DEFIBRILLATOR 1. Introduction Defibrillator is a process in which electronic device sends an electric shop to the heart to stop an extremely Rapid irregular Heartbeat and restore the normal heart rhythm, Defibrillation is a common treatment for life threatening cardiac dysthythmia ventricular fibrillation and pulseless ventricular tachycardia, 2. Definition Defibrillator is a device that delivers a therapeutic dose of electrical energy (electrical shock) to the affected heart fever related hot or other shockable Rhythm to force the heart to produce more normal cardiac rhythm, » Qbiective Define defibrillation Describe need and history of defibrillation Describe the principle and mechanism of defibrillation Types and classes of defibrillator VVVV 4. Purpose of defibrillation Defibrillation is performed to correct life threatening fibrillation of the heart which could result in cardiac arrest. It should be performed immediately after identifying that the patient is experiencing a cardiac emergency has no pulse and is unresponsive. 5. Principle of defibrillator > Energy is storage a capacitor is charged at relatively slow rate from AC line.Energy stored in capacitor is then delivered at a relatively Rapid rate to chest of the patient. Simple arrangement involved the discharge of capacitor energy through the patient's on resistance. The discharge resistance which the patient represents as purely ohmic resistance of 5 to 100Q approximately for a typical electrode size of 80 cm? This particular waveform figure is called lower wave form. The pulse width of this waveform is generally 10ms. hanism lato. Fibrillation cause the heart to stop pumping blood leading to brain damage Defibrillator deliver a brief electric shock to the heart which enables the heart natural pacemaker to regain control and establish a normal heart rhythm. Steps of defibrillation Give 2 min CPR before analysis Power on ADE Attach electrode pad Check rhythm Clear Give shock (120 - 200 J) Resume CPR for 2 minutes before analysis cardiac Rhythm again Consider giving vasopressor / anti arrhythmias derive subsequent shock ‘ypes of defibrillators . Manual external defibrillator . Manual internal defibrillator . Semi-automated external defibrillator4. Automated external defibrillator (AED) 5. Implantable cardioverters defibrillators (Automated internal cardiac defibrillator) 6. Wearable cardiac defibrillator A. Manual external defibrillator Electrode placed directly around the heart area of chest higher voltage required then internal defibrillator. B. jal defibi for > Just like normal defibrillator > Electric charge is usually formed in by internal pedals in closed or direct contact with the heart. > These devices are mainly used in operating theatre where the chest can be opened or being treated by a surgeon. C. Semi-automa' rnal del lator > Carries features of both full manual as well as automated units of defibrillator. > Has a ECG display and manual override in it. > Generally used by paramedics and emergency medicine techniques. D. Implantable cardioverter defibrillator (ICD) Automated internal cardiac defibrillator (AICD) > An implanted device that detects and terminates life-threatening episodes of VF /VT in high-risk patients. E. Wearable cardiac defibrillator > Life vestAutomated external defibrillator > AEDis portable type of external defibrillator that automatically diagnosis the ventricular fibrillation in a patient. > Automatic refers to the ability to autonomously analyze the patient condition. > AED is provided with self adhesive electrodes instead of hard held paddles. Paddle placement 4 positions > Anterior lateral most convenient > Anterior posterior > Anterior left intra scapular > Interior right interscapular Anterior lateral position > On right of sternum below clavicle (2™ & 3" ICS) other left 4" or S*ICS mid axillary line. Reversing paddle markings “sternum and apex” does not affect defibrillation Paddles placed along axis of heart AP placement used in children with adult paddles v v Paddle size Adult : large Paddles, 10-30 cm diameter Pedriatic _: small paddles <1 yr Infant <10kg- 4.5 om Children > 10kgs - 8 cmMonitoring Monitoring that patient