1. A detailed view…..

2. CENTRAL OBJECTIVE
⚫By the end of the class, the learner will acquire
adequate technical knowledgeand skill forusing
defibrillatorand will be able toapply this knowledge in
clinical areas skillfullyand aid in nursing research with
a positiveattitude

3. SPECIFIC OBJECTIVES
⚫Understand meaning of defibrillatorand cardioversion
⚫Focus on indicationsand contraindications of defibrilation
⚫Learn various typesof defibrillatorand cardioversion
⚫Enumerateequipments needed fordefibrilation
⚫Identify shockable and non- shockable rhythms
⚫Acquire skill in performing advanced lifesupport and
defibrillation
⚫Discuss about nurses responsibilities in preparation of
patientand performing defibrillation
⚫Demonstrate the procedureof defibrilation
⚫Incorporateevidence based nursing skills in practiceof
Defibrilation and cardioversion

4. Definition- Defibrillation
Defibrillation is non synchronized random
administration of shock during a cardiac
cycle performed tocorrect life-threatening
arrhythmias of the heart including
ventricular fibrillation and pulseless
ventricular tachycardia

5. Definition - Cardioversion
Cardioversion isa synchronized administrationof shock
during the R wavesor QRS complexof a cardiaccycle
During defibrillation and cardioversion, electrical
current travels from the negative to the positive
electrode by traversing myocardium
⚫heartcells tocontract
⚫interruptsand terminatesabnormal electrical rhythm
⚫allows the sinus node toresume normal pacemaker
activity

6. Indications
Indications fordefibrillation:
⚫Pulselessventriculartachycardia (VT)
⚫Ventricular fibrillation (VF)
⚫Cardiac arrestdue toor resulting in VF

7. Indications
Indications forelectrical cardioversion:
⚫Supraventricular tachycardia (av node reentrant
tachycardia [AVNRT] and av reentrant tachycardia [AVRT])
⚫Atrial fibrillation
⚫Atrial flutter (types I and II)
⚫Ventricular tachycardia with pulse
⚫Any patientwith reentrant tachycardiawith narrow orwide
QRS complex (ventricular rate >150 bpm) who is unstable
(eg, ischemic chest pain, acute pulmonary edema,
hypotension, acute altered mental status, signs of shock)

8. Contraindications
⚫Dysrhythmiasdue toenhanced automaticity
⚫eg: digitalis toxicity, catecholamine-induced
arrhythmia
⚫Multifocal atrial tachycardia

9. Equipment
⚫ Defibrillators
⚫ Paddleoradhesivepatch
⚫ Conductivegel orpaste
⚫ ECG monitorwith recorder
⚫ Oxygen equipment
⚫ Intubation kit
⚫ Emergencypacing equipment
⚫ Blood pressurecuff
⚫ Pulserecorder
⚫ Oxygen saturation monitor
⚫ Intravenousaccess
⚫ Suction device
⚫ Code Cartwith ACLS medications

13. TYPES OF DEFIBRILATOR
⚫Advanced lifesupport (ALS) unit

14. TYPES OF DEFIBRILATOR
⚫Automated external defibrillator(AED)

15. TYPES OF DEFIBRILATOR
⚫Implantablecardioverterdefibrillators (ICDs)

16. TYPES OF DEFIBRILATOR
⚫Wearabledefibrillators

17. TYPES OF DEFIBRILATOR
⚫Biphasicversus monophasic modes

19. Types of Cardioversion
⚫Chemical cardioversion
⚫Electrical cardioversion
Otherconsiderations
⚫Internal cardioversion
⚫Cardioversion in patientswith digitalis toxicity
⚫Cardioversion in patientswith permanent
pacemakers/ICDs
⚫Cardioversion during pregnancy

20. NURSES RESPONSIBILITIES
⚫Patientpreparation and sedation
⚫General instructions
⚫Patient preparation forelective procedures
⚫Paddleplacement
⚫Predefibrillation care
⚫(preparation of defibrillation)
⚫Postdefibrillation care

