Back to top

Circulation - Defibrillation (manual)

This procedure is performed alongside CPR

Indications

Ventricular fibrillation

Pulseless ventricular tachycardia

Contraindications (absolute in bold)

Perfusing rhythms

Signs of life

Wet patient

Advanced directive to not resuscitate

Non-shockable rhythms (asystole, pulseless electrical activity)

Alternatives

None

Informed consent

Medical emergency

Consent is not required

Potential complications

Transmitted shock to clinician

Fire (if oxygen in vicinity)

Skin burns

Myocardial damage

Procedural hygiene

Standard precautions

PPE: non-sterile gloves

Area

Anywhere with a manual defibrillator

Staff

Defibrillating clinician

Airway clinician

Rotating team members doing CPR or a mechanical device (e.g. LUCAS-2)

Equipment

Defibrillator and pads

Positioning

Supine on hard surface with a dry chest

Consider removing jewellery and shaving hair

Place pads antero-laterally (right parasternum second intercostal space, left mid-axillary line sixth intercostal space)

Medication (required for repeated cycles of CPR and defibrillation)

Oxygen 15l via BVM

Adrenaline IV 1mg in 10ml (1:10,0000)

Amiodarone IV 300mg

Sequence (defibrillation during CPR)

Turn defibrillator to ‘DEFIB’

Charge defibrillator to 200J continuing CPR (4J/kg if <8yrs old)

Rhythm checks minimising interruptions to CPR (COACHED mnemonic)

If shock required hold the ‘SHOCK’ button to deliver the shock

If shock is not required disarmed by dialling to ‘MONITOR’, reducing the selected energy or pressing disarm

Immediately restart CPR without reassessing the rhythm or feeling for a pulse

Post-procedure care

Continue chest compression for two minutes until rhythm check

Confirm ventilation via BVM or LMA/ETT

Monitor ETCO2 (sudden increase suggests ROSC)

Tips

Place axillary pad under large breasts

Place pads 8cm from pacemaker box (avoiding malfunction)

Perform a pulse check only if the rhythm is organised

Discussion

There is limited evidence regarding pad placement choices. The key idea is to ensure the myocardium to be depolarised is between the two pads. With a supine arrested patient, ANZCOR suggest placing pads on the exposed chest in an anterior-lateral position. One pad is placed on the mid-axillary line over the sixth left intercostal space and the other on the right parasternal area over the second intercostal space.

In patients with an implantable cardioverter defibrillator or a permanent pacemaker, the placement of pads should not delay defibrillation. Aim to place pads 8cm away from the generator box. The anterior-posterior and anterior-lateral pad placements on the chest are acceptable.

Rescuers should minimise interruptions to CPR while defibrillating the patient. Rescuers should be able to safely charge a manual defibrillator during CPR when using pads and disarm the defibrillator if a shock is not required. Manual chest compressions should not continue during the delivery of a shock because safety has not been established.

We support the use of the COACHED method for defibrillation:

C – continue Compressions

O – oxygen away (unless closed circuit)

A – all else clear

C – charging

H – hands off

E – evaluate rhythm

D – defibrillate or disarm

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Australian and New Zealand Committee on Resuscitation. Electrical therapy for adult advanced life support. East Melbourne: ANZCOR; 2016. 12pp. ANZCOR Guideline 11.4. Available from: https://resus.org.au/guidelines/

Resuscitation Council (UK). Advanced life support. 7th edn. London, UK; Resuscitation Council; 2016. 200pp. Available from: https://www.resus.org.uk/publications/advanced-life-support-manual/

NSW Agency for Clinical Innovation. Defibrillation and cardioversion. Sydney: ACI; 2015. 12pp. Available from: https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0008/380285/Defibrillation_and_Cardioversion.pdf

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Knight BP. Basic principles and technique of external electrical cardioversion and defibrillation. In: UpToDate. Waltham (MA): UpToDate. 2019. Available from: https://www.uptodate.com/contents/basic-principles-and-technique-of-external-electrical-cardioversion-and-defibrillation

Ionmhain UN. Defibrillation basics. Life in the fast lane. 2019. Available from: https://litfl.com/defibrillation-basics/

© Agency for Clinical Innovation 2021