Performing Emergency Manual External Defibrillation (Asynchronous)

Skill 15-3

Performing Emergency Manual External Defibrillation (Asynchronous)

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 self-adhering electrode pads delivering the current are placed on the patient's chest; during cardiac surgery, electrode paddles are placed directly on the myocardium.

Manual defibrillation is accomplished with an external defibrillator (Figure 1) and depends on the operator for analysis of rhythm, charging, proper application of the self-adhering electrode pads to the patient's thorax, and delivery of the shock. It requires the user to have immediate and accurate dysrhythmia recognition skills. The following guidelines are based on the AHA (2020b) guidelines.

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 manual external defibrillation should be performed by health care providers who are certified in advanced cardiac life support (ACLS) measures.

Equipment

Defibrillator (biphasic*)
External self-adhering electrode pads (or internal paddles sterilized for cardiac surgery)
Electrocardiogram (ECG) monitor with recorder, depending on equipment available (usually part of the defibrillator)
Oxygen therapy equipment
Bag-valve-mask
Airway equipment
Emergency pacing equipment
Emergency cardiac medications
Razor

*Biphasic defibrillators have replaced monophasic shock defibrillators, which are no longer manufactured. Biphasic defibrillators are safer and more effective (AHA, 2020a).

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.

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 breathing pattern
Injury risk

Outcome Identification and Planning

The expected outcomes to achieve when performing manual external defibrillation 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 may 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 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 automated external defibrillator (AED) or defibrillator, if available. Put on gloves, if available. Begin CPR, as indicated (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 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. Turn on the defibrillator.	Charging prepares for defibrillation.
4. Expose the patient's chest and apply electrode pads to the 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 electrode pads. Assess the cardiac rhythm.	Proper setup ensures proper functioning. This placement puts the heart directly in the current pathway (Morton & Fontaine, 2018). Application by a second rescuer minimizes interruptions in chest compressions. Connecting the monitor leads to the patient allows for assessment of the cardiac rhythm and determination of the need for defibrillation.
5. Set the energy level for a clinically appropriate energy level for the defibrillator, beginning with 120 to 200 J (joules) (depending on the specific biphasic defibrillator in use) (AHA, 2020a).	Proper setup ensures proper functioning and appropriate intervention.
6. If the patient remains in VF or pulseless VT, loudly state a “Clear the patient” message. Visually check that no one is in contact with the patient or the bed. Press the button to deliver the shock.	Standing clear of the bed and patient avoids accidental shocking of personnel. Pressing the shock button discharges the electric current for defibrillation.
7. After the shock, immediately resume CPR, beginning with chest compressions. After five cycles (about 2 minutes), reassess the cardiac rhythm. Continue until advanced care providers take over; the patient starts to breathe, move, or otherwise react; you are too exhausted to continue; or an advanced health care provider discontinues CPR.	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. Once started, CPR must continue until one of these conditions is met. In an acute care setting, help should arrive within a few minutes.
8. If necessary, prepare to defibrillate subsequent shocks per ACLS protocol; if initial cardioversion is unsuccessful, energy is increased in subsequent attempts, depending on the defibrillator in use (AHA, 2020a).	Additional shocking may be needed to stimulate the heart. Commercially available defibrillators will either provide fixed energy settings or allow for escalating energy settings (AHA, 2020a).
9. Announce that you are preparing to defibrillate and follow the procedure described above.	Additional shocking may be needed to stimulate the heart.
10. If defibrillation restores a normal rhythm:
a. Check for signs of circulation; check the central and peripheral pulses, and obtain a blood pressure reading, heart rate, and respiratory rate.	The patient will need continuous monitoring to prevent further problems. Continuous monitoring helps provide for early detection and prompt intervention should additional problems arise.
b. If signs of circulation are present, check breathing. If breathing is inadequate, assist with breathing. Administer rescue breathing at a rate of one breath every 6 seconds, for a rate of 10 breaths/min (refer to Skill 15-1).	Rescue breathing maintains adequate oxygenation.
c. If breathing is adequate, place the patient in the recovery position. Continue to assess the patient.
d. Assess the patient's level of consciousness, cardiac rhythm, blood pressure, breath sounds, skin color, and temperature.	Reassessment determines the need for continued intervention and provides optimal treatment.
e. Obtain baseline ABG levels (Skill 18-11) and a 12-lead ECG (Skill 15-4), if prescribed.	These assessments provide data to help inform continued intervention and optimal treatment.
f. Provide supplemental oxygen, ventilation, and medications, as needed.	This provides optimal treatment.
g. Anticipate the possible use of targeted temperature management, including therapeutic hypothermia.	Lowering of a patient's core temperature after cardiac arrest may improve survival and functional recovery (AHA, 2020a; Morton & Fontaine, 2018).
11. Keep the electrode pads on the patient in case of recurrent VT or VF.	Keeping the pads in place provides preparation for future use.
12. 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.
13. Prepare the defibrillator for immediate reuse.	The patient may remain unstable and could require further intervention.

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 you discovered the patient unresponsive and started CPR. Document the procedure, including the patient's ECG rhythms both before and after defibrillation; the number of times defibrillation was performed; the voltage used during each attempt; whether a pulse returned; the dosage, route, and time of drug administration; whether CPR was used; how the airway was maintained; and the patient's outcome. 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

Defibrillator fails to fire: Check that the power is turned on. If the defibrillator is battery operated, check if the battery is low. Check that it is fully charged.
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).
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. 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. Dry the chest with a cloth or towel before attaching the electrode pads.

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).
Alternative placement of self-adhering electrode pads: Anterior-posterior placement. Place one pad anteriorly at the precordium to the left of the lower sternal border and the other pad posteriorly under the patient's body beneath the heart and immediately below the scapula (Figure 3).
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).
Defibrillation can cause accidental electric shock to those providing care.
Defibrillators vary from one manufacturer to another, so familiarize yourself with your facility's equipment. Perform maintenance according to the manufacturer's recommendations and facility policy.

Infant and Child Considerations

If pediatric defibrillator pads are not available, use adult pads. Make sure the pads do not touch each other or overlap (AHA, 2020b).

Older Adult Considerations

Nurses can help promote informed 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 CPR 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 15-3

EVIDENCE FOR PRACTICE