21. PATIENT PREPARATION AND
SEDATION
⚫emergent maneuver - promptly performed in
conjunctionwith or priortoadministrationof
inductionorsedativeagents
⚫no preparation foremergency
⚫ACLS measures - obtaining intravenous access and
preparing airway managementequipment, sedative
drugs, and a monitoring device
⚫Cardioversion - under induction or sedation (short-
acting agent such as midazolam)unless patient is
hemodynamically unstableorcardiovascularcollapse
is imminent

22. GENERAL INSTRUCTIONS
Preventpotential complicationswhile using defibrillator
such as:
⚫Burns to the patient
⚫Shock tooperator/ otherpersonnel
⚫Fire / sparks
⚫Arrhythmias
⚫Ineffectiveshock

23. Patient preparation for elective
procedures
⚫Nil peros (NPO) for 8 hours priorto the procedure
⚫Stopdigoxin 48 hours prior to the procedure
⚫Continue medications on the morning of the
procedureunderthedirectionof the physician

24. Paddle placement
⚫2 conventional positions:
⚫ Anterolateral
⚫ a single paddle is placed on the left fourthor fifth
intercostal spaceon the midaxillary line.
⚫ The second paddle is placed just to the right of the sternal
edgeon the second or third intercostal space
⚫ moreeffective forpersistentatrial fibrillation
⚫ Anteroposterior
⚫ a single paddle is placed to the rightof the sternum
⚫ otherpaddle is placed between the tipof the leftscapula
and the spine
⚫ preferred in patientswith implantabledevices

25. Predefibrillation care (preparation
of defibrillation)
⚫Explain procedure, if patient is consciousor to the
relatives
⚫Position in supinewithoutany pillow for head
⚫Confirm cardiacarrest (VT orVF by checking
patient’sclinical condition)
⚫ensure thecardiac arrest team is alerted; get readya
defibrillatorand cardiac arrest trolley
⚫Commencecardiopulmonaryresuscitation (CPR) at 30
compressions to twoventilations

26. Predefibrillation care
⚫As soon as thedefibrillatorarrives, switch iton and prepare
the patient’schest if necessary. Ensure CPR continues
⚫Ensure 'synchronize’ mode isoff
⚫Applyself-adhesive defibrillation electrodes to the patient’s
bare chest following the manufacturer’s recommendations.
Ensure CPR continues. If paddles are used, apply
conductive gel to paddles.
⚫Once theelectrodes are in placeand areconnected to the
defibrillator, ECG analysis can start; depending on the
defibrillator, this will begin automatically or the user will
be prompted to press an ECG analysis button. Briefly stop
CPR

27. Predefibrillation care
⚫Keep one paddle anteriorly at 2nd intercostals space right
of sternum and anotherpaddle laterallyat 5th intercostals
space to left of sternum at midaxillary line or at cardiac
apex. Ensure there is 10 cm distances between paddles
⚫If a shockable rhythm is detected, ensure the appropriate
shock energy has been selected. Some advisory
defibrillators will do thisautomaticallywhile others require
the manual check. Most advisory defibrillators will charge
upautomatically, while some – typically theolder models –
requiretheoperator to press a “charge button”
⚫Discontinue oxygen inhalation to prevent fire hazards.

28. Predefibrillation care
⚫Shout “stand clear” and perform a quickvisual check
of thearea toensure thatall peopleare clear
⚫Applypressureof 25 pounds perpaddle. Do not lean
forward.
⚫Press the shock button todischarge the shock
⚫Reassesscardiac monitortodetermine rhythmand
subsequentaction, while paddlesare still on chest.
⚫If VF / VT is still present, resetand increase energy at
200 to 300 J and deliver

29. Predefibrillation care
⚫If VF/VT is not revered, deliver 360 J and reassess
cardiac rhythm
⚫When VF/VT persist, administer emergency drugs, e.g.
inj. adrenaline and atropine and give cardiopulmonary
resuscitation (CPR) for 1 minute
⚫Repeatdefibrillation at 360 J for 3 timesas ordered
⚫Discontinueprocedure
⚫Cleanand replace paddles for next use

