Defibrillation
View of defibrillator position and placement, using hands free electrodes.
Defibrillation is the definitive treatment for the life-threatening cardiac arrhythmias, ventricular
fibrillation and pulselessventricular 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.
History
Defibrillation was first demonstrated in 1899 by Prevost and Batelli,
two physiologists from University of Geneva, Switzerland. They discovered that small electric
shocks could induce ventricular fibrillation in dogs, and that larger charges would reverse the
condition.
The first use on a human was in 1947 by Claude Beck, professor of surgery at Case Western
Reserve University. Beck's theory was that ventricular fibrillation often occurred in hearts which
were fundamentally healthy, in his terms "Hearts are too good to die", and that there must be a
way of saving them. Beck first used the technique successfully on a 14 year old boy who was
being operated on for a congenital chest defect. The boy's chest was surgically opened, and
manual cardiac massage was undertaken for 45 minutes until the arrival of the defibrillator.
Beck used internal paddles on either side of the heart, along with procainamide,
an antiarrhythmic drug, and achieved return of normal sinus rhythm.
These early defibrillators used the alternating current from a power socket, transformed from the
110-240 volts available in the line, up to between 300 and 1000 volts, to the exposed heart by
way of 'paddle' type electrodes. The technique was often ineffective in reverting VF while
morphological studies showed damage to the cells of the heart muscle post mortem. The nature
of the AC machine with a large transformer also made these units very hard to transport, and
they tended to be large units on wheels.
Closed-chest method
Until the early 1950s, defibrillation of the heart was possible only when the chest cavity was
open during surgery. The technique used an alternating current from a 300 or
greater volt source delivered to the sides of the exposed heart by 'paddle' electrodes where
each electrode was a flat or slightly concave metal plate of about 40 mm diameter. The closed-
chest defibrillator device which applied an alternating current of greater than 1000 volts,
conducted by means of externally applied electrodes through the chest cage to the heart, was
pioneered by Dr V. Eskin with assistance by A. Klimov in Frunze, USSR (today known
as Bishkek,Kyrgyzstan) in mid 1950s.[2]
Move to direct current
A circuit diagram showing the simplest (non-electronically controlled) defibrillator design, depending on the inductor
(damping), producing a Lown, Edmark or Gurvich Waveform
In 1959 Bernard Lown commenced research into an alternative technique which involved
charging of a bank of capacitors to approximately 1000 volts with an energy content of 100-
200 joules then delivering the charge through an inductance such as to produce a heavily
damped sinusoidal wave of finite duration (~5 milliseconds) to the heart by way of 'paddle'
electrodes. The work of Lown was taken to clinical application by engineerBarouh Berkovits with
his "cardioverter".
The Lown waveform, as it was known, was the standard for defibrillation until the late 1980s
when numerous studies showed that a biphasic truncated waveform (BTE) was equally
efficacious while requiring the delivery of lower levels of energy to produce defibrillation. A side
effect was a significant reduction in weight of the machine. The BTE waveform, combined with
automatic measurement of transthoracic impedance is the basis for modern defibrillators.
Portable units become available
A major breakthrough was the introduction of portable defibrillators used out of the hospital. This
was pioneered in the early 1960s by Prof. Frank Pantridge in Belfast. Today portable
defibrillators are among the many very important tools carried by ambulances. They are the only
proven way to resuscitate a person who has had a cardiac arrest unwitnessed by EMS who is
still in persistent ventricular fibrillation or ventricular tachycardia at the arrival of pre-hospital
providers.
Gradual improvements in the design of defibrillators, partly based on the work developing
implanted versions (see below), have led to the availability of Automated External Defibrillators.
These devices can analyse the heart rhythm by themselves, diagnose the shockable rhythms,
and charge to treat. This means that no clinical skill is required in their use, allowing lay people
to respond to emergencies effectively.
Change to a biphasic waveform
Until the late 1980s, external defibrillators delivered a Lown type waveform (see Bernard Lown)
which was a heavily damped sinusoidal impulse having a mainly uniphasic characteristic.
