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.
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)
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.
The first responder initiates CPR until the defibrillator arrives. Use the following sequence:
Initiate compressions while cart is en route
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.
Resume CPR following defibrillation and complete the first 2 minute cycle of compressions.
Complete one full cycle of CPR even if the patient has a return of sinus rhythm (unless the patient is actively pushing you away).
Place the back board after the first full cycle of CPR. Continue with ACLS per algorithm.
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).
Should be initiated at the onset of intubation.
End-Tidal CO2 Benefits:
Confirm ETT placement
Guide compression quality (goal for ETCO2 >20 mmHg)
Improved technique (e.g. prompt to identify need to switch CPR provider if < 10 mmHg)
Consider ROSC for an abrupt sustained increase to normal levels (35-40 mmHg) or at least 10 mmHg increase above level at onset of CPR
Guide decision to terminate CPR. Levels < 10 mmHg after 20 minutes indicates low probability of ROSC. This assumes that the ETCO2 is not < 10 mmHg because of overbagging (induced hyperventilation)
Activate Code Blue
Call a code blue simultaneously with initiation of CPR. Notify the critical care physician STAT.
Prepare Patient for Defibrillation
Apply gel defibrillation pads (orange) to chest and administer the initial shock using the defibrillation paddles (this can facilitate quicker delivery of shock).
Bed and patient flat
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.
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:
Gel pads protect the patient against burns and enhance contact.
Arcing will occur if shock is delivered too close to electrodes.
Continue CPR while preparing defibrillator.
Turn Defibrillator on and ensure dial is set to "Defib".
Confirm the default charge is 200 joules.
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
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.
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".
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.
Do not check for pulse. Immediately return to CPR for 2 minutes.
Do not stop compressions for rescue breathing. Second provider delivers 1 rescue breath by face mask/ETT every 6 seconds.
Charge paddles to 200 Joules before 2 minutes of CPR is completed. After the first shock is delivered, you can change to multipurpose pads for subsequent defibrillations.
CPR immediately after shock provides myocardial oxygenation which improves shock success.
Higher respiratory rates increase intrathoracic pressure which decreases perfusion of organs.
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.
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
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.
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).
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.
Return to Steps 8-10
Continue to treat possible causes of arrhythmia.
Return to Step #11 Administer Epinenphrine
Continue CPR as per step # 9 followed then by step # 10.
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 U Uterine atony C Cardiac disease: MI/ischemia/aortic dissection/cardiomyopathy H Hypertension/preeclampsia/eclampsia O Review standard ACLS guidelines (Hs and Ts) P Placental abruptio, previa S Sepsis
Document in cardiac arrest record.
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.
American Heart Association. 2015 & 2018 Integrated ACLS Guidelines:
Last Update: November 5, 2018, February 10, 2020 (KK/BM)