31st Annual International Conference of the IEEE EMBS

Minneapolis, Minnesota, USA, September 2-6, 2009

Defibrillator Synchronization Tester

Fatma N. Demirbilek, Mike Krajnak, and George Stolarczyk

Abstract—A defibrillator sync output signal connector The delivery of a therapeutic dose of electric current to
provides an ECG synchronization signal that can be used by the heart during the R-wave of the cardiac cycle is the key
some defibrillators for the purpose of performing to the successful conversion of supraventricular
synchronized cardioversion [1]. This process is used to stop
an abnormally fast heart rate or cardiac arrhythmia by the
tachyarrhythmias to normal sinus rhythm. It is critical to
delivery of a therapeutic dose of electric current to the heart have the patient monitor and the defibrillator synchronized
during the R-wave of the cardiac cycle. Timing the shock to properly during cardioversion. To ensure the proper
the R-wave prevents the delivery of the shock during the synchronization, the patient monitor’s defibrillator sync
vulnerable period of the cardiac cycle, which could induce and analog output function need to be checked. Note that
ventricular fibrillation [2]. GE patient monitors include a the synchronization is not required in the most frequent
selectable analog output feature, which provides an analog
ECG or arterial blood pressure signal. The blood pressure
uses of defibrillators: ventricular fibrillation and in AEDs.
signal can be used to synchronize balloon pumps to provide But whether the clinical use is frequent or infrequent is not
cardiac assist to post-MI patients with poor injection fraction. as important to us as much as the simple fact that
Proper operation requires the defibrillator sync and analog defibrillator sync testing is required. Checkouts are done
output function to be checked. Checkouts are typically done during planned maintenance and after major part
during planned maintenance and after major part replacements such as a patient monitor’s main CPU board.
replacements such as patient monitor’s main CPU board.
Checking out defibrillator sync signals could be done using a
The GE defibrillator sync tester can be used as an easy
GE defibrillator sync tester. The defibrillator sync tester to use, portable and low-cost solution when checking out
provides a loop back path for the defibrillator sync signals to the defibrillator sync/analog out signals on the patient
be displayed on the patient monitor screen and eliminates the monitors.
need for an external oscilloscope.

I. INTRODUCTION II. THEORY

V ENTRICULAR fibrillation (VF) and ventricular

tachycardia (VT) are the most common causes of
sudden cardiac arrest. During sudden cardiac arrest, the
The purpose of the defibrillator sync tester is to show
that the ECG, arterial blood pressure, and marker input
signals from the defibrillator sync out connector on the
heart suddenly and unexpectedly stops beating normally; patient monitor to the defibrillator are accurate.
blood stops flowing to the vital organs including the brain We do this by first providing a set of known reference
and as a result the individual stops breathing and collapses ECG signals into the patient monitor. The monitor
into unconsciousness. Sudden cardiac arrest could happen processes the ECG signals normally and sends the arterial
regardless of preexisting heart diseases [3,4]. Although blood pressure or ECG signal to the defibrillator sync
sudden cardiac arrest is not the same as a heart attack, output connector. The patient monitor also generates a
which is the result of a loss of blood supply to the heart marker out signal that indicates the peak of the R-wave
muscle, a heart attack does increase the risk for sudden within 35 milliseconds of each ECG QRS complex per
cardiac arrest. The time and mode of death are unexpected. AAMI: EC13 [9]. The test procedure then consists of
Sudden cardiac death can be defined as any cardiac death comparing relevant input and output signals to ensure they
occurring out of the hospital, taking place in the are the same.
emergency room or dead on arrival in the emergency room The general procedure relies on supplying reference
[5-7]. signals using a patient simulator. Then the patient
Sudden cardiac arrest is survivable. Defibrillation is the simulator ECG input and defibrillator sync output signal
standard curative response to sudden cardiac arrest. The can be displayed and compared. Current practice is to use
sooner defibrillation is provided after cardiac arrest, the an oscilloscope to display both signals comparison of the
greater the likelihood that the patient will survive a signals.
ventricular fibrillation or ventricular tachycardia event. It The defibrillator sync tester replaces the need for an
has been demonstrated that within the first ten minutes of a oscilloscope by selectively replacing one of the patient
sudden cardiac arrest, a patient's survival rate improves 10 ECG input leads with a defibrillator sync signal. The
percent for every minute that is saved by getting the patient monitor will then display the original ECG signal
defibrillator to the patient [8]. and the looped back signal sent from the defibrillator sync