30. Post defibrillation Care
⚫Assess patient responsiveness/sensorium.
⚫Check airway, breathing and circulation.
⚫Monitorcardiac rhythm continuouslyand assessVital
signs including BP half hourly until stable.
⚫Maintain oxygenation.
⚫Detectarrhythmias and sideeffectsof drugs used
during emergency
⚫Providecomfortand psychological support topatient
and family

31. Post defibrillation Care
⚫Administeranalgesic as ordered if patientexperiences
pain overdefibrillation site.
⚫Document Joules, numberof shocksand responseof
patient.
⚫If defibrillation is unsuccessful, explain situation to
familywith the helpof doctor
⚫Instruct After the procedure, do not drive, operate
machinery, orsign importantdocuments for 24 hours
and/oruntil sedation has wornoff

32. Complications
⚫The most common complications are harmless
arrhythmias, such as atrial, ventricular, and junctional
premature beats.
⚫Serious complications include ventricular fibrillation
(VF) resulting from high amountsof electrical energy,
digitalis toxicity, severe heart disease, or improper
synchronizationof the shock with the R wave.

33. Complications
⚫Thrombo embolization is associated with cardioversion,
especially in patients with atrial fibrillation who have not
been anticoagulated prior to cardioversion. American
Heart Association (AHA) guidelines recommend to
anticoagulate for 3-4 weeks before and after cardioversion.
⚫Myocardial necrosis can result from high-energy shocks. ST
segment elevation can be seen immediately and usually
lasts for 1-2 minutes.
⚫Myocardial dysfunction due to an absence of cardiac
output and coronary blood flow during arrest, resulting in
ischemia.

34. Complications
⚫Pulmonary edema is a rare complication of
cardioversion. It is probablydue to transient leftatrial
standstill and leftventricularsystolicdysfunction. It is
more common in atrial fibrillation due to valvular
heartdiseaseor leftventricularsystolicdysfunction.
⚫Allergic reaction tosedation medication.

35. Complications
⚫Painful skin burns can occur after cardioversion or
defibrillation; theyare moderate tosevere in 20-25% of
patients. They most likely are due to improper
techniqueand electrode placement. Itoccurs less with
use of biphasic waveform defibrillators and use of gel-
based pads. Prophylactic use of steroid cream or
topical ibuprofen reduces painand inflammation.

36. JOURNAL ABSTRACT
⚫Philip W, Kodoth V
, McEneaney D, Rodrigues P
, Jose
V, Waterman N et al. Towards Low Energy Atrial
Defibrillation. PMCID 2015 Sep; 15(9): 22378–22400

37. BIBLIOGRAPHY
⚫Sharon L. Lewis , Shannon Ruff Dirksen Margaret
McLean Heitkemper , Linda Bucher, Medical-Surgical
Nursing: Assessmentand Management of 9thEdition
⚫Smeltzer S C, Bare B , Brunner &suddarth’s Medical
surgical nursing, edition 10th, ( 2000), Westline
Industrial drive, Missouri.
⚫Joyce Black , Jane Hokanson Hawks, Esther
Matassarin-JacobsMedical-Surgical Nursing: Clinical
Management for Positive Outcomes, 7th Edition

38. BIBLIOGRAPHY
⚫Susan Woods, Erika S Sivarajan, Sandra Underhill,
Elizabeth J Bridges, Cardiac Nursing, 5th Edition,
LippincottWilliam & Wilkins
⚫Clement I. Basic concepts of Nursing procedures.
Second edition. New Delhi: Jaypee brothers; 2006
⚫Johnson Priyadarshini. Clinical Nursing Procedure
manual. Chennai: KVMathew BI publications
⚫Soni S. Textbook of Advanced Nursing Practice. New
Delhi: Jaypee Brothers

39. BIBLIOGRAPHY
⚫Philip W, Kodoth V
, McEneaney D, Rodrigues P
, Jose
V, Waterman N et al. Towards Low Energy Atrial
Defibrillation. PMCID 2015 Sep; 15(9): 22378–22400
⚫Ventricular Fibrillationand PulselessVentricular
Tachycardia
⚫https://acls-algorithms.com/vfpulseless-vt/

40. EVALUATION….???

41. THANK YOU