Cardiology In Critical
After review/study of
these pages and attendance at a Critical Care Nursing Skills Lab,
the critical care nurse will be able to:
- State the two
dysrhythmias for which defibrillation is indicated.
- Given a
hypothetical patient scenario, demonstrate the proper
emergency measures to be followed.
- State two key
differences between adult and pediatric defibrillation.
Defibrillation is achieved by delivering a strong electric
current though electrodes placed on the surface of a patients
chest wall. Proper electrode placement ensures that the axis of
the heart is directly situated between the sources of current (defibrillator
paddles). Since dysrhythmias are chaotic with no coordinated
ventricular response, the electric current is delivered randomly.
It is through implementation of emergent defibrillation that
ventricular fibrillation and pulseless ventricular tachycardia
can be terminated and cardiac output restored.
- To eradicate life-threatening
ventricular fibrillation or pulseless ventricular
- To restore cardiac
output lost due to dysrhythmias and reestablish tissue
perfusion and oxygenation.
- Conductive medium-
- Cardiac monitor
- Emergency cart and
- Emergency pacing
- Verify V-fib
or V-tach by ECG and correlate with clinical state.
Assess to determine absence of pulse. Call for help
and perform CPR until defibrillator and crash cart
- Prepare for
- Turn power
"ON". Defaults to 200 joules.
correct paddles- adult, pediatric or internal.
patient and/or paddles with proper conductive
that defibrillator is in asynchronous mode.
*** If other than
200 joules desired, press "ENERGY SELECT"
and select desired amount
- Turn on ECG
recorder for continuous printout.
- Places one
paddle at the hearts Apex just left of the
nipple in midaxillary line. Place the other paddle
just below the right clavicle to the right of the
sternum, applying 25 lbs. / square inch pressure to
- ***Press "CHARGE"
on defibrillator front panel or on the Apex paddle.
Wait until indicator stops flashing to indicate fully
- ***State "ALL
CLEAR" and visually check that all personnel are
clear of contact with bed, patient and equipment.
- ***Checks rhythm
immediately before discharge.
- 8. Depress
both buttons simultaneously and maintain pressure
until electrical current delivered. (Maintain 25 lbs/in2)
- ***Assess conversion of
- 10. If first
defibrillation unsuccessful, immediately charge
paddles to 300 joules and repeat steps 2 through 9.
- If second
defibrillation unsuccessful, immediately charge
paddles to 360 joules and repeat steps 2 through 9.
- If third
attempt is unsuccessful, continue CPR, initiate ACLS
protocols, intubate and obtain IV access. Assess
patient status and precipitating factors to prevent
further decompensation of patient.
defibrillator and paddles, discard supplies, and wash
procedure in patient record or cardiac arrest
- May be
mistaken for artifact or leads may be off.
situation. If a second person is getting the
defibrillator, establish an airway and begin CPR.
- Convert to
pediatric size for children or internal if the
patient is has an open chest.
electrical conduction through subcutaneous tissue
and assists in minimizing burns.
- Limit to
paddle area.Use 2 joules/kg for children.
- Will not
fire if it is in synchronous mode due to absence
of R wave
- Establishes a
visual recording and a permanent record of current
ECG status and response to intervention.
s achieved by passing an electric current through
cardiac muscle mass to restore a single source of
impulse generation. Decreases transthoracic
resistance and improves flow of current across axis
- This will
charge unit with current.
safety to caregivers, since electric current can be
conducted from the patient to another individual if
- ECG rhythm may
change, ensure it is a rhythm that requires
release may result in failure to discharge energy.
May also be delivered by depressing discharge button
on the defibrillator.
- If rhythm has
converted, must reassess.
action increases chance for successful depolarization
of cardiac muscle. Transthoracic resistance decreases
by approximately 8 % with the second shock.
action increase chance of successful depolarization
of cardiac muscle. "Stacked shocks"
sequence is more important than adjunctive drug
therapy and delays between shocks to deliver
medications are detrimental.
- Necessary to
maintain the delivery of oxygenated blood to vital
- Conductive gel
accumulated on defib paddles impedes surface contact
and increases transthoracic resistance.
- Provides for
completion of medical/ nursing records.
status. Reorient to person, place, and time.
status. Auscultate lung sounds, Monitor rate, depth,
& quality of breathing. Oxygen as ordered.
status. Get 12-lead ECG and continue to monitor
rhythm and blