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· ventricular arrhythmia (ventricular tachycardia or ventricular fibrillation) and associated cardiac arrest (unresponsive patient without a pulse)
· awake, responsive patients
· any arrhythmias in a patient with a pulse
· many different machines/models
· become familiar with equipment where you are practicing
· adult size (8-9cm diameter) for patient weight > 10 kg.
· pediatric size ( 2.2 cm diameter) for patient weight < 10 kg.
· Electrode pads
· Self – adhesive
· Conductive material
· Gel, paste or pads
PRE-PROCEDURE PATIENT EDUCATION:
· Not necessary (or possible) for an emergent, potentially life-saving procedure in an unresponsive patient
· Sudden death/cardiac arrest patients in VF or VT without a pulse should be defibrillated as soon as possible (even before CPR, medications or advanced airway procedures)
· Initiate CPR/ACLS protocols until defibrillator available
· Power on the defibrillator and select “unsynchronized/defibrillation” mode
· turn monitor selector to “paddles”
· Apply conductive materials (depends on what is available) before paddle placement
· Apply defibrillator monitor cables, pads, or “quick-look” paddles to patient in cardiac arrest to determine rhythm
· Paddle placement:
· First (“sternum”) paddle: to the right of the upper sternum and below the clavicle
· Second (“apex”) paddle: to the left of the nipple in the midaxillary line, centered in the 5th intercostal space
· Avoid placing both paddles next to one another on the anterior chest wall
· Lead placement:
· “White-on-the-right” will help you to remember the white electrode is placed on the right side of the chest just below the right clavicle
· “smoke over fire” will help you to remember that the black lead is placed on the left chest just below the left clavicle, and the red lead is placed in the left midaxillary line below the expected PMI of the heart
· electrode pad placement:
· can be placed as described above for paddles, or
· anterior pad just to the left of the sternum, and posterior pad on the patient’s back to the left of the spine. (This technique “sandwiches” the heart between the pads)
· assess rhythm to confirm VF/VT:
· if you see a flatline, turn up the gain to rule out fine VF, if flatline remains (and you have checked monitor, connections, and the patient) rotate paddles 90 degrees and re-assess rhythm to assure VF or (pulseless) VT remains
· choose energy level and charge defibrillator (“charge” buttons may be located on the paddles or on the machine itself)
· deliver shock(s) by simultaneously pressing the discharge buttons located on the paddles (or on the monitor for electrode pads) after ensuring “all clear” from the patient for equipment and providers
· re-assess patient, consider recommended medications, further management
COMPLICATIONS, Prevention & Management:
· Soft tissue injury can occur after repeated shocks. The presence of liquid (body fluids, medications, or IV fluids) may cause electrical arching thermal burns to the skin and soft tissue and produce ineffective defibrillation by allowing the current to pass across the trunk rather than transthoracic. To minimize this potential complication, ensure that any body fluids or liquids are wiped away from the skin before defibrillation attempts.
· Myocardial and epicardial injury may result from the electrical current (not direct thermal injury)applied in defibrillation. Use the minimal recommended energy levels to minimize injury
· Post-defibrillation cardiac dysrhythmias are more common following prolonged VF and higher energy level countershocks. Early defibrillation at the recommended energy levels minimizes this complication. Follow ACLS protocols to manage resulting dysrhythmias.
· Electrical injuries to health care providers can result if participants remain in contact with the patient during delivery of a countershock, because they can serve as a ground for the current discharged. Fires which can result from sparks in the presence of nitroglycerin patches or ointment, flammable gasses, or an oxygen-rich environment can also be a source of injury to the patient or healthcare providers. Ensure “all clear” from the patient prior to delivery of shock to avoid these complications.
DOCUMENTATION FOR THE MEDICAL RECORD:
· most facilities have a “code sheet” to be filled out by a member of the code team. This sheet should be reviewed for accuracy and completeness and signed by the physician (resident and/or attending) in charge of the code.
· A brief progress note should be written in the chart to include the circumstances of the “code,” patient outcome, disposition, and the notification of attending physician and family members. You should also make reference to the code sheet for medications given and other details of the code.
ITEMS FOR EVALUATION:
· Performs accurate patient assessment and recognizes VF/VT
· Understands indications / contraindications for defibrillation
· Applies and operates defibrillator/monitor properly and safely
· Completes appropriate documentation for medical record
· Effectively communicates with patient, family and involved physicians