DEFIBRILLATOR

Defibrillation is the definitive treatment for the life-threatening cardiac arrhythmias, ventricular fibrillation and pulseless ventricular tachycardia. Defibrillation consists of delivering a therapeutic dose of electrical energy to the affected heart with a device called a defibrillator. This depolarizes a critical mass of the heart muscle, terminates the arrhythmia, and allows normal sinus rhythm to be reestablished by the body's natural pacemaker, in the sinoatrial node of the heart. Defibrillators can be external, transvenous, or implanted, depending on the type of device used or needed. Some external units, known as automated external defibrillators (AEDs), automate the diagnosis of treatable rhythms, meaning that lay responders or bystanders are able to use them successfully with little, or in some cases no training at all.

NEED FOR A DEFIBRILLATOR

Ventricular fibrillation is a serious cardiac emergency resulting from the asynchronous contraction of the heart muscles. This uncoordinated movement of the ventricle walls of the heart may result from coronary occlusion, from electric shock or from abnormalities of the body chemistry. Because of this irregular contraction of the muscle fibres, the ventricles simply quiver rather than pumping the blood effectively.

In fibrillation, the main problem is that the heart muscle fibres are continuously stimulated by adjacent cells so that there is no synchronized succession of events that follow the heart action. Consequently, the control over the normal sequence of cell action cannot be captured by ordinary stimuli. Ventricular fibrillation can be converted into a more efficient rhythm by applying a high energy shock to the heart. This sudden surge across the heart causes all muscle fibres to contract simultaneously. Possibly, the fibres may then respond to normal physiological pacemaking pulses. The instrument for administering a shock is called a defibrillator.

TYPES OF DEFIBRILLATOR
A) Manual external defibrillator

External defibrillator / monitor The units are used in conjunction with (or more often have inbuilt) electrocardiogram readers, which the healthcare provider uses to diagnose a cardiac condition (most often fibrillation or tachycardia although there are some other rhythms which can be treated by different shocks). The healthcare provider will then decide what charge (in joules) to use, based on proven guidelines and experience, and will deliver the shock through paddles or pads on the patient's chest. As they require detailed medical knowledge, these units are generally only found in hospitals and on some ambulances

B) Manual internal defibrillator

These are the direct descendants of the work of Beck and Lown. They are virtually identical to the external version, except that the charge is delivered through internal paddles in direct contact with the heart. These are almost

exclusively found in operating theatres, where the chest is likely to be open, or can be opened quickly by a surgeon.

C) Automated external defibrillator (AED)

An automated external defibrillator, open and ready for pads to be attached.

WHERE SHOUD AED BE PLACED The locating of a public access AED should take in to account where large groups of people gather, and the risk category associated with these people, to ascertain whether the risk of a sudden cardiac arrest incident is high. For example, a center for teenage children is a particularly low risk category (as children very rarely enter heart rhythms such as VF(Ventricular Fibrillation or VT(Ventricular Tachycardia), being generally young and fit, and the most common cause of pediatric cardiac arrest is trauma - where the heart is more likely to enter asystole or PEA, where an AED is of no use), whereas a large office building with a high ratio of males over 50 is a very high risk environment.

In many areas, emergency services vehicles are likely to carry AEDs, with some ambulances carrying an AED in addition to a manual unit. In addition, some police or fire service vehicles carry an AED for first responder use. Some areas have dedicated community first responders, who are volunteers tasked with keeping an AED and taking it to any victims in their area. It is also increasingly common to find AEDs on transport such as commercial airlines and cruise ships.

