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      manual defibrillation

 

The length of the pre-shock pause, the interval between stopping chest compressions and delivering a shock, is inversely proportional to the chance of successful defibrillation. Every 5 second increase in the duration of the pre-shock pause almost halves the chance of successful defibrillation, therefore it is critical to minimise the pause. The lengthy ‘top-to-toe’ safety check (e.g., “head, middle, bottom, self, oxygen away”) performed after the defibrillator has charged and before shock delivery, commonly taught and used in clinical practice, will therefore significantly diminish the chances of successful defibrillation. This statement concerning defibrillation technique provides guidance that should decrease the duration of the pre-shock pause without increasing the risk to rescuers.

Current Resuscitation Council (UK) guidance and teaching materials state that the pre-shock pause should be less than 10 seconds; we believe that it is possible to reduce this further still without endangering team members. To help achieve this and further minimise the pre-shock pause:

  1. All rescuers should wear gloves during every resuscitation attempt.
     
  2. Use self-adhesive defibrillation electrodes to deliver the shock. These should be applied whilst chest compressions are ongoing.
     
  3. Safety issues should be addressed and planned for during chest compressions.
     
  4. Before stopping chest compressions the team should plan what to do if the rhythm is shockable:
     
    1. on stopping chest compressions if the rhythm is shockable everyone should “stand clear” and remove the oxygen if appropriate,
       
    2. identify who will charge the defibrillator and deliver a safe shock if the rhythm is shockable,
       
    3. identify who will immediately resume chest compressions after the shock is delivered.
       
  5. When the team leader asks for compressions to stop:
     
    1. the cardiac arrest rhythm should be confirmed as shockable and everyone should stand clear of the patient,
       
    2. if the rhythm is shockable the defibrillator is immediately charged whilst individuals are standing clear,
       
    3. during the charging process there should be a clear instruction to “stand clear” with a rapid visual safety check,
       
    4. the shock is delivered with minimal delay,
       
    5. chest compressions should restart immediately after the shock.
       
  6. If there are delays caused by difficulties in rhythm analysis or if individuals are still in contact with the patient, chest compressions should be restarted whilst plans are made to decide what to do when compressions are next stopped.
     
  7. A prolonged safety check during charging and before shock delivery is not necessary and is no longer recommended.
     
  8. Consider delaying intravenous drugs until after the shock has been delivered and chest compressions restarted.
     
  9. Rescuers must not compromise their safety.
There are very few reports of harm to rescuers during defibrillation even when the rescuer has been in contact with the patient. It is highly likely that future resuscitation guidelines will advocate that:
  • chest compressions are continued during charging of a manual defibrillator
     
  • when ventricular fibrillation or pulseless ventricular tachycardia (VF/VT) is identified, chest compressions are continued whilst the defibrillator is charged
     
  • shortly before the end of the chest compressions, the team leader ensures everyone is clear
     
  • at the end of the period of chest compressions, the shock is delivered by the person who was doing chest compressions.

 
ALS Subcommittee
January 2009
  
 
Further reading
 
Nolan JP, Deakin CD, Soar J, Bottiger BW, Smith G. European Resuscitation Council guidelines for resuscitation 2005. Section 4. Adult advanced life support. Resuscitation 2005;67 Suppl 1:S39-86
 
 Nolan J, Soar J, Lockey A, et al. Advanced Life Support 5th edition. London: Resuscitation Council (UK); 2006.
 
 Edelson DP, Abella BS, Kramer-Johansen J, et al. Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation 2006;71(2):137-45.
 
 Perkins GD, Davies RP, Soar J, Thickett DR. The impact of manual defibrillation technique on no-flow time during simulated cardiopulmonary resuscitation. Resuscitation 2007;73(1):109-14.
 
 Lloyd MS, Heeke B, Walter PF, et al. Hands-on defibrillation: an analysis of electrical current flow through rescuers in direct contact with patients during biphasic external defibrillation. Circulation 2008; 117:2510-2514.
 
 Perkins GD, Lockey AS. Defibrillation-Safety versus efficacy. Resuscitation 2008; 79:1-3.
 
 

 
 
 
 
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