Defibrillation
Contents from the
 ONTARIO BASE HOSPITAL GROUP
EDUCATION SUB-COMMITTEE
To be certified in Defib
1. Be employed
by an Ontario Ambulance
Service as a Paramedic
2. Have approval of the Base Hospital Medical
Director
3. Have a current BCLS basic rescuer certificate
On completion of the SAED Course, the PCP will be certified to
perform that controlled act under the direction of the Base
Hospital Medical Director.
Successful recertification must occur annually.
The guidelines for certification, recertification and decertification
have been developed by the Ontario Base Hospital Group (refer
to the ALS standards).
Using the Semi-Automatic External Defibrillator (SAED) or Manual
Defib and mannequin, you will be able to correctly perform the
procedures for cardiac arrest including proper SAED pad
placement, rapid defibrillation, trouble shooting and
maintenance procedures. Emphasis will be placed on safe
operation of the SAED while following approved protocols. The
protocols will cover management of:





VSA patients with shockable rhythms e.g ?
VSA patients with non-shockable rhythms e.g?
Treatment of cardiac arrest associated with hypothermia
Treatment of cardiac arrest associated with blunt/pen trauma
Treatment of cardiac arrest associated with airway
obstruction
Also critical in this
module
• Safety
• Airway management
• Ventilation and 1 and 2 person CPR
• Reporting procedures for cardiac arrest
• Cardiac physiology and anatomy
• ECG monitoring and post arrest care
Defibrillation: You will
be able to discuss
•types of cardiac arrest and their initial
management
•defibrillation and the indications for use of
the SAED
•possible outcomes of defibrillation
•safeguards necessary to ensure operator
and patient safety when using the device
A paramedic is…..
“A person employed by, or a volunteer in, an ambulance
service who meets the qualifications as a paramedic as
set out in the regulations, and who is authorized to
perform one or more controlled medical acts under the
authority of a Base Hospital Medical Director, but does
not include a physician, nurse or other health care
provider who attends on a call.”[1]
The SAED/MDefib provider can only perform controlled
acts under standing orders from a Base Hospital or as
directed by Base Hospital Physician
[1] Ambulance Act, Revised Statutes of Ontario, 1990,
Chapter A. 19, August 16, 2002
Needed for a SAED
program in Ontario
 Base Hospital
 Base Hospital Physician
 Certified Ambulance Service
 Central Ambulance Communications
Centre (CACC)
• Quality assurance program
MEDICAL / LEGAL
CONSIDERATIONS
Guidelines for protection against "negligence" when
functioning as a Primary Care Paramedic include:
1.performing to one’s level of training within the
Paramedic’s scope of practice outlined by the Base
Hospital
2. complying with protocols
3. documenting accurately
4. checking equipment
5. reporting problems
Now to the fun stuff!
Since 1988 prehospital care in Ontario has included automated and semiautomated defibrillation. As CPR and defibrillation work in tandem, a
greater percentage of cardiac arrest victims can be saved if treated
quickly following a collapse. As the diagram below illustrates, EVERY
SECOND COUNTS
Remember this????
And this??
Chain of SurvivalPurpose
EARLY ACCESS
to 911 system. To get medics moving.
EARLY CPR
to help circulated oxygen to the patient's heart and
brain.
EARLY DEFIBRILLATION
May be AED on scene, such as health clubs, fd etc
shocks to restore normal heart rhythm.
EARLY ADVANCED CARE
provided by als or hospital staff.
Remember….Time is
Muscle!
Ventricular Fibrillation
• Ventricular Fibrillation (VF) presents with chaotic
electrical activity as the result of multiple ectopic
foci originating in the ventricles.
• There are no organized QRS complexes.
• This lethal rhythm is seen in approximately
seventy percent of sudden cardiac arrests.
• Fine and Coarse VF are differentiated by the
amplitude of the activity.
Fine VF has an amplitude of less than 5 mm (1
large square) whereas coarse VF is greater that 5
mm in amplitude
Ventricular Tachycardia
Ventricular Tachycardia (VT) is
characterized by a wide complex, rapid
rate that is generally regular in nature.
May be as slow as 140 and as fast as 340
May deteriorate to Vfib
Can be with or without a pulse!!
Causes of Vfib/Vtach
electrical instability
respiratory failure
potassium imbalance
electrocution
near drowning
irritation, inflammation or injury of electrical
conduction system
temperature extremes
chest wall trauma
What is this??
Artifact!!
(usually patient movement!)
or 60 cycle interference from….. ???
or from Ambulance movement
Or from Poor contact between skin and electrode, or defective cables, which
cause chaotic and irregular deflections in the baseline which may be
mistaken for ventricular fibrillation
Intervention (Stop vehicle to analyze-DO NOT TOUCH PATIENT!)
Every attempt must be made to correct or eliminate the presence of artifact
before the rhythm is identified, and every precaution must be taken to
ensure that what is seen as ventricular fibrillation is not artifact in disguise.
