Defibrillation

OVERVIEW
Defibrillation is defined as the process wherein an electric shock is sent
to the heart to stop an arrhythmia with the use of an electrical device called
a defibrillator, resulting in the return of a productive heart rhythm. It 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).
It is often used in emergency cases for the purpose of correcting lifethreatening arrhythmias such as countering the onset of ventricular
fibrillation or pulseless ventricular tachycardia, which is a common cause of/
and cardiac arrest.
There are 4 major categories of defibrillators: Advance Life Support
(ALS) defibrillators which are used by healthcare professionals in hospitals
and ambulances, allow professionals to monitor the patient rhythm and
manually intervene if it is determined that a shock is required; Automatic
External Defibrillators (AEDs) which are designed for use by laypersons and
basic life support-trained personnel. They are widely available in airports,
schools,

casinos

and

other

public

areas; Implantable

Cardioverter

Defibrillators (ICDs) which are implanted directly into the patients chest and
designed to protect those patients at high risk of sudden death. Generally,
these are patients who have either a known medical condition that puts
them at risk, or have actually experienced an episode of VF/VT; and lastly,
Wearable Defibrillators which is considered an intermediate care option for
patients with a short-term known risk of sudden death or who are not
candidates for an implantable device.

When it comes to cardiac emergencies, the procedure must be

performed immediately after identifying that the patient is experiencing an
arrhythmia. You may identify this through signs like lack of pulse and
unresponsiveness; you may also confirm the arrhythmia in ECG tracings. You
may note randomly occurring chaotic electrical activity without discernable
depolarization or repolarization waveforms for V-fib. V-tach on the other hand
appears as wide complex tachycardia on the tracings.
PURPOSE
1. To eradicate life-threatening ventricular fibrillation or pulseless
ventricular tachycardia.
2. To restore cardiac output lost due to arrhythmias and re-establish
tissue perfusion and oxygenation.
DEFIBRILLATOR: Parts
Pulse Generator It is like a small computer that runs on a battery. It
checks your heart's electrical signals and delivers electrical energy
when it senses an abnormal rhythm.
Leads - are insulated wires that carry the heart signal to the pulse
generator. They also carry energy from the pulse generator to the
heart.
Electrodes - key part of any defibrillation system. The proper selection
and placement of electrodes can determine the effectiveness of the
procedure.
Design:
Metal paddle - with an insulated handle. It must be held in place on
the patient's skin while a shock or a series of shocks is delivered.
Before the paddle is used, a gel must be applied to the patient's skin,

in order to ensure a good connection and to minimize electrical

impedance.
adhesive pad when patient is at risk for arrhythmia.
Placement:
anterior-posterior scheme- It is the preferred scheme for long-term
electrode placement. One is placed at the left precordium and the
other behind the heart.
anterior-apex scheme - anterior electrode is placed on the right,
below the clavicle and another electrode is applied to the left side of
the patient, just below and to the left of the pectoral muscle
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.
2. Prepare for defibrillation
a. Turn power "ON". Defaults to 200 joules.
b. Select correct paddles- adult, pediatric or internal.
c. Prepare patient and/or paddles with proper conductive agent.

d. Checks

that

defibrillator

is

in

asynchronous

mode.

* If other than 200 joules desired, press "ENERGY SELECT" and

select desired amount
3. Turn on ECG recorder for continuous printout.
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.
5. *Press "CHARGE" on defibrillator front panel or on the Apex paddle.
Wait until indicator stops flashing to indicate fully charged.
6. *State "ALL CLEAR" and visually check that all personnel are clear of
contact with bed, patient and equipment.
7. *Check rhythm immediately before discharge.
8. Depress both buttons simultaneously and maintain pressure until
electrical current delivered. (Maintain 25 lbs/in2)
9. *Assess conversion of dysrhythmia.
10.
If first defibrillation unsuccessful, immediately charge paddles to
300 joules and repeat steps 2 through 9.
11.
If second defibrillation unsuccessful, immediately charge paddles
to 360 joules and repeat steps 2 through 9.
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.
13.
Clean defibrillator and paddles, discard supplies, and wash
hands.
14.
Documents procedure in patient record

or cardiac arrest

flowsheet.
RATIONALE/Nursing Considerations
1. May be mistaken for artifact or leads may be off.
2. Assess situation. If a second person is getting the defibrillator,
establish an airway and begin CPR.
a. Convert to pediatric size for children or internal if the patient is has
an open chest.