stay in converted rhythm Keep patient well oxygenated Check serum K* & Mg" levels Maintain acid base balance Get 12 lead ECG after procedure Check for chest pain and access. Get CPK and troponin done Access patient’s skin VVVVVV VV Factors to consider during defibrillation . Duration of VF The longer VF lasts the harder it is to cure The quicker the better Shock early shock often Likelihood of resuscitation decrease by 7 to 10% with every passing minute vVvVvV Vv 2. Myocardial environment slash condition Hypoxia, acidosis, hyperthermia, electrolyte imbalance drug toxicity impede conversion 3. Heart size body type Pediatric requirement lower than adult 4. Use largest size paddles > Completely chest without pedals lowerly each other > In paediatric minimum of 3 cm distance between pads Note: Small Paddles : concentrate the current bum heart Large paddles : reduces current densityPrevious counter shock Repeat shock lower resistance Give one shop at a time and then continue CPR Subsequent shop either equal or higher energy vvvys ~ Paddle size 7. Paddle placement > Inpacemaker/ ICD at least 12 cm from general 90 degree to AICD electrode avoid placing bets directly over no delay in defibrillation. Paddles skin interface Only gel should be used (ECG gelly) Cream, paste, saline pads Gel decrease resistance to the flow of current Never use alcohol vve vv Paddle contact pressure Firm pressure of 25 Pounds In child <10kgs — 3 kg pressure In large children > 10kgs — 5kg pressure Deflate lung, shortens the path of current Do not loosen paddles they slip vVvvvvVV®? CARDIOVERSION Cardioversion is the delivery of energy that synchronized to the large R waves or QRS complex. > Ituses energy less that that used for defibrillation in shockable SCA > Avoid delivery shock during repolarization period (T wave on ECG) Indications > Atrial flutter > Atrial fibrillation > Wide complex tachycardia of uncertain typeContra indications > Digitalis induced dysthythmias > Refractory to cardioversion > May precipitate to more serious ventricular dysthythmias > Juctional tachycardia or ectopics/ multifocal atrial tachycardia > Automatic foci not reverted by cardioversion Cardioversion Dose/ Details Synchronized Cardioversion Initial recommended doses > Narrow regular: 50-100 J > Narrow regular —: 120-200) > Wide regular :100J > Wide irregular __: defibrillation dose (not synchronized) Cardioversion can be elective or Emergency Elective Cardioversion Preprocedure consideration History and physical examination (neurological) Concurrent illness Current medication including anticoagulation Fasting 6hrs Correct electrolyte imbalance Obtain 12 lead ECG Digoxin to be withheld for 48 hrs Continue other medications Transthoracic Echo or TEE VVVVVVVVVCardioversion Anesthetic Drugs IV sedation : Proprofol, Etomidate, Thiopentone, Benzodiazepines Etomidate : Haemodynamically mor4e stable myoclonus 40% interference with ECG Interpretation Steps Check environment at procedure site Turn on defibrillator Anesthetic technique as required Apply electrodes Press syne control Select application energy level ‘3° shout and shock Deliver shock VVVVVVVY Post Procedure monitoring > Record delivery energy and result > Continuous ECG monitoring > 12 Lead ECG > If successful response check for peripheral pulses, BP, airway patency and Loc. Inspect skin under the pads > Ifnot successful, check and reassess. v Complications of Cardioversion > Systemic embolization > Post shock cardiac arrhythmias « Asystole ¢ Heart block Atrial / ventricular ectopias © Ventricular tachy arrhythmias > Translucent ST & T wave changesRisks in Defibrillation > Skin burns form the defibrillation paddles are the most common complication of defibrillation > Other risks include injury to the heart muscle, abnormal heart rhythms and blood clots.BIBLIOGRAPHY 1) Willis A Tacker “External Defibrillators” in Biomedical Engineering Handbook, J. Bronzino , CRC Press, 1995. 2) En.wikipedia.org/wiki/ defibrillation 3) http:/Avww.slideworld.org/viewslides.aspx/defibrillator 4) Brunner & Sudharth’s Textbook of Medical Surgical Nursing. 5) Basavanthappa BT, Essential of Medical Surgical Nursing, Published by Jaypee- 567.