Critical Care Trauma Centre

DEFIBRILLATION BY MEDICAL DIRECTIVE

Purpose:

Defibrillation is the treatment for ventricular fibrillation. The success of resuscitation of patients with ventricular fibrillation relates to how quickly electrical energy can be applied to the myocardium. The longer the heart fibrillates, the greater the myocardial oxygen consumption and deterioration of myocardial function. The chance of successful defibrillation is reduced as the fibrillation time increases.

Equipment Required:

  • Crash cart with Zoll biphasic defibrillator
  • Multipurpose pacing/defibrillation pads
  • PPE- non-sterile gloves, gown and facemask with shield (assess risk for need of gown and facemask with shield)

Ensure that patient and health care provider safety standards are met during this procedure including:

  • Risk assessment and appropriate PPE
  • 4 Moments of Hand Hygiene
  • Procedural Safety Pause is performed
  • Two patient identification
  • Safe patient handling practices
  • Biomedical waste disposal policies 
  • Electrical safety
  1. Identify life-threatening rhythm
  2. Activate Code Blue
  3. Initiate CPR
  4. Prepares for defibrillation
  5. Prepare defibrillator
  6. Maintain Environmental Safety environment
  7. Discharge paddles
  8. Continue CPR
     
  1. Reassess rhythm
  2. Administer epinephrine
  3. Consider cause for non-responsiveness
  4. Administer amiodarone
  5. Return to #8-9
  6. Obstetrical ACLS
  7. Document
  8. Order requirements

 

PROCEDURE

 1.

Identify Life-Threatening Rhythm

A certified critical care nurses may initiate defibrillation under the following circumstances: 

  • Ventricular Fibrillation (VF)
  • Pulseless Ventricular tachycardia (VT)

Note: Arterial line pressures < 60 mmHg may be associated with pulselessness. CPR should be initiated immediately.

Successful conversation of these rhythms occurs with rapid delivery of the first shock of energy.

Pulseless VT is often short-lived and deteriorates to VF.

 2.y

Initiate CPR

The first responder initiates CPR until the defibrillator arrives. Use the following sequence:

  1. Initiate compressions while cart is en route
  2. Confirm that the patient has a shockable rhythm and defibrillate as soon as the cart arrives. Use the paddles. If non-shockable rhythm, continue CPR per algorithm.
  3. Resume CPR following defibrillation and complete the first 2 minute cycle of compressions. 
  4. Complete one full cycle of CPR even if the patient has a return of sinus rhythm (unless the patient is actively pushing you away).
  5. Place the back board after the first full cycle of CPR. Continue with ACLS per algorithm.  

Effective Compressions

Position hands on the sternum at the nipple line. Perform chest compressions at a rate of 100 - 120/minute to a depth of 5 to 6 cm (2 - 2.5 inches) of chest wall diameter.  

During CPR, minimize interruptions of compressions and allow for good chest recoil. 

Whenever feasible, switch the person who is performing compressions after each 2 minute cycle (the effectiveness of CPR decreases beyond this).

CPR during Pregnancy:

Use the same hand positions for pregnant patients as non-pregnant (no longer recommended to move them to a more cephalic placement during pregnancy). 

A second person is required to maintain continuous manual left uterine displacement with patient in the supine position (see Obstetrical Emergencies).

 

 3.

Activate Code Blue

Call a code blue simultaneously with initiation of CPR. Notify the critical care physician STAT.

 4.

Prepare Patient for Defibrillation

Initial defibrillation:

Apply gel defibrillation pads (orange) to chest and administer the initial shock using the defibrillation paddles (this can facilitate quicker delivery of shock).

Prepare Patient:

  • Side rails
  • Bed and patient flat
  • Chest exposed
  • Apply gel pads in correct position:
    • One pad on upper chest, below the right clavicle. The second pad below the left nipple at the midaxillary line (see diagram).
    • Ensure paddles have no contact with metal jewelry, pharmacological patches (e.g., fentanyl, nitroglycerin) or transparent dressings.
Anterior placement

 

Apply Pacemaker/Defibrillator Pads:

Paddles may be used to deliver additional shock or you may switch to the combination pacemaker/defibrillation pads.  This decision is based on the need for pacing or recurrent defibrillation. Pads can be placed in the anterior or anterioposterior position.

Position for Pacemaker/Defibrillator Pads:

Anterioposterior pad placement

Safety: 

Gel pads protect the patient against burns and enhance contact.
Arcing will occur if shock is delivered too close to electrodes.

 5.

Prepare Defibrillator:

  1. Continue CPR while preparing defibrillator.
  2. Turn Defibrillator on and ensure dial is set to "Defib".
  3. Confirm the default charge is 200 joules.
  4. Charge paddles before placing them on the chest. The paddles can be charged using the "Charge" button on the paddle or on the front of the monitor
  5. Press paddles firmly to the chest using 25 - 30 lbs of force.

Ensure the paddles do not come in contact with ECG leads.

 

The only treatment for fibrillation is delivering electrical current immediately to the myocardium. Biphasic defibrillators are more successful at converting VF with the first shock.

 6.

Maintain Environment Safety

Ensure that there is no contact with any metal objects and no one is in contact with the patient or bed. Call "All Clear".