Anticipating Cardiac
Arrest
Patient complaining of chest discomfort: past history of MI,
Nitroglycerin (NTG) taken with minimal or no relief
heart rate < 50 or > 120 beats per minute
Electrical Instability of the Ventricles
Decreased cardiac output
What is defibrillation?
Defibrillation is the delivery of Direct Current (DC)
through the heart muscle. Defribrillation depolarizes
the entire myocardium. This is generally followed by
a brief period of asystole. The aim is that following
defibrillation the heart will repolarize uniformally and
that the heart’s intrinsic pacemaker, the SA node, will
resume pacing the heart.
Remember CPR does not return the
hearts rhythm to normal.
What is the defibrillator?
• Energy source
• Conduits (paddles or cables for pads)
• Defibrillator is a capacitor that stores
NRG
• Consists of capacitor, high voltage
power supply and delivery conduits
(pads or paddles)
General Considerations
Wet patients
(drowning etc)
Medication patches
Implanted pacemakers
Young patients
Excessive chest hair
Monophasic vs Biphasic
Monophasic defibrillators deliver the energy in one direction
and therefore require higher energy to defibrillate the heart.
Biphasic defibrillators deliver energy in two directions. For
half the shock energy is delivered in one direction then the
energy is delivered in the opposing direction for the latter half
of the shock. This allows for lower peak energies to be
delivered.
The success of defibrillation
depends on:
• Time elapsed since arrest
• Quality of electrical contact between
•
•
•
•
•
treatment electrode and chest wall
Myocardial oxygenation during CPR
Chest wall size
Defibrillating energy
The total number of shocks delivered
The time interval between successive shocks
(chest wall impedance to electrical flow drops
with successive shocks-max 2 minutes
between).
.
Monitor/Defibrillators must be
brought in on the following
VSA
call types
Unconscious/decreased level of consciousness
Collapse, falls
Syncopal episode
Chest pain
Stroke/TIA
Shortness of breath
Seizures
Overdose
Electrocution
Drowning/scuba diving incidents
Hypothermia and heat related illness
Unknown
Quality Assurance
The cardiac monitor/defibrillator must be
checked and appropriate documentation
filled out in accordance with local policy
and procedure at the beginning of each
shift
Two examples:
Self-Test
Charge and discharge test at 10-50J
What does the machine say to show success in these two tests?
Troubleshooting
Paramedics must learn to recognize the most
common problems that can occur when treating
cardiac arrest patients with a SAED.
These include:
•
Poor electrode contact on patient's chest. Diaphoretic
patients need to be dried off. Excessive body hair may also
cause poor electrode contact, hair may need to be trimmed.
Extra sets of adhesive pads should be readily available.
•
Before placing electrodes, always be sure to remove
anything on the surface of the patient's chest. This includes
bandages, NTG patch(s), and other objects that might
interfere with the placement of the electrodes on the patient's
skin surface.
•
If you encounter an implanted pacemaker, place the
treatment electrode two to four inches away from the
pacemaker site and as close to the normal pad placement as
possible.
Troubleshooting cond
If you encounter persistent problems with a set of electrodes,
please follow local service policy for reporting
malfunctions.
Failed or low battery: replace with charged spare battery as
soon as possible. Remember to continue CPR during
battery exchange – Plug monitor into AC power if
available and appropriate.
Loose cable-electrode connections. Check to see that
connectors are properly snapped into place both at the
machine and on the pads. Always carry spare
electrodes
Monitor/cable movement. Patient movement during lifting,
moving, and transport may cause motion artifact.
Reporting Equipment Problems:
Report any equipment problems as per local service
protocols.
Interacting With The
AED Trained Fire
Department (F.D.)
•
•
•
•
•
•
•
•
Upon arrival, Paramedics will take over responsibility for
the patient care
Obtain report from the Fire Department staff.(called a D
Form)
Any transfer of care, including changing to the Paramedic
SAED, should take place during a period of CPR.
Can complete whole algorithm on their machine
Have the Firefighter who is operating the AED turn off
machine and remove their treatment electrodes as per
their protocol
Connect Paramedic SAED to the patient
Complete the SAED protocol
The Firefighter will complete a medical assist report (D
Documentation
Complete the ACR. Pertinent documentation should include:
• time of arrest,
• witnessed/unwitnessed arrest,
• HPI,
• duration of CPR,
•
physical findings,
• treatments,
• patient response to treatments,
• vital signs,
• PMHx,
• Rx,
• allergies) and
• detailed documentation of times (call time, arrival, departure, ER
arrival).
Documentation Con’t
• Forward the completed ACR to the Base
Hospital as per local Base Hospital policy.
• The Base Hospital will audit 100% of SAED
calls. If there are concerns, The the crew
may receive feedback on the call in the way
of a written call evaluation if there are
concerns. . Please feel free to discuss calls
with the Base Hospital staff
• Remember too according to ambulance act,
you need to do a VSA report (a special form
of incident report)
Transfer of Care to
Hospital
Assure an orderly transfer of patient care to the hospital team.