978-1-4244-3296-7/09/$25.00 ©2009 IEEE 3012

tester. In effect, we are using the patient monitor as the III. METHOD AND TEST INSTRUCTIONS
oscilloscope.
Specifically we loop back the signal from the A. Required equipment
defibrillator sync output and connect to the ECG lead V 1) GE Analog Out/Defib Sync Tester (Figure 2).
input. The analog signal on the patient monitor’s
defibrillator sync output uses a scale of 1V out per
millivolt of ECG signal. The defibrillator sync tester
incorporates a voltage divider (Figure 1) to rescale the
defibrillator sync signal back to an acceptable range before
it can be sent back to the patient monitor.

Fig. 2. GE Analog Out/Defib Sync Tester

2) Appropriate analog output cable for the patient

monitor under testing.
Note: It is recommended that the ends of the un-
terminated analog output cable are stripped and
tinned with a soldering Iron.
3) Multiparameter patient simulator (with ECG and
Fig. 1. Tester Circuit Diagram arterial blood pressure).
Note: The patient simulator may have to be isolated
The defibrillator sync tester uses a 10Ω and 10kΩ from ground or run on battery power to eliminate
resisters in series such that the output voltage is given by: noise while doing this test.
4) Arterial blood pressure patient cable.
R1 5) Lead ECG patient cable and leadwires.
Vout = Vin
R1 + R2 B. Setup and Test Procedure
1) The defibrillator sync tester should not be used while
10Ω the monitor is connected to a patient.
Vout = Vin Note: Before starting the test procedure, verify that
10000Ω + 10Ω
pace detect is off and ECG filter is in monitoring
mode. The patient monitor user manual can be
Vout ≈ 0.001 ⋅ Vin referenced to turn off the pacer detect and monitoring
mode.
The defibrillator sync tester also includes a rotary switch 2) Connect the patient simulator to the 5 lead ECG cable
to allow selection of any of the defibrillator sync connector which is connected to the monitor under test. Set the
signals to substitute for the lead V signal: ECG, arterial simulator to Normal Sinus Rhythm (NSR) 80 bpm.
blood pressure, or marker. 3) On the patient monitor if the second waveform is not
Thus if we want to compare the patient simulator the V lead, set waveform 2 to the V lead.
generated ECG lead I, we select the lead I display on the Note: The patient monitor user manual can be
monitor and set the rotary switch to the ECG position and referenced to set waveform 2.
display the lead I output as the lead V input signal on the 4) Connect the arterial blood pressure cable from the
patient monitor. For example in Figure 4 the patient simulator to the patient monitor. Zero the pressure on
simulator lead I is shown on top of the display and the loop the simulator and on the patient monitor. Set the
backed lead 1 is displayed as lead V. simulator to 120/80 BP dynamic waveform output.
Note: The patient monitor and simulator user manuals
can be referenced to zero the pressure.
5) On the patient monitor set the BP ART scale to 160.

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 Note: The patient monitor user manual can be D. BP Test
referenced to set BP scale. 1) Set the selector switch of the tester to BP.
6) Connect the analog output/defib sync cable to the 2) On the patient monitor observe that the V lead
analog output/defib sync port on the patient monitor. waveform matches the BP waveform (Figure 5).
7) Connect the bare wires from the analog output cable to
their corresponding connections on the tester. Connect
the tester ground to the analog out ground. Use the
patient monitor service manual to determine the
ground terminal and wire.
Note: “Mark out” from Analog output/ Defib sync
cable connects to “MARK” on the tester.
Note: The patient monitor’s service manuals can be
referenced for the test cable pinout and color codes.
8) Plug the RL ground cable from the tester into the
patient simulator’s RL terminal. Ensure both patient
lead wire and the tester ground cable are connected to
the RL terminal.
9) Disconnect the V lead of the patient cable from the
simulator and connect it to the “V LEAD” terminal of
Fig. 5. BP test results
the tester (Figure 3).
E. Marker Out Test
1) Set the selector switch of the tester to “MARK”.
2) On the patient monitor observe that the V lead
waveform has a marker pulse corresponding to the R
wave of the primary ECG waveform (Figure 6).