b. Enhances electrical conduction through subcutaneous tissue and

assists in minimizing burns.
c. Limit to paddle area.Use 2 joules/kg for children.
d. Will not fire if it is in synchronous mode due to absence of R wave
3. Establishes a visual recording and a permanent record of current ECG
status and response to intervention.
4. 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. This will charge unit with current.
6. Maintains safety to caregivers, since electric current can be conducted
from the patient to another individual if contact occurs.
7. ECG rhythm may change, ensure it is a rhythm that requires
defibrillation.
8. Premature release may result in failure to discharge energy. May also
be delivered by depressing discharge button on the defibrillator.
9. If rhythm has converted, must reassess.
10.
Immediate action increases chance for successful depolarization
of

cardiac

muscle.

Transthoracic

resistance

decreases

by

approximately 8 % with the second shock.

11.
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.
Necessary to maintain the delivery of oxygenated blood to vital
organs.
13.
Conductive gel accumulated on defib paddles impedes surface
contact and increases transthoracic resistance.
14.
Provides for completion of medical/ nursing records.
POST-DEFIBRILLATION CARE:
EVALUATE
1. Neurologic status. Reorient to person, place, and time.

2. Respiratory status. Auscultate lung sounds, Monitor rate, depth, &

quality of breathing. Administer oxygenation as ordered.
3. Cardiovascular status. Get 12-lead ECG and continue to monitor
rhythm and blood pressure, pulse and respirations frequently until
stable.
4. Initiate IV antidysrhythmic therapy.
5. Monitor for burns. Treat if indicated.
6. Documentation. Include neurologic, respiratory and cardiovascular
assessment before and after defibrillation. All code related information
should be completed on the code summary flowsheet.
7. Patient/family education. Assess understanding of past, current and
future needs.
RATIONALE
1. Temporary altered LOC occurs following defibrillation. Cerebral anoxia
or emboli may develop as a post-procedure complication.
2. Respiratory centers of the brain may be depressed as a result of
hypoxia.
3. Dysrhythmias may develop after defibrillation .
4. Ventricular dysrhythmias are indicative of myocardial irritability, and if
antidysrhythmic therapy is not administered, recurrence of ventricular
dysrhythmias is probable.
5. Electric current in contact with subcutaneous tissue can cause loss of
skin integrity.
6. Provides a record

of

pre-procedure

patient

status,

nursing

interventions, post-procedure patient status, and both expected and

unexpected outcomes. Serves as a legal medical record of the events.
7. Prepares patient and family for both expected and unexpected
outcomes.
PRECAUTIONS
1. Check all equipment for proper grounding to prevent current
leakage.

2. Disconnect

temporary

pacemaker

and

other

electrical

equipment.
3. Do not defibrillate directly over an implanted pacemaker.
Defibrillation may result in damage to equipment.
RELATED CARE
1. Support patient and family as necessary after defibrillation.
2. Clear defibrillator of remaining electrical current immediately; never
set charged defibrillator paddles down. Prepare equipment for future
use.
3. Support patient with CPR as appropriate.
4. Check possible causes of failure to convert ventricular dysrhythmias:
a. Defibrillator not functioning
b. Debris on paddles which impairs conductivity
c. Low amplitude fibrillatory waves, which can be associated
with

long-standing

ventricular

fibrillation,

acidosis

and

hypoxia; this requires CPR measures prior to defibrillation.

d. Frayed wires and faulty equipment.
5. Recognize the following differences for internal defibrillation:
a. Use sterile internal defibrillator paddles.
b. Use sterile gel pads between myocardium and defibrillation
paddles.
c. Charge defibrillator to prescribed voltage; a significantly
lower (15-30 joules) energy level is used.
6. Recognize the following changes for pacemaker defibrillation:
a. Turn off temporary external pacemaker.
b. Avoid placing defibrillator paddles over permanent pulse
generator or electrode.
COMPLICATIONS
1. Dysrhythmias Pulmonary edema
2. Cardiac arrest Pulmonary or systemic emboli
3. Respiratory arrest Equipment malfunction

4. Neurologic impairment Death

5. Altered skin integrity

Oropharyngeal airway
Overview
An oropharyngeal airway is an ideal way to restore the patency of an
airway that's become obstructed by the tongue in an
unconscious patientor to aid in ventilation during

a code.

