Definition
Defibrillation means delivering electrical current transthoracically through paddles to terminate lethal arrhythmias.
Purpose
To treat lethal arrhythmias such as pulseless ventricular tachycardia and ventricular fibrillation.
Indications
- Ventricular fibrillation.
- Pulseless ventricular tachycardia.
Types of defibrillators
1.Direct Current Defibrillator
It delivers an electrical current of preset voltage to the heart through paddles placed on the chest wall.
2.Automated External Defibrillator
Automated external defibrillator delivers shock to a patient after it identifies pulseless ventricular tachycardia and ventricular fibrillation. The device has two electrodes (pads), so it has to be positioned over clean and dry skin. Position of electrodes is same as that of direct current defibrillator.
These electrodes sense the electrical activity of heart and analyze the rhythm. If the rhythm is a shockable one, the device gives visual and auditory signals and provides directions to the lay person to deliver shock.
3.Automatic Implantable Cardioverter Defibrillator
Automatic implantable cardioverter defibrillator (AICD) is a device that delivers electric shock directly to the heart muscles in order to terminate lethal dysrhythmias. It has a pulse generator and a sensor that continuously monitors rhythm and detects dysrhythmias. It automatically delivers a counter shock.
AICD is surgically implanted by lateral thoracotomy or median sternotomy in subxiphoid or sub intercostal regions.
A) Direct current defibrillator
Articles
- Direct current defibrillator with paddles.
- Interface material (disposable conductive gel pads, electrode gels, and paste).
- Resuscitation articles.
Procedure
| Nursing action | Rationale | |
| 1. | Before procedure Explain the procedure to the family. | Allays anxiety and helps in cooperation. |
| 2. | Position the patient in supine without any pillow. | |
| 3. | During procedure Confirm ventricular tachycardia or ventricular fibrillation by checking monitor and patient’s clinical condition. Defibrillation is to be started within 10-20 seconds of onset of arrhythmia. Remove oxygen from area. | Defibrillation should be done before myocardial cells are anoxic or acidotic. |
| 4. | Expose anterior chest. Stat CPR immediately. | |
| 5. | Apply interface material to the patient or to the paddles. The electrode paddles should be in firm contact with the patient’s skin. | The interface material helps provide better conduction and prevents skin burns. Do not allow any paste on the skin between the electrodes. Electroconductive gel should not be smeared on chest wall as current may short circuit thus causing severe burns to the patient. |
| 6. | Put on defibrillator and switch off synchronizer mode. | |
| 7. | The initial defibrillation should be 200 joules of delivered energy. A second attempt at the same level (200-300 J) should be given if the first attempt is unsuccessful. A third attempt with an increase of energy level to 360 joules should be attempted. Allow only approximately 5 seconds between the successive attempts to assess rhythm and pulse. | The shock is measured in joules or watt seconds. Less time between successive shocks enhances effectiveness. High doses of shock cause myocardial damage. Transthoracic impedance is reduced with repeated delivery of shock. |
| 8. | Apply one electrode anteriorly at the second intercostal space to the right of sternum and another paddle laterally at the midclavicular line on the left side (apex). About 20-25 Ib of pressure is applied to paddles to minimize transthoracic impedance. | The paddles are placed so that the electrical discharge flows through as much myocardial mass as possible. If anteroposterior paddles are used, the anterior paddle is held with pressure on the apex, while the patient lies on the posterior paddle under the left intrascapular region. In this method, the counter shock moves directly through heart. |
| 9. | Grasp the paddles by handles. | Handling the paddles safely will reduce the risk of electrical shock. |
| 10. | Charge the paddles. Once paddles are charged, give the command for personnel to stand clear off the patient and the bed. Call “clear”3 times. With the first call, see that you move away from bed and patient. With the second call, ensure that others are away and with the third call, look quickly to make sure all are clear from the patient and bed. | If a person touches the bed, he/she may act as a ground for the current and receive a shock. |
| 11. | Push the discharge button in both paddles simultaneously. | |
| 12. | Reassess and monitor for rhythm change, holding paddles in position over chest. | Determines the rhythm of the heart. |
| 13. | If the rhythm is not reverted back, deliver two more shocks in succession (200-300J,360J). | |
| 14. | Resume CPR efforts until stable rhythm, spontaneous respiration, pulse, and BP returns. | After the three attempts using defibrillator, CPR efforts should resume. Total delay should be of no more than 5 seconds to oxygenate the patient and restore circulation. |
| 15. | When ventricular tachycardia and ventricular fibrillation persist, administer emergency drugs such as injection adrenaline 1 mg and injection atropine and give CPR for one minute. Repeat defibrillation at 360 joules and continue procedure as per ACLS guidelines. | |
| 16. | After procedure Clean and replace paddles for next use. | |
| 17. | Record the procedure and effectiveness. | |
| 18. | Check for burns on the skin. |
Follow-up activities
- After the patient is defibrillated and rhythm is restored, lidocaine is usually given to prevent recurrent episodes.
- Continue intensive monitoring.
B) Automated external defibrillator
Procedure
| Nursing action | Rationale | |
| 1. | Ascertain unconsciousness and pulselessness. | |
| 2. | Position the patient in supine position. | |
| 3. | Start CPR by AED is being applied. | |
| 4. | Place electrode on the patient’s anterior chest, just below the right clavicle and below the left nipple. | Appropriate electrode position ensures passage of current through the majority of myocardium. |
| 5. | Turn AED on and follow the audio or visual instruction from the AED. | The AED will analyse the rhythm in 5 – 15 seconds and determine the need of defibrillation based on that analysis. It will then let the operator know how to proceed. |
| 6. | Suspend CPR or any movement of the patient during the analysis. | External movement will impair the AED accuracy in analysing the rhythm. |
| 7. | If after analysing the rhythm a shock is advised, the AED will instruct the operator to prepare for a shock. It will charge the unit, give warning to “stand clear” and deliver 3 successive shocks. | |
| 8. | After the first shock, do not restart CPR. Allow the AED to reanalyse the rhythm. If a second shock is indicated, the AED will proceed as above. Most AEDS will deliver 3 successive shocks. | Delivering the shock in rapid succession or “stacking “the shocks decreases thoracic impedance and enhances the effectiveness of defibrillation. |
| 9. | After the third shock is delivered, if there is no pulse, continue CPR for 1 minute then begin the analysis of procedure again. | Oxygenation and circulation must be restored, or the patient’s chances of survival decrease markedly. |
| 10. | If the patient regains a pulse, continue to support ventilation. Keep AED electrode attached and the unit on in case the patient loses consciousness again. |
Complications
- Damage to myocardium due to repeated high energy electrical shocks.
- Chest burns due to repeated high-energy discharges and poor contact between the paddles and the skin.
- Electrocution of the bystanders.
- Formation of short circuits between paddles due to excessive amount of conduction gel applied on the paddles. This causes loss of electrical energy.
Nursing considerations
- Defibrillation is an emergency procedure; the article should be kept ready at all times.
- The conduction gel should be kept along with defibrillator to prevent waste of time in search of gel.
- The defibrillator should be checked for its proper functioning every shift/every day.
- When using paddles, apply appropriate conductant between paddles. Do not substitute any other type of conductant, such as ultrasound gel or saline-soaked pads.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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