Biphasic defibrillation, however, alternates the direction of the pulses, completing one cycle in
approximately 10 milliseconds. Biphasic defibrillation was originally developed and used for
implantable cardioverter-defibrillators. When applied to external defibrillators, biphasic
defibrillation significantly decreases the energy level necessary for successful defibrillation.
This, in turn, decreases risk of burns and myocardial damage.
Ventricular fibrillation (VF) could be returned to normal sinus rhythm in 60% of cardiac arrest
patients treated with a single shock from a monophasic defibrillator. Most biphasic defibrillators
have a first shock success rate of greater than 90%.
Implantable devices
A further development in defibrillation came with the invention of the implantable device, known
as an implantable cardioverter-defibrillator (or ICD). This was pioneered at Sinai
Hospital in Baltimore by a team that included Stephen Heilman, Alois Langer, Jack
Lattuca, Morton Mower, Michel Mirowski, and Mir Imran, with the help of industrial collaborator
Intec Systems of Pittsburgh[4]. Mirowski teamed up with Mower and Staewen, and together they
commenced their research in 1969 but it was 11 years before they treated their first patient.
Similar developmental work was carried out by Schuder and colleagues at the University of
Missouri.
The work was commenced, despite doubts amongst leading experts in the field of arrhythmias
and sudden death. There was doubt that their ideas would ever become a clinical reality. In
1962 Bernard Lown introduced the external DC defibrillator. This device applied a direct current
from a discharging capacitor through the chest wall into the heart to stop heart fibrillation. In
1972, Lown stated in the journal Circulation - "The very rare patient who has frequent bouts of
ventricular fibrillation is best treated in a coronary care unit and is better served by an effective
antiarrhythmic program or surgical correction of inadequate coronary blood flow or ventricular
malfunction. In fact, the implanted defibrillator system represents an imperfect solution in search
of a plausible and practical application."
The problems to be overcome were the design of a system which would allow detection of
ventricular fibrillation or ventricular tachycardia. Despite the lack of financial backing and grants,
they persisted and the first device was implanted in February 1980 at Johns Hopkins
Hospital by Dr. Levi Watkins, Jr. Modern ICDs do not require a thoracotomy and possess
pacing, cardioversion, and defibrillation capabilities.
The invention of implantable units is invaluable to some regular sufferers of heart problems,
although they are generally only given to those people who have already had a cardiac episode.
Types
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 someambulances. For instance, every NHS ambulance in the United
Kingdom is equipped with a manual defibrillator for use by the attending paramedics and
technicians. In the United States, many advanced EMTs and all paramedics are trained to
recognize lethal arrhythmias and deliver appropriate electrical therapy with a manual defibrillator
when appropriate.
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.
Automated external defibrillator (AED)
An AED at a railway station in Japan. The AED box has information on how to use it in Japanese, English, Chinese
and Korean, and station staff are trained to use it.
These simple-to-use units are based on computer technology which is designed to analyze the
heart rhythm itself, and then advise the user whether a shock is required. They are designed to
be used by lay persons, who require little training to operate them correctly. They are usually
limited in their interventions to delivering high joule shocks for VF (ventricular fibrillation) and VT
(ventricular tachycardia) rhythms, making them generally of limited use to health professionals,
who could diagnose and treat a wider range of problems with a manual or semi-automatic unit.
The automatic units also take time (generally 10–20 seconds) to diagnose the rhythm, where a
professional could diagnose and treat the condition far more quickly with a manual unit.[ These
time intervals for analysis, which require stopping chest compressions, have been shown in a
number of studies to have a significant negative effect on shock success. This effect led to the
recent change in the AHA defibrillation guideline (calling for two minutes of CPR after each
shock without analyzing the cardiac rhythm) and some bodies recommend that AEDs should not
be used when manual defibrillators and trained operators are available.