7.

Deliver Shock/Discharge paddles

Discharge energy by simultaneously depressing the SHOCK button on the paddles or monitor (second person).

Deliver shock following exhalation.

Air filled lungs decrease electrical conduction. Patient may be in a respiratory arrest.

7.

Continue CPR

  • Do not check for pulse. Immediately return to CPR for 2 minutes (5 cycles of 30:2 compression:ventilation ratios for non intubated patient).
  • If patient is intubated, continue with manual bagging of 8-10 bpm (1 breath every 6 seconds). DO NOT STOP COMPRESSIONS.
  • Charge paddles to 200 Joules before 2 minutes of CPR is completed.

CPR immediately after shock provides myocardial oxygenation which improves shock success.

Higher respiratory rates increase intrathoracic pressure which decreases perfusion of organs.

Safety:

If paddles or multipurpose pads have been charged and are no longer required, do not discharge the energy into the machine or the air. To safely discharge the paddles/pads, turn the dial on the machine from "defib" to "monitor", then return paddles to device. 

8.

Reassess Rhythm

  • Quickly reassess rhythm at the end of 2 minute CPR cycle to ensure that patient has not returned to VF or VT.
  • If patient is in VT/VF, proceed to deliver the next shock (as above) at 200 Joules
  • Resume CPR after completion of the shock

9.

Administer Epinephrine

While CPR is being performed, administer epinephrine 1 mg IV direct per after the second defibrillation.

A certified critical care nurse may give epinephrine 1 mg IV direct after the second defibrillation shock has been delivered by Medical Directive. The certified critical care nurse may repeat epinephrine 1 mg IV direct every 3 minutes until Return of Spontaneous Circulation (ROSC). 

If the patient does not have IV access, epinephrine may also be given by a certified critical care nurse by Medical Directive down the endotracheal tube.

Epinephrine may be ordered earlier by a physician during the cardiac arrest. This will require an order as it is outside the Medical Directive. 

Epinephrine can increase cerebral and coronary perfusion pressures by alpha vasoconstriction. Delivery of drug during compressions minimizes interruptions to CPR.

10.

Consider Causes for Non-responsiveness

Return to step # 8-9.
Troubleshoot for possible causes of non-responsive VT/VF (e.g. electrolyte disturbance, hypoxemia, MI).

Consider H's and T's

Hypovolemia
Hypoxia
Hydrogen ions
Hypo/hyperkalemia
Hypothermia
Toxins
Tamponade
Tension pneumothorax
Thrombosis: coronary/pulmonary
Consider adrenal endocrine (adrenal insufficiency, hypoglycemia)

11.

Administer Antiarrhythmic

While CPR is being performed, administer amiodarone 300 mg IV direct per amiodarone procedure.

If contraindicated, administer lidocaine 1 mg/kg per defibrillation procedure under medical directive.

A certified critical care nurse may give lidocaine by Medical Directive if amiodarone is contraindicated at a total bolus dose of 1.5 mg/kg (preloaded syringe).

An order is required to initiate an amiodarone or lidocaine infusion.

12.

Return to Steps 8-10

Maintain ABC’s.
Continue to treat possible causes of arrhythmia.

Return to Step #11 Administer Epinenphrine

Continue CPR as per step # 9 followed then by step # 10.

13.

Obstetrical Considerations

The priority during resuscitation of the pregnant patient is the mother. Activate Code OB STAT and early (as soon as patient shows signs of deterioration in condition).  Code OB is available at Victoria Hospital only. At UH, page a general surgeon STAT for perimortem cesarean: 

Follow standard ACLS algorithms with the following modifications:

  • Hand position in the same location as for the non pregnant patient (it is no longer recommended to position the hands closer to the head)
  • Perform CPR in the supine position with one person assigned to manually display the uterus toward the patient's left.
    • Use two hand uterine "pull" technique if standing on patient's left side or one hand "push" if standing on patients right side.
  • All IVs above the diaphragm
  • Consider calcium chloride if patient was receiving magnesium sulphate
  • Remove fetal monitor (external and internal) prior to defibrillation
  • The goal is to start perimortem C-section at 4 minutes during cardiac arrest

Causes for Maternal Cardiac Arrest (Beauchops)

B     Bleeding/DIC
E     Embolism cardiac/pulmonary/ amniotic
A    Anaesthetic complications
   Uterine atony
C    Cardiac disease: MI/ischemia/aortic dissection/cardiomyopathy
   Hypertension/preeclampsia/eclampsia
   Review standard ACLS guidelines (Hs and Ts)
   Placental abruptio, previa
S    Sepsis

14.

Document

Document in cardiac arrest record.

15.

Order Requirements

The medical directive for ACLS provides the authority to initiate interventions.

The RN who initiates the medical directive should be identified in the cardiac arrest record.  

References:

American Heart Association. 2015 & 2018 Integrated ACLS Guidelines: 
https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-7-adult-advanced-cardiovascular-life-support/

Developed by:
Judy Hackett RN BScN CCTC

Clinical Educator, CCTC
August 14, 2006

Last Update: October 16, 2017, November 5, 2018 (KK/BM)