20 A under the influence of
slightly less than 3 kV .
- The waveform then decays back to zero within 5ms and then produces
a smaller negative pulse also about 5ms.
Lown wave form defibrillator
Simple Block Diagram - Defibrillator
The energy stored in the capacitor is proportional to
the square of the voltage between its plates.
o The amount of energy typically stored in the capacitor
of a defibrillator, so that it can be later delivered to
the patient, ranges from 50 to 400 joules.
All of this energy does not get into the patient.
o Some is lost in the internal resistance of the defibrillator
circuit, RD and some is wasted in the paddle—skin
resistance, RE .
• To calculate how much of this
energy gets to the patient,
resistance RT, consider the
equivalent circuit.
– The four resistors in this
circuit are in series.
That is, the capacitor stores energy, WA, which develops a
voltage, V, across its metal plates.

The amount of energy in units of joules is given by

V2
WA  C
2

– where C is the value of the capacitance measured in units of

farads and V is the voltage across the capacitor.
Therefore, the current in each of them is the same.
– And the energy absorbed by any one resistor is
proportional to the total available energy, according
to the voltage division principle.
• The formula for the energy absorbed by the thorax, WT is

RT
WT  WD
RD  2 RE  RT
Monopulse is a modified Lown waveform and commonly
found in certain portable defibrillator. It is created by the same
circuit of Lown but without inductor L.
Tapered delay wave form , a lower amplitude 1.2 kV and longer
duration 15ms to a chive the energy level. It is created by
placing two L–C sections
Trapeziodal low voltage / long duration ( 800 V : 500 V & 20ms)
Placement of Electrode/Paddle
Waveforms and its importance

Energy-based defibrillators can deliver energy in a variety

of waveforms, broadly characterized as

 Monophasic or

 Biphasic
Monophasic waveform.
Defibrillators with this type of waveform deliver current in one
polarity and were the first to be introduced. They can be
further categorized by the rate at which the current pulse
decreases to zero. If the monophasic waveform falls to zero
gradually, the term damped sinusoidal is used. If the waveform
falls instantaneously, the term truncated exponential is used
(figure 1).
The damped sinusoidal monophasic waveforms have been the
mainstay of external defibrillation for over three decades
Biphasic waveform

This type of waveform was developed later. The delivered

current flows in a positive direction for a specified time and
then reverses and flows in a negative direction for the
remaining duration of the electrical discharge (figure 2).
With biphasic waveforms there is a lower defibrillation
threshold (DFT) that allows reductions of the energy levels
administrated and may cause less myocardial damage. The use
of biphasic waveforms permits a reduction in the size and
weight of AEDs.

Figure 2. Biphasic waveform

How defibrillators account for human
impedance variability

Monophasic (older) defibrillators

Current flows only one direction
 impedance not measured
How defibrillators account for human
impedance variability

Biphasic (modern) defibrillators

– Current flows first in one direction, then
reverses and flows in opposite direction.
– Impedance measured and energy delivery
is adjusted internally based on energy
setting or (for AEDs) arrhythmia
Electrodes

For the external defibrillation are usually metal discs about 3-5
cm in diameter and are attached to highly insulated handles.

Button
External Paddle
For internal defibrillation when the chest is open, large spoon-
shaped electrodes are used.

Electrodes used in
cardiac defibrillation (a)
A spoon-shaped internal
electrode that is applied
directly to the heart. (b)
A paddle-type electrode
that is applied against the
anterior chest wall.
Internal Paddle
Types of defibrillator

1. Manual external defibrillator

Used in conjunction with (or more often have inbuilt) ECG

readers, which the clinician uses to diagnose a cardiac
condition (most often fibrillation or tachycardia although
there are some other rhythms which can be treated by

different shocks).
External Manual Defibrillator
2. Manual internal defibrillator

They are virtually identical to the external version, except that the
charge is delivered through internal paddles in direct contact with
the heart. These are almost exclusively found in operating
theatres, where the chest is likely to be open, or can be opened
quickly by a surgeon.
Manual internal defibrillator
3. Automated or Advisory external defibrillator (AED)

Which is capable of accurately analyzing the ECG and of

making reliable shock decisions. They are designed to detect
ventricular fibrillation with sensitivity and specificity
comparable to the well trained paramedics, then deliver
(automatic) or recommend (advisory) an appropriate high
energy.
Automated or Advisory external defibrillator (AED)
4. DC defibrillator with synchronizer

For the termination of VF, DC defibrillator is used to restore

synchronized working of the heart with the pacemaker of the
body. But for the termination of VT, AF and other arrhythmias, it
is essential to use a defibrillator with auricular fibrillation.
In this case, the pump action of the ventricles still exists.
However, at defibrillation of a heart in auricular fibrillation, the
shock may bring the ventricles into fibrillation.

There is, however, a period in the heart cycle in which the

danger is least. Defibrillation must take place during that
period. Defibrillation must take place during that period. This
is called Cardio-version.
In this technique, the ECG of the patient is fed to the defibrillator
and the shock is given automatically at the right moment.

Thus, the function of the synchronizer circuit is to permit

placement of discharge at the right point on the patient’s
electrocardiogram. The application of the shock pulse during the
vulnerable T wave is avoided, otherwise there is a likelihood of
producing ventricular fibrillation.
With the synchronizer unit, the shock is delivered approx. 20
to 30ms after the peak of the R wave of the patient’s ECG.

The synchronizer unit contains within it, an ECG amplifier

which receives QRS complex of the ECG and uses this to
trigger a time delay circuit.
After an interval of the desired delay time, the defibrillating
capacitor will discharged across the chest through the
electrodes.

The moment the discharge take place, the synchronizer unit

produces a marker pulse on the monitor to show the instant
where the counter-shock has occurred in the ECG cycle.
For effective and efficient results, the output of the
defibrillating circuit is kept isolated or floating. In a floating,
the total energy is always contained between the two
electrodes. There is no loss of energy to extraneous grounds
and a high efficiency is therefore maintained.

Moreover, there is no direct path to ground and the

danger of shock by accidental contact with the patient during

the period of defibrillation does not exist.
Schematic Diagram of Cardioversion

Here, the leads are placed in the standard position on the chest,
and the defibrillator paddles or adhesive electrodes are placed
appropriately.

The EGG from the patient is amplified by the EGG unit and
presented to the QRS detector.
Schematic Diagram of Cardioversion
This is the point in time that the heart normally depolarizes and
delivering the defibrillation pulse at that time should not cause
the heart to fibrillate.

The timing is important to keep the current pulse from hitting

the heart during the T wave, when the ventricle may
become partially depolarized and cause the heart to
fibrillate.
DC Defibrillator with Synchronizer
Safety

Equipment that does not have the ‘defibrillator protected’ symbol as

shown below should be disconnected from the patient before
defibrillation to prevent damage, heating or arcing effects. The defibrillator
should never be discharged with the paddles shorted together, as this may
cause burning and damage to the electrical contacts.