HOW TO USE AED:

An automated external defibrillator is used in cases of life threatening cardiac arrhythmias which have led to cardiac arrest. The rhythms the device will treat are usually limited to:

Ventricular fibrillation (shortened to VF or V-Fib) Pulseless Ventricular tachycardia (shortened to VT or V-Tach)

AEDs, like all defibrillators, are not designed to shock asystole ('flat line' patterns) as this will not have a positive clinical outcome. The asystolic patient only has a chance of survival if, through a combination of CPR and cardiac stimulant drugs, one of the shockable rhythms can be established, which makes it imperative for CPR to be carried out prior to the arrival of a defibrillator. In each of the two types of shockable cardiac arrhythmia, the heart is active, yet in a life-threatening, dysfunctional pattern. In ventricular fibrillation, the electrical activity of the heart becomes chaotic, preventing the ventricle from effectively pumping blood. In ventricular tachycardia, the heart beats too fast to effectively pump blood. Ultimately, ventricular tachycardia leads to ventricular fibrillation. The fibrillation in the heart decreases over time, and will eventually reach asystole. Uncorrected, these cardiac conditions rapidly lead to irreversible brain damage and death. After approximately three to five minutes, irreversible brain/tissue damage may begin to occur. For every minute that a person in

cardiac arrest goes without being successfully treated (by defibrillation), the chance of survival decreases by 10 percent.

D) Semi-automated external defibrillators

These units are a compromise between a full manual unit and an automated unit. They are mostly used by pre-hospital care professionals such as paramedics and emergency medical technicians. These units have the automated capabilities of the AED but also feature an ECG display, and a manual override, where the clinician can make their own decision, either before or instead of the computer. Some of these units are also able to act as a pacemaker if the heart rate is too slow (bradycardia) and perform other functions which require a skilled operator.

TWO TYPES OF WAVEFORMS USED:

1 1 2

Monophasic Current

Biphasic Current

Monophasic:
Current delivers in One direction

Monphasic Damp Sine

SMART Biphasic

Biphasic: J by Delivers selected Delivers 150 Current delivered (up energy to a 50 ohm changing duration in two directions patient. to 20 msec). No impedance Effective impedance compensation. compensation.
High peak current leads to dysfunction; tail Comparison end of high impedance waveform associated with refibrillation. Lowest peak current with reduced risk of of refibrillation and Waveforms dysfunction.

BASIC ORENTATION:

DEFIBRILLATION CONTROLS:
Defibrillation controls consist of an energy select knob and a set of soft keys that perform the function diplayed as a laebel above each button. These controls assist in both AED and manual mode defibrillation.

AUDIOVIUAL CONTROLS

Adjust the volume of voice prompts and the QRS beeper. At the lowest setting, the QRS beeper I muted. The voice prompts and other alert tones cannot be muted.

Adjusts the size of the ECG waveform displayed, printed, and stored. Pressing and simultaneouly generates a 1mV calibration pulse. MONITORING CONTROLS Monitoring controls consist of a set of softkey that perform monitoring functionality. These functions are diplayed in the softkey label below each button. Monitoring off key also control heart rate and SpO2 alarms, and selection of the ECG source to monitor.

PRINT CONTROLS Print control performs the function shown on each button. The print control forms are:

Prints ECG data, defibrillation events, and marked events real-time or with a 6 second delay. Press to start printing.

Print the event summary. Printing may be stopped by pressing the summary or strip button .

Inserts a time-stamped annotation in the event summary. May be configured to print an annotated ECG strip when pressed.

MANUAL MODE CONTROLS Manual mode controls provide access to manual defibrillation, and synchronised cardioversion and optional pacing functionality.

Manual mode controls: energy select knob and placing controls Energy select

DISPLAY BUTTONS Can enable both manual mode and AED mode. The AED mode. On position activates AED mode, manual On enables Manual Mode, synchronised cardioversion and placing.

Button below the display that enables the synchronised cardioversion when first pressed in manual mode; disables synchronised cardioversion when pressed again. Ativates the pacing function buttons, allowing you to use the buttons below to define pacing rate, mode, and current output. Also turns off the pacer function when pressed a second time.

Adjusts the pacing rate.

Starts pacing. Delivers pacer pulses when first pressed; stops pacing when pressed again. Selects demand or fixed mode for pacing.

Adujsts the current output for pacing.