Fig. 3. Tester connectivity to the patient simulator

C. ECG Test
1) Set the selector switch of the tester to ECG.
2) On the patient monitor observe that the V lead
waveform matches the primary ECG waveform Fig. 6. Marker Out test results
(Figure 4).
F. Marker In Test
1) Set the selector switch of the tester to ECG.
2) Connect the analog output/ defib sync cable “Marker
in” and “Marker out” wires together by connecting
both to the “MARK” on the tester.
3) On the patient monitor verify markers are present on
the ECG waveform (Figure 9).
Note: Markers are shown below from the GE DASH
patient monitor. The marker display may vary
depending on the model of the monitor.

Fig. 4. ECG test results

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 [3] R. J. Myerburg, A. Castellanos, “Cardiac arrest and sudden cardiac
death,” In: Braunwald E, ed. Heart Disease: A Textbook of
Cardiovascular Medicine. Philadelphia, W. B. Saunders; pp. 890-
931, 2001.
[4] D. S. Pinto, et al. “Sudden cardiac death,” In: Fuster V, ed. Hurst’s
The Heart. New York: McGraw-Hill; pp. 1015-1048, 2001.
[5] R. F. Gillum, “Sudden cardiac death in Hispanic Americans and
African Americans,” Am J Public Health. 87, pp. 1461-1466,1997.
[6] R. F. Gillum, A Folsom, R. V. Luepker, et al. “Sudden death and
acute myocardial infarction in a metropolitan area,” 1970-1980: The
Minnesota Heart Survey. N Engl J Med. 309, pp. 1353-1380, 1983.
[7] R. F. Gillum “Sudden coronary death in the United States 1980-
1985”. Circulation; 79, pp. 756-765, 1989.
[8] M. S. Eisenberg, B. T. Horwood, and R. 0. Cummins et al, “Cardiac
arrest and resuscitation: A tale of 29 cities,” Annals of Emergency
Medicine, 19, pp. 179-186, 1990.
Fig. 7. Marker In test results [9] Cardiac monitors, heart rate meters, and alarms, American National
Standard ANSI/AAMI EC13, Arlington, VA, Association for the
G. Test complete Advancement of Medical Instrumentation, 2002.
If any of these tests fail, troubleshoot analog output or
remove the patient monitor from the service.

IV. CONCLUSION
In general we have shown that a simple tester that
leverages a patient monitor’s built in display capability can
be an effective and inexpensive alternative to an
oscilloscope for testing the defibrillator sync output of a
standard patient monitor.
There are some drawbacks to the tester. It is highly
specialized to this one test. It relies on a visual comparison
of the signals. At a typical ECG display time scale of
25mm/sec a difference of 35ms is slightly less then 1mm
and can be difficult to detect. However, visual comparison
has been judged to be sufficient for use in the previous
procedures. Even in the case when an oscilloscope is used,
the ability to quantify the timing difference in two
channels is not used. In the case where more general
purpose and/or more quantitative measurements are
required an oscilloscope is still the instrument of choice.
But these cases are expected to be infrequent.
As a result GE now manufactures and sells a standalone
defibrillator sync tester. We expect the tester to make it
easier to execute the defibrillator sync test procedure for
service providers. We also hope to reduce the possibility
that the procedure might be inadvertently missed. As a
result signals required to operate a defibrillator are
properly verified.

ACKNOWLEDGMENT
We would like to acknowledge Mike McLeod for design
and research support.

REFERENCES
[1] R. J. Fairbanks et al. “Usability Study of Two Common
Defibrillators Reveals Hazards,” Annals of Emergency Medicine, 50
(4), pp. 424-432, 2007.
[2] E. H. Shortliffe et al. “Medical Systems and Rehabilitation,” Human
Factors and Ergonomics Society, 2004.

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