Automated external defibrillators are generally either held by trained personnel who will attend
incidents, or are public access units which can be found in places including corporate
and government offices, shopping centres, airports,restaurants, casinos, hotels, sports
stadiums, schools and universities, community centers, fitness centers and health clubs.
An automated external defibrillator, open and ready for pads to be attached
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 causes of pediatric cardiac arrest are respiratory arrest and trauma - where the
heart is more likely to enter asystole or PEA, (where an AED is of no use). On the other hand, 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. EMT-Basics in most
areas are not trained in manual defibrillation, and often carry an AED instead. Some
ambulances carry 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. The presence of an AED can be a particularly decisive factor in cardiac patient
survival in these scenarios, as professional medical assistance may be hours away.
In order to make them highly visible, public access AEDs often are brightly coloured, and are
mounted in protective cases near the entrance of a building. When these protective cases are
opened, and the defibrillator removed, some will sound a buzzer to alert nearby staff to their
removal but do not necessarily summon emergency services. All trained AED operators should
also know to phone for an ambulance when sending for or using an AED, as the patient will be
unconscious, which always requires ambulance attendance.
Semi-automated external defibrillators
A Lifepak semi-automatic defibrillator/ECG monitor mounted in an ambulance. These units are designed for use only
by healthcare professionals and are capable of measuring blood pressure and blood oxygen saturation in addition to
the primary functions.
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.
Implantable cardioverter-defibrillator (ICD)
Also known as automatic internal cardiac defibrillator (AICD). These devices are implants,
similar to pacemakers (and many can also perform the pacemaking function). They constantly
monitor the patient's heart rhythm, and automatically administer shocks for various life
threatening arrhythmias, according to the device's programming. Many modern devices can
distinguish between ventricular fibrillation, ventricular tachycardia, and more benign arrhythmias
like supraventricular tachycardia and atrial fibrillation. Some devices may attempt overdrive
pacing prior to synchronised cardioversion. When the life threatening arrhythmia is ventricular
fibrillation, the device is programmed to proceed immediately to an unsynchronized shock.
There are cases where the patient's ICD may fire constantly or inappropriately. This is
considered a medical emergency, as it depletes the device's battery life, causes significant
discomfort and anxiety to the patient, and in some cases may actually trigger life threatening
arrhythmias. Some emergency medical services personnel are now equipped with a
ring magnet to place over the device, which effectively disables the shock function of the device
while still allowing the pacemaker to function (if the device is so equipped). If the device is
shocking frequently, but appropriately, EMS personnel may administer sedation.
Wearable cardiac defibrillator
A development of the AICD is a portable external defibrillator that is worn like a vest.[9] The unit
monitors the patient 24 hours a day and will automatically deliver a biphasic shock if needed.
This device is mainly indicated in patients awaiting an implantable defibrillator. Currently only
one company manufactures these and they are of limited availability.
Modelling defibrillation
The efficacy of a cardiac defibrillator is highly dependent on the position of its electrodes. Most
internal defibrillators are implanted in octogenarians, but a few children need the
devices. Implanting defibrillators in kids is particularly difficult because children are small, will
grow over time, and possess cardiac anatomy that differs from that of adults. Recently,
researchers were able to create a software modeling system capable of mapping an
individual’s thorax and determining the optimal position for an external or internal cardiac
defibrillator.
With the help of pre-existing surgical planning applications, the software uses myocardial
voltage gradients to predict the likelihood of successful defibrillation. According to the critical
mass hypothesis, defibrillation is effective only if it produces a threshold voltage gradient in a
large fraction of the myocardial mass. Usually, a gradient of three to five volts per centimeter is
needed in 95 % of the heart. Voltage gradients of over 60 V/cm can damage tissue. The
modeling software seeks to obtain safe voltage gradients above the defibrillation threshold.
Early simulations using the software suggest that small changes in electrode positioning can
have large effects on defibrillation, and despite engineering hurdles that remain, the modeling
system promises to help guide the placement of implanted defibrillators in children and adults.
