Performing Emergency Automated External Defibrillation

Skill 15-2

Performing Emergency Automated External Defibrillation

Rapid defibrillation for shockable rhythms (ventricular fibrillation [VF] and pulseless ventricular tachycardia [VT]) is a critical part of Basic Life Support and administration of cardiopulmonary resuscitation (CPR) (see Skill 15-1) (AHA, 2020a). Early defibrillation is critical to increase patient survival (AHA, 2020a). Electrical therapy can be administered by defibrillation, cardioversion , or a pacemaker (see Fundamentals Review 15-1 at the beginning of the chapter).

Defibrillation delivers large amounts of electric current to a patient over brief periods of time. It is the standard treatment for VF and is also used to treat pulseless VT. The goal is to depolarize the irregularly beating heart temporarily and allow more coordinated contractile activity to resume. It does so by completely depolarizing the myocardium, producing a momentary asystole. This provides an opportunity for the natural pacemaker centers of the heart to resume normal activity.

The automated external defibrillator (AED) is a portable, computer-based external defibrillator that automatically detects and interprets the heart's rhythm and informs the operator if a shock is indicated (Figure 1). The defibrillator responds to the patient information by advising “shock” or “no shock.” Fully automatic models automatically perform rhythm analysis and shock, if indicated. These are usually found in out-of-hospital settings. Semiautomatic models require the operator to press an “Analyze” button to initiate rhythm analysis and then press a “Shock” button to deliver the shock, if indicated. Semiautomatic models are usually found in acute care and other health care settings. An AED will not deliver a shock unless the electrode pads are correctly attached, and a shockable rhythm is detected. Some AEDs have motion-detection devices that ensure the defibrillator will not discharge if there is motion, such as motion from personnel in contact with the patient. The strength of the charge is preset. Once the pads are in place and the device is turned on, follow the prompts given by the device. The following guidelines are based on the AHA (2020b) guidelines. AHA guidelines state that these recommendations may be modified for the in-hospital setting, where continuous electrocardiographic or hemodynamic monitoring may be in place. CPR should be immediately initiated (see Skill 15-1), and the AED/defibrillator should be used as soon as it is available.

The application of the AED as soon as it is available allows for analysis of cardiac status and delivery of an initial shock, if indicated, for adults and children. After an initial shock, resume CPR immediately for about 2 minutes (until prompted by AED to allow rhythm check). Provide sets of one shock alternating with 2 minutes of CPR until the AED indicates a “no shock indicated” message; the patient starts to move, breathe, or otherwise react; or until advanced cardiac life support (ACLS) is available (AHA, 2020b).

In the health care setting, including community-based care settings, it is imperative that personnel be aware of the patient's stated instructions regarding a wish not to be resuscitated. This should be clearly expressed and documented in the patient's health record.

Delegation Considerations

The initiation and provision of CPR, including use of an AED, is appropriate for all health care providers.

Equipment

AED (some models have the pads, cables, and AED preconnected)
Self-adhesive, pregelled electrode monitor-defibrillator pads (6)
Cables to connect the pads and AED
Razor
Towel

Assessment

Assess the patient for unresponsiveness, effective breathing, and signs of circulation. Assess the patient's vital parameters and determine the patient's level of responsiveness. Check for partial or complete airway obstruction. Assess for the absence or ineffectiveness of respirations. Assess for the absence of signs of circulation and pulses. An AED should be used only when a patient is unresponsive, not breathing, or not breathing normally and lacks signs of circulation (pulseless, lack of effective respirations, coughing, movement). Determine the age of the patient; some AED systems are designed to deliver both adult and child shock doses. Choose the correct electrode pad for the size/age of the patient. If available, use child pads or a child system for children younger than age 8 years (refer to Special Considerations at the end of this Skill).

Determine whether special situations exist that require additional actions before the AED is used or that contraindicate its use (refer to Box 15-1 for details of these situations and appropriate actions).

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Impaired cardiac output
Altered tissue perfusion
Altered breathing pattern

Outcome Identification and Planning

The expected outcomes to achieve when performing AED are that it is performed correctly without adverse effect to the patient, and the patient regains signs of circulation, with organized electrical rhythm and pulse. Additional outcomes include that the patient regains respirations; the patient's heart and lungs maintain adequate function to sustain life; the patient does not experience serious injury; and ACLS is initiated, as indicated.

