DEFIBRILLATION

Defibrillation is achieved by delivering a strong electric current though electrodes placed on the surface of a patients chest wall. Proper electrode placement ensures that the axis of the heart is directly situated between the sources of current (defibrillator paddles). Since dysrhythmias are chaotic with no coordinated ventricular response, the electric current is delivered randomly. It is through implementation of emergent defibrillation that ventricular fibrillation and pulseless ventricular tachycardia can be terminated and cardiac output restored.

PURPOSE:
1. To eradicate life-threatening ventricular fibrillation or pulseless ventricular tachycardia. 2. To restore cardiac output lost due to dysrhythmias and reestablish tissue perfusion and oxygenation.

SPECIAL EQUIPMENT: 1.Defibrillator 2.Conductive medium- defibrillator pads

3.Cardiac monitor with recorder

4.Emergency cart and medications

5.Emergency pacing equipment

PROCEDURE:
1. Verify V-fib or V-tach by ECG and correlate with clinical state. Assess to determine absence of pulse. Call for help and perform CPR until defibrillator and crash cart arrives.
-- May be mistaken for artifact or leads may be off.

2. Prepare for defibrillation

--Asses situation. If a second person is getting the defibrillator, establish an airway and begin CPR. a. Turn power "ON". Defaults to 200 joules. --Convert to pediatric size for children or internal if the patient is has an open chest. b. Select correct paddles- adult, pediatric or internal. --Enhances electrical conduction through subcutaneous tissue and assists in minimizing burns. c. Prepare patient and/or paddles with proper conductive agent. --Limit to paddle area. Use 2 joules/kg for children. d. Checks that defibrillator is in asynchronous mode. --Will not fire if it is in synchronous mode due to absence of R wave *** If other than 200 joules desired, press "ENERGY SELECT" and select desired amount

3. Turn on ECG recorder for continuous printout. --Establishes a visual recording and a permanent record of current ECG status and response to intervention.

4. Places one paddle at the hearts Apex just left of the nipple in midaxillary line. Place the other paddle just below the right clavicle to the right of the sternum, applying 25 lbs. / square inch pressure to paddles. ---Defibrillation s achieved by passing an electric current through cardiac muscle mass to restore a single source of impulse generation. Decreases transthoracic resistance and improves flow of current across axis of heart.

5. ***Press "CHARGE" on defibrillator front panel or on the Apex paddle. Wait until indicator stops flashing to indicate fully charged.

--This will charge unit with current.

6. ***State "ALL CLEAR" and visually check that all personnel are clear of contact with bed, patient and equipment. --Maintains safety to caregivers, since electric current can be conducted from the patient to another individual if contact occurs. 7. ***Checks rhythm immediately before discharge. --ECG rhythm may change, ensure it is a rhythm that requires defibrillation. 8. Depress both buttons simultaneously and maintain pressure until electrical current delivered. (Maintain 25 lbs/in2)

---Premature release may result in failure to discharge energy. May also be delivered by depressing discharge button on the defibrillator.
9. ***Assess conversion of dysrhythmia.

--If rhythm has converted, must reassess.

10. If first defibrillation unsuccessful, immediately charge paddles to 300 joules and repeat steps 2 through 9. --Immediate action increases chance for successful depolarization of cardiac muscle. Transthoracic resistance decreases by approximately 8 % with the second shock. 11. If second defibrillation unsuccessful, immediately charge paddles to 360 joules and repeat steps 2 through 9. --Immediate action increase chance of successful depolarization of cardiac muscle. "Stacked shocks" sequence is more important than adjunctive drug therapy and delays between shocks to deliver medications are detrimental. 12. If third attempt is unsuccessful, continue CPR, initiate ACLS protocols, intubate and obtain IV access. Assess patient status and precipitating factors to prevent further decompensation of patient. --Necessary to maintain the delivery of oxygenated blood to vital organs.

13. Clean defibrillator and paddles, discard supplies, and wash hands. --Conductive gel accumulated on defib paddles impedes surface contact and increases transthoracic resistance.

14. Documents procedure in patient record or cardiac arrest flowsheet. --Provides for completion of medical/ nursing records.

POST-DEFIBRILLATION CARE: EVALUATE:

Neurologic status. Reorient to person, place, and time.

--Temporary altered LOC occurs following defibrillation. Cerebral anoxia or emboli may develop as a post-procedure complication. Respiratory status. Auscultate lung sounds, Monitor rate, depth, & quality of breathing. Oxygen as ordered.

--Respiratory centers of the brain may be depressed as a result of hypoxia. Cardiovascular status. Get 12-lead ECG and continue to monitor rhythm and blood pressure, pulse and respirations frequently until stable.

--Dysrhythmias may develop after defibrillation .

Initiate IV antidysrhythmic therapy.

--Ventricular dysrhythmias are indicative of myocardial irritability, and if antidysrhythmic therapy is not administered, recurrence of ventricular dysrhythmias is probable. Monitor for burns. Treat if indicated. --Electric current in contact with subcutaneous tissue can cause loss of skin integrity. Documentation. Include neurologic, respiratory and cardiovascular assessment before and after defibrillation. All code related information should be completed on the code summary flowsheet.

--Provides a record of pre-procedure patient status, nursing interventions, postprocedure patient status, and both expected and unexpected outcomes. Serves as a legal medical record of the events. Patient/family education. Assess understanding of past, current and future needs.

--Prepares patient and family for both expected and unexpected outcomes.

QUESTION:

During the procedure which is defibrillation, in what place would you put the paddle?