Recent mathematical models of defibrillation are based on the bidomain model of cardiac
tissue. Calculations using a realistic heart shape and fiber geometry are required to determine
how cardiac tissue responds to a strong electrical shock.
Interface with the patient
The most well-known type of electrode (widely depicted in films and television) is the traditional
metal paddle with an insulated (usually plastic) handle. This type must be held in place on the
patient's skin while a shock or a series of shocks is delivered. Before the paddle is used, a gel
must be applied to the patient's skin, in order to ensure a good connection and to
minimize electrical resistance, also called chest impedance (despite the DC discharge). These
are generally only found on the manual external units.
Newer types of resuscitation electrodes are designed as an adhesive pad. These are peeled off
their backing and applied to the patient's chest when deemed necessary, much the same as
any other sticker. These electrodes are then connected to a defibrillator. If defibrillation is
required, the machine is charged, and the shock is delivered, without any need to apply any gel
or to retrieve and place any paddles. These adhesive pads are found on most automated and
semi-automated units, and are gradually replacing paddles entirely in non-hospital settings.
Both solid- and wet-gel adhesive electrodes are available. Solid-gel electrodes are more
convenient, because there is no need to clean the patient's skin after removing the electrodes.
However, the use of solid-gel electrodes presents a higher risk of burns during defibrillation,
since wet-gel electrodes more evenly conduct electricity into the body.
Some adhesive electrodes are designed to be used not only for defibrillation, but also for
transcutaneous pacing and synchronized electrical cardioversion.
In a hospital setting, paddles are generally preferred to pads, due to the inherent speed with
which they can be placed and used. This is critical during cardiac arrest, as each second of
nonperfusion means tissue loss. However, in cases in which cardiac arrest is suspected,
patches placed prophalactically are superior,as they provide appropriate EKG tracing without
the artifact visible from human interference with the paddles. Adhesive electrodes are also
inherently safer than the paddles for the operator of the defibrillator to use, as they minimize the
risk of the operator coming into physical (and thus electrical) contact with the patient as the
shock is delivered, by allowing the operator to stand several feet away. Adhesive patches also
require no force to remain in place and deliver the shock appropriately, whereas paddles require
approximately 25 lbs of force to be applied while the shock is delivered.[Citation Needed]
Placement
Anterio-apical placement of external defibrillator electrodes (When defibrillation is unsuccessful, anterior-posterior
placement is also sometimes attempted)
Resuscitation electrodes are placed according to one of two schemes. The anterior-posterior
scheme (conf. image) is the preferred scheme for long-term electrode placement. One electrode
is placed over the left precordium (the lower part of the chest, in front of the heart). The other
electrode is placed on the back, behind the heart in the region between the scapula. This
placement is preferred because it is best for non-invasive pacing.
The anterior-apex scheme can be used when the anterior-posterior scheme is inconvenient or
unnecessary. In this scheme, the anterior electrode is placed on the right, below the clavicle.
The apex electrode is applied to the left side of the patient, just below and to the left of the
pectoral muscle. This scheme works well for defibrillation and cardioversion, as well as for
monitoring an ECG.
Popular culture references
As devices that can quickly produce dramatic improvements in patient health, defibrillators are
often depicted in movies, television, video games and other fictional media. Their function,
however, is often exaggerated, with the defibrillator inducing a sudden, violent jerk or convulsion
by the patient; in reality, although the muscles may contract, such dramatic patient presentation
is rare. Similarly, medical providers are often depicted defibrillating patients with a "flat-line"
ECG rhythm (also known as asystole); this is not done in real life. Only the cardiac arrest
rhythms ventricular fibrillation and pulselessventricular tachycardia are normally defibrillated.
(There are also several heart rhythms that can be "shocked" when the patient is not in cardiac
arrest, such assupraventricular tachycardia and ventricular tachycardia that produces a pulse;
this procedure is known as cardioversion, not defibrillation.)