Implementation

Action	Rationale
1. Verify scene safety. Check for patient responsiveness. Look for no breathing or only gasping. Call for help, pull the call bell, and call the facility emergency response number. Call for emergency equipment and the AED or defibrillator, if available. Put on gloves, if available. Begin CPR (see Skill 15-1).	Verification of scene safety makes sure the environment is safe for rescuers and the patient. Assessing responsiveness prevents starting CPR on a conscious patient. Activating the emergency response system initiates a rapid response. Accessing equipment supports appropriate interventions. Gloves prevent contact with blood and body fluids. Initiating CPR preserves the patient's heart and brain function while awaiting defibrillation.
2. Provide defibrillation (if indicated) at the earliest possible moment, as soon as the AED becomes available.	Early defibrillation (along with high-quality CPR and all components of the Chain of Survival) is necessary to improve chances of survival from pulseless VT and VF (AHA, 2020b). The AED quickly delivers a shock (defibrillation) to the heart muscle to interrupt shockable rhythms and resets the heart's electrical system so a normal (organized) heart rhythm can return (AHA, 2020b).
3. Prepare the AED. Power on the AED by pushing the power button. Some devices will turn on automatically when the lid or case is opened.	Proper setup ensures proper functioning.
4. Attach the AED cables to the adhesive electrode pads (may be preconnected).	Proper setup ensures proper functioning.
5. Stop chest compressions. Peel away the covering from the electrode pads to expose the adhesive surface. Attach the electrode pads to the patient's chest. Place one pad on the upper right sternal border, directly below the clavicle. Place the second pad lateral to the left nipple, with the top margin of the pad a few inches below the axilla (anterolateral positioning) (Figure 2). Alternatively, if two or more rescuers are present, one rescuer should continue chest compressions while another rescuer attaches the AED pads. Attach the AED connecting cables to the AED box, if not preconnected.	Proper setup ensures proper functioning. The most common placement of the electrode pads is the anterior-lateral position (Morton & Fontaine, 2018). This placement puts the heart directly in the current pathway (Morton & Fontaine, 2018). Application by a second rescuer minimizes interruptions in chest compressions.
6. Once the pads are in place and the device is turned on, follow the prompts given by the device. Clear the patient and analyze the rhythm. Ensure no one is touching the patient. Loudly state a “Clear the patient” message. Press the “Analyze” button to initiate analysis, if necessary. Some devices automatically begin analysis when the pads are attached. Avoid all movement affecting the patient during analysis.	Movement and electrical impulses cause artifacts during analysis. Avoidance of artifacts ensures accurate rhythm analysis.
7. If a shockable rhythm is present, the device will announce that a shock is indicated and begin charging. Once the AED is charged, a message will be delivered to shock the patient.	The shock message is delivered through a written or visual message on the AED screen, an auditory alarm, or a voice-synthesized statement.
8. Before pressing the “Shock” button, loudly state a “Clear the patient” message. Visually check that no one is in contact with the patient or the bed (Figure 3). Press the “Shock” button. If the AED is fully automatic, a shock will be delivered automatically.	Ensuring a clear patient avoids accidental shocking of personnel. Avoidance of contact with the patient avoids accidental shock to personnel.
9. Immediately resume CPR, beginning with chest compressions. After about 2 minutes (until prompted by AED or about five complete cycles of CPR), allow the AED to analyze the heart rhythm. If a shock is not advised, resume CPR, beginning with chest compressions. Do not recheck to see if there is a pulse. Follow the AED voice prompts.	Resuming CPR provides optimal treatment. Even when a shock eliminates the dysrhythmia, it may take several minutes for a heart rhythm to establish and even longer to achieve perfusion. Chest compressions can provide coronary and cerebral perfusion during this period. Some AEDs in the community for use by untrained lay rescuers are automatically programmed to cycle through three analysis/shock cycles in one set. This would necessitate turning off the AED after the first shock and turning it back on for future analysis and defibrillation. Be familiar with the type of AED available for use.
10. Continue CPR and use of the AED until advanced care providers take over, the patient starts to breathe or move or otherwise react, you are too exhausted to continue, or an advanced health care provider discontinues CPR.	Once started, CPR must continue until one of these conditions is met. In an acute care setting, help should arrive within a few minutes.
11. Remove gloves and other PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.

Evaluation

The expected outcomes have been met when defibrillation has been performed correctly without adverse effect to the patient; the patient has regained signs of circulation, with organized electrical rhythm and pulse; the patient has regained respirations; the patient's heart and lungs have maintained adequate function to sustain life; the patient has not experienced serious injury; and ACLS has been initiated, as indicated.

