DEFIBRILLATOR

Course Code: 07.02.702 Dr. Awadh Al-Kubati

Cardiac Physiology
 The heart is a synchronized double pump
 Right part pumps blood to lungs, left part pumps to body organs
 Heart pumps blood effectively only when contractions of all muscle fibers are precisely synchronized
 Several conditions compromise the heart’s pumping ability
 Some, like Ventricular fibrillation (VF) and rapid ventricular tachycardia (VT), can be corrected by an
electric shock
 Others, like bigeminy, are not shockable – must be avoided by careful reading of ECG before shock
Defibrillator Basics
 Defibrillators apply electric shock to establish more normal cardiac rhythm in patients
experiencing ventricular fibrillation (VF) or another shockable rhythm
 Brief pulse of energy intended to cause simultaneous depolarization of all myocardial fibers
 Objective: to terminate tachycardic arrhythmias so that SA-node resume primary pacemaker
function again
 The earlier defibrillation occurs, the better the chances for survival
 For every minute that passes after the onset of VF, the chance of survival decreases by 10%
DC Defibrillator Components
 Energy supply via rechargeable batteries that are charged by mains connection
 Capacitor as energy store (E = ½ C V2)
 Charging circuit for capacitor
 Discharge circuit to deliver current pulse at different, preselectable energy levels
 Pulse range: 3-8 ms at current of 10–27A (internal) and 22–60A (external)
 ECG monitoring and analysis to ensure shock is applied for only shockable arrhythmias
Defibrillator Waveform
 Defibrillator waveform is a graph of the current delivered versus time
 Shape of wave dictates how much energy is supplied to patient and over what period this energy is
administered
 Optimum amount of energy for defibrillator pulse is amount of energy which causes least
myocardial damage
 Until recently, all external defibrillators used monophasic waveforms
 Most, if not all, defibrillators entering the market today offer biphasic waveforms
Defibrillator Waveform: Biphasic Advantages
 Studies suggest that patients who receive biphasic shocks have a more normal post-
shock rhythm than patients who receive monophasic shocks
 More effective on first shock and gentler on heart with less dysfunction
 Defibrillation success achieved with lower energy and voltage
 Device-dependent amount of energy is 150–200 J for first defibrillation and 200–360 J for all
others, whereas it is always 360 J with monophasic wave
 Whereas optimum energy flow in monophasic defibrillation is in range 30-40 A, with
biphasic shock it is in range 15-20 A
Thoracic Impedance
 Definition: resistance in body which opposes energy pulse from defibrillator
 Ranges between 15 and 150 Ω; usually it is 70–80 Ω
 Must be taken into consideration when necessary energy is administered, as patient’s
thoracic impedance is crucial to amount of energy required
 Because impedance varies to large degree in humans, dynamic adaptation of energy
pulse waveform (e.g., peak-to-peak voltage and pulse duration) is important feature
 Modern devices automatically measure thoracic impedance and take into account before
defibrillation to deliver energy more accurately
Defibrillator Types
 Divided into manual, semiautomated, and fully automated external defibrillators, in
addition to defibrillator implants
 Semiautomated: user is shown defibrillation recommendation, but trigger of pulse is done by user
 Fully automated: everything is done by device
Automatic External Defibrillator (AED)
 AEDs differ from conventional manual defibrillators in that AEDs can analyze the ECG
rhythm to determine whether defibrillation is necessary
 This eliminates need for user to interpret cardiac rhythm before delivering shock
 AEDs are designed to be used primarily by first responders to cardiac emergencies, who may not
be fully trained in cardiac life support
 Semiautomated operation
 Device determines defibrillation settings but administration of pulse is triggered by user
 Fully automated operation
 Everything is done by device
Cardioversion
 Operating modes: synchronous and asynchronous operation
 Synchronous: heart’s own pulses are taken into account (QRS triggering)
 Asynchronous: reserved for strictly emergency defibrillations
 Synchronized defibrillation is referred to as cardioversion
 Pulse of energy is triggered by R wave in the ECG
 Synchronization is carried out to prevent pulse being delivered in vulnerable phase (T wave) and to
prevent risk of ventricular fibrillation being triggered
 Application: implantable cardioverter-defibrillator (ICD)
Electrodes and Contact Agents
 Adhesive electrodes (pads) preferred
 Quicker to administer the first pulse of energy
 Possible to defibrillate from safe distance and without leaning over patient
 Gel pads: contact gel included – avoid risk of arcing and short circuit
 Normal plate electrodes (paddles)
 Contact gel needed between skin surface and metal plate to reduce skin impedance and better
electrical contact and to prevent burns
 AAMI standard recommends minimum area of 150 cm2
 Diameter of common electrodes is 8–12 cm for adults
Methodological Notes
 All commercially available defibrillators are operated the same
 As a rule, visual and/or audible signal generated when defibrillator is operational (when
capacitor is charged)
 Electrodes (with gel) placed firmly on thorax and pressed on, and preselected energy dose
is triggered from handles
 Practice of performing defibrillation 3 times within a minute using mono- and biphasic
defibrillators is obsolete
 Replaced by delivery of single shock at full energy (one-shock strategy)
 Monophasic: 360 J, Biphasic: at least 150–200 J advised
 Following shock, cardiopulmonary resuscitation (CPR) performed for 2 min before
administering next shock if necessary
 Monophasic defibrillators: energy level is kept at 360 J
 Biphasic defibrillators: energy level is successively increased
Possible Complications of Defibrillation Use
 Induced ventricular fibrillation as a result of incorrect triggering, which can ultimately
lead to asystole (cardiac arrest)
 Currents > 10mA flowing through the heart can cause fibrillation in ventricles
 Post-defibrillation arrhythmias
 Ventricular and supraventricular extra-systoles and ventricular flutter
 Myocardial necrosis (death of heart muscle tissue)
 Arterial embolisms
 Burns and irritation of the skin, for example, due to insufficient amount of electrode
contact paste being used on electrode surface
 Injury to lung, collapsed lung, or bleeding in lung cavities
 Developing hole in blood vessels
Technical Safety Aspects: Use
 Avoid direct contact with electrodes (life-threatening), conductive contact with patients or
people (safe distance)
 There should be no moisture on patient’s skin (electrical bridge), and patient should also be
positioned to be electrically isolated
 Avoid using too much electrode contact paste on paddles
 Chance of electrical bridge forming with risk of short circuiting output
 Only perform cardioversion if ECG is free from artifacts and if reliable ECG monitoring is
possible
 All other devices connected to patient must be defibrillation-proof
 Otherwise, they must be disconnected from patient during defibrillation
 Caution should be exercised with patients with energized implants
 Functioning of implant may be restricted or suspended
 Implant itself may be damaged or even become unusable.
Technical Safety Aspects: Device
 Defibrillators must only be used in explosion-proof atmosphere
 Disconnect devices which are not defibrillator proof from patient
 Equipment labeled according to DIN-IEC 601 as defibrillator proof
 Maximum energy 360 J
 Trigger buttons only on both paddles (connected in series)
 Protective circuits: ensure reduced power setting when defibrillator is switched off
and ensure energy recovery no later than 1 min after defibrillator charging
 Because of their unforeseeable and frequently changing use, defibrillators should
always be connected to mains electricity at their device base locations so they are
operational and ready for use
Power Supply (charge unit)
Oscillator
Switching Power Amplifier
Output and Control Circuit
Defibrillator Compete Circuit