This device, which is easily inserted at the

bedside,

can

also

be

used

to

facilitate

suctioning in an unconscious or semi-conscious

patient and can prevent him from biting his tongue
and the inside of his lips and cheeks (though it's not
indicated for someone who's actively seizing).
Oropharyngeal airways are generally made of
plastic, and have a semicircular design that conforms to the

hard
curvature

of the palate. When properly inserted, an oropharyngeal airway will hold the
tongue away from the posterior pharynx so air can pass through and around
the device. To determine the correct size for a patient, measure the

oropharyngeal airway from the corner of the patients mouth to the angle of
the jaw.
Types
Berman airways- It has channels along each side that allow a suction
catheter or endotracheal tube to slide into the pharyngeal space
Guedel airways - It is a tubular device. While its central lumen can be
used for suctioning, it can't support an ET tube.
COPA (Cuffed Oropharyngeal Airway) is a variant with an inflatable cuff
to seal the oropharynx and has a universal connector attached to the
bite block to allow ventilation limited popularity and scope.
Contraindication: Using an oropharyngeal airway on a conscious patient
with an intact gag reflex is contraindicated. If your patient has the ability to
cough they still have a gag reflex and you should not use an oral airway. If
the patient has a foreign body obstructing the airway, an oropharyngeal
airway should also not be used.
Parts
Flange - When properly inserted, the flange is the piece that
protrudes from the mouth and rests against the lips, preventing the
device from sinking into the pharynx.
Body - follows the contour of the roof of the mouth, and will curve
over and rest on top of the tongue.
Tip- The distal end; sits at the base of the tongue
Steps in inserting: Oropharyngeal airway
Before inserting an oral airway, make sure you select the appropriate
size. Large adults require a size 5 - 6; medium adults require a size 4 5; and small adults need a size 3 - 4.

 To get the right size, use the device itself as a measure. When you
place it on the patient's cheek with the flange parallel to his front
teeth, the tip of the oropharyngeal airway should reach no further than
the angle of the jaw. If the airway is too long, it could obstruct
breathing by displacing the tongue against the oropharynx. If it's too
short, it won't be able to hold the tongue away from the pharynx, and
patency won't be restored.
Before insertion, suction the patient's mouth and pharynx to remove
any secretions. Place the patient in a supine or semi-Fowler's position,
and tilt the head back, unless this is contraindicated. With gloved
hands, remove dentures (if they're present), and prepare to insert the
device.
1. Open the patient's mouth using the cross-finger method, placing your
thumb on the patient's bottom teeth and your index finger on the upper
teeth, then gently pushing them apart.
2. With the patient's mouth open as wide as possible, begin inserting the
airway upside down, with the curvature toward the tongue to prevent
pushing the tongue back into the pharynx. Avoid dislodging teeth or
damaging mouth tissue by gently sliding the airway over the tongue
toward the back of the mouth.
3. When the airway reaches the back of the tongue, rotate the device 180
degrees. The tip should point down as it approaches the posterior wall of
the pharynx, and the curvature should follow the contour of the roof of the
mouth. An alternative method is to hold the airway in its normal upright
position and use a tongue blade to hold the tongue down. Slide the airway
carefully over the tongue and into position.

4. If the patient gags or appears to be gasping for air after insertion, remove
the airway immediately. Recheck the size before attempting reinsertion.
5. If there are no obvious problems, check to be sure the patient's lips and
tongue are not between the teeth and the device. You'll also check to see
that ventilation is taking place, of course, by auscultating the lungs and
observing that the chest rises equally on both sides.
If

your

patient

isn't

breathing

spontaneously

or

is

breathing

inadequately, initiate artificial ventilation using a mouth-to-mask or

Ambu-bag and mask technique.
As a general rule, the airway will stay in place without securement by
keeping the patient's head in a tilted position. Taping an oropharyngeal
airway in place can lead to aspiration if the patient starts to gag or
cough and can't expel the device.

Complications:
gagging, vomiting and aspiration
soft tissue trauma to the tongue, palate and pharynx
biting down on the hard surface can injure the teeth