Documentation

Guidelines

Document the time the patient was discovered unresponsive and CPR was initiated. Document the time(s) AED shocks were initiated. Continued intervention, such as by the code team, is typically documented on a code form, which identifies the actions and drugs provided during the code. Provide a summary of these events in the patient's health record.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

You find a patient lying on the floor: Determine the patient's level of responsiveness. If the patient is unresponsive, quickly clear an area, call for assistance and AED, and begin CPR (refer to Skill 15-1).
“Check pads” or “Check electrodes” message appears on the AED: The electrode pads are not securely attached to the chest, or the cables are not securely fastened. Check that the pads are firmly and evenly adhered to the patient's skin. Verify connections between the cables and the AED and the cables and electrode pads. Check that the patient is not wet or diaphoretic or has excessive chest hair. See actions below for appropriate interventions in these situations.
Patient has a hairy chest: The adhesive electrode pads may stick to the chest hair instead of to the skin, preventing adequate contact with the skin. Note whether the patient has a hairy chest before the AED pads are applied; if needed, use a razor to shave the area where the AED pads will be placed (AHA, 2020b). If AED pads are already in place and there is insufficient contact or seal due to excess hair, press firmly on the current pads to attempt to provide sufficient adhesion. If unsuccessful, briskly remove the current pads to remove a good portion of the chest hair. If a significant amount of hair remains, quickly shave the area with the razor in the AED case, minimizing delay in shock delivery (Olasveengen et al., 2020). Apply a second set of electrode pads over the same sites. Continue with the procedure.
Patient is noticeably diaphoretic, or the skin is wet: The electrode pads will not attach firmly to wet or diaphoretic skin. Quickly wipe the chest with a cloth or towel before attaching the electrode pads (AHA, 2020b).

Special Considerations

General Considerations

Every effort should be taken to minimize interruptions in chest compressions. A shorter duration of interruptions in chest compressions is associated with better outcomes(AHA, 2020b).
Most defibrillators use multifunctional electrode patches to both monitor and administer electrical therapy. Although paddles are still available, they are seldom used, as positioning requires additional “hands off” time, which depletes myocardial oxygen and energy stores (Morton & Fontaine, 2018, p. 330).
Nurses should know the distinction between automatic and automated AEDs. Automatic AEDs charge and independently deliver a shock when indicated. Automated AEDs require action on the part of the user to deliver the shock. Familiarity with the device is important to its safe and effective use (Morton & Fontaine, 2018, p. 331).
Appropriate maintenance of the AED is critical for proper operation. Check the AED for any visible signs of damage. Check the “ready for use” indicator on the AED daily. Perform maintenance according to the manufacturer's recommendations and facility policy.

Infant and Child Considerations

Most AED models are designed for both pediatric and adult resuscitation attempts; use the pediatric AED pads for children younger than age 8 years (AHA, 2020b). Follow the AED manufacturer's instructions for placement of pediatric AED pads; some require placing pediatric pads in a front and back (anteroposterior) position, while others require right-left (anterolateral) placement. Anteroposterior placement is common for infants (AHA, 2020b).
If pediatric pads are not available, use adult pads. Make sure the pads do not touch each other or overlap (AHA, 2020b). Adult pads deliver a higher shock dose, but a higher shock dose is better than no shock (AHA, 2020b).
Many AEDs are equipped with a pediatric attenuator to decrease (attenuate) the delivered energy to make them suitable for infants and children younger than age 8 years; a pediatric attenuator is often attached to the pediatric AED pads (AHA, 2020b).

Older Adult Considerations

Nurses can help promote informed, shared decision making about CPR to older adults and their families. Educate, support, and advocate for patients as they face this critical choice (Einav et al., 2021). Provide evidence-based information, supportive listening, and a willingness to respect their choices (Sharma et al., 2016).

EVIDENCE FOR PRACTICE
Cardiopulmonary Resuscitation and Emergency Cardiac Care The AHA provides guidelines for cardiopulmonary resuscitation and emergency cardiac care and has incorporated these guidelines into the Basic Life Support and Advanced Life Support education for health care providers who respond to cardiovascular and respiratory emergencies. Refer to the Evidence for Practice in Skill 15-1 for details.

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Skill 15-2

EVIDENCE FOR PRACTICE