Provide a brief report of clinical information including:
• Time down (e.g., time of arrest)
• witnessed/unwitnessed arrest,
• HPI
• duration of CPR
• Treatments
• patient response to treatments
• vital signs
• PMHx
• Rx (meds) pertinent
• Allergies.(pertinent)
Caring for Family and
Bystanders
Even though Tthe primary concern of the Paramedic is
the patient, but it is both appropriate and necessary
to communicate effectively with the other people at
the scene: family, friends and spectators.
Respect the patient's and family's right to privacy.
Isolate the patient from spectators whenever
possible.
Briefly inform the family of the patient's status and
condition during and after resuscitation. It is
important to identify the patient, establish the
relationship of those present, accurately restate the
events leading up to the cardiac arrest, briefly outline
the efforts by the ambulance crew (CPR and whether
the patient was defibrillated), and portray the patient's
present condition - briefly and objectively.
The procedure -Step 1Anticipation of Scene
-think through your roles- who is doing
what
Run through the algorithm with your
partner
Take in all your necessary equipment
If you are on a call with a patient
experiencing ACS, anticipate an arrest!
The procedure -Step 2Scene
Observe for any hazards in the environment
such as water or flammable gases or
liquids. Move patient only if necessary.
Transport all the equipment needed to manage
the cardiac arrest to the patient's side.
Position the patient for effective CPR and
defibrillation.
Position team members and the defibrillator
based on assessment of available space,
layout and workspace
Procedure Step 3 Patient
: Check Patient and Start CPR
L.O.C.
Assess responsiveness
C - Circulation:
Assess and manage
Start cardiac compressions
A - Airway
Assess and manage
Position and suction
B - Breathing:
Assess and manage
Ventilation with Bag-valve-mask
Cardiac Arrest
Algorithm
Read the indications!
 Read procedure section
Step 4 & Step 5:
Step 4 : Turn on machine before or
after attaching treatment electrodes
according to local protocols.
Step 5 :Prepare Patient and Attach
Electrodes
Pad Placement
Two options
- anterior –posterior (sandwich) is best,
closer distance but more difficult due to
size of patient (best if you can log roll
them)
- Apex-sternum – more common
Defib Pad Placement
Attach anterior pad to R shoulder below the
clavicle R of the sternum
Lateral pad is anterior axillary line at the level of
the base or apex of heart -ensure good
contact- shave if required
Pad placement
Sternum pad to the right of the sternum, with the top edge just
touching the bottom of the right clavicle.
Apex pad to the left lateral chest at the mid-axillary line
(approximately at the nipple line).
An implanted pacemaker may require you to move the pad two
to four inches away from the pacemaker site.
Unless there is too much hair to get an acceptable tracing,
Taking additional time to clip chest hair at the pad sites may
not be worth the effort, as every second counts
Note: Improper positioning or connection of the pads and
cables will result in either
•
•
•
An error message or "CHECK ELECTRODES" signal from the SAED.
Less energy delivered to the myocardial cells resulting in fewer cells
being depolarized and lowering the chances for a successful
defibrillation.
Skin burns
Step 6 Rhythm analyses!
The "ANALYZE" button is pressed and rhythm
analysis is activated. Everyone must be
clear of the patient! The SAED will also
advise you to clear with a voice prompt,
"ANALYZING NOW, STAND CLEAR".
Everyone must be away from the patient
before rhythm analysis starts.
Assessment: All those present must remain
clear during the analyzing assessment.
Rhythm assessment may take up to 5
seconds
Analyze and Shocking
If Vfib or Vtach >180 (depends on machine) is detected,
the machine will charge to the preset J setting
The “Shock” button will flash when it is charged and ready
You NEED TO WATCH THE PATIENT AND SAY
CLEARLY “ I am clear you are clear everyone is
clear”, BEFORE YOU PUSH THE BUTTON!
After shock(s) has been delivered back on chest ASAP.
If you receive a “No Shock Indicated” (NSI)
–check pulse then begin CPR Resume CPR as per
protocol for two minutes and re-analyze
Three cycles on scene and one enroute
(Three on floor and one out the door!)
Some info for
Paramedic
Again, defibrillation may be interfered with by
other equipment
Notify partner/other helpers of procedure
Watch for skin burns
Ensure everyone clear when you defib!
Defibrillation
Must be 25 lbs pressure with paddles or
good contact with skin on pads to
ensure good contact and success of
defibrillation
Can also defib anterior/posterior but more
difficult and cumbersome in the VSA
patient (imagine large VSA patient)
LP 12/Zoll
Familiarization
Ensure you know how to :
change energy settings
“dump” a charge
retrieve a code summary 2 ways
set clock
test machine at start of shift
what various cables are called
etc:
See Monitor familiarization list on website