DISPLAY LAYOUT
The following figures show the layout of the display in: AED Mode, with ECG and SpO2 monitoring capabilities enabled AED Mode, with ECG and SpO2 monitoring capabilities disabled Manual mode

The incident timer shows the elapsed time since the heartstart XL was turned on. Provided patient contact was established. If the heartstart is powered on after being off for less than two minutes, the incident timer resumes where it left off. If power is off for more than two minutes, the incident timer rests to zero (00:00:00). If an event summary is printed, the incident timer will be set to zero the next time the unit is turned on.

User messages accompany voice prompts to guide you through the defibrillation process. System and momentary messages Alert you to conditions that require your attention Provide status information, or Offer recommendations

A system message remains on the display until the condition that generated the message no longer exists. A momentary message is temporary and appears on the display for a minimum of three seconds.

CONNECTING TO POWER The heartstart XL is powered by ac power and the M3516A battery. Prior to inserting the battery, make sure that the battery is charged and has been properly maintained. It is recommended that a second, charged battery be available at all times.

DEFIBRILLATING IN AED MODE

The heartstart XLs AED mode is designed to guide you through standard treatment algorithms for cardiac arrest, including those provided by the American Heart Association and the European Resuscitation Council. Configuration choices allow you to customize AED mode to better follow a

specific treatment algorithm and to meet the unique needs of your life saving team.

The process begins only after you have: Assessed that the patient is unresponsive, not breathing, pulseless, Prepared for defibrillation by attaching pads and cables, Inserted a data card( if desired),and Turned the energy select knob to AED on. DEFIBRILLATION (using the default configuration) In its default configuration, the defibrillation process is: Turn the energy select knob to AED On. Energy select knob

The heartstart XL checks to see if the pads patient cable and multifunction defibrillator electrode pads are properly connected. If either connection is compromised, you are prompted to fix the problem.

2. Analysis begins automatically-there is no need to press

ANALYSE. Once analysis is complete, the heartstart XL tells you SHOCK ADVISED or NO SHOCK ADVISED.

3. If a shock is advised, press SHOCK.

After a shock is delivered, the heartstart XL automatically prompts you to press pause and begin CPR, if needed. DEFIBRILLATION (with a modified configuration) DEVICE INITIATED ANALYSIS- initiates ECG analysis when the heartstart XL is first turned on. The default configuration is on. If you choose to set this parameter to off, you need to press ANALYSE to initiate analysis in step 2 of the defibrillation process. AUTOMATIC RE- ANALYSIS initiates ECG analysis in between shocks within a multishock series. The default configuration setting is on. If you choose to set this parameter to off, you need to press ANALYZE to initiate analysis in between shocks within a multishock series. RHYTHM MONITORING- Monitors the ECG for potentially shockable rhythms when the heartstart XL is not analyzing, defibrillating or paused. The default setting is on if you choose to set this parameter to off, the heartstart XL will not look for potentially shockable rhythms during these idle times. Idle times include

 Power on when device initiated analysis is off. In between shocks within a multishock series, when auto reanalysis is off. If rhythm is off, you need to observe the patient during idle times and determine when to press ANALYSE. DEFIBRILLATING 1. Turn the energy select knob to AED on. In this first step of the defibrillation process, the heartstart XL checks to see if the pads patient cable and the pads are connected. If they are, it proceeds to step 2. If the pads patient cable is not properly attached, you are prompted to CONNECT PADS CABLE.

Once the cable is connected, the Heartstart XL will ensure the pads have adequate connect with the patients skin. Connect quality is measured by monitoring the electrical impedance between the two pads. If the pads have not been applied or are not making proper contact with the patient, you are prompted to APPLY PADS and CHECK CONNECTIONS.

2. If instructed, press ANALYSE.

If device-initiated analysis is OFF, the heartstart XL monitors the rhythm provided rhythm monitoring is on. The heartstart XL prompts you to press ANALYSE if a potentially shockable rhythm is detected.

If device initiated analysis is ON, you do not need to press ANALYSE; ECG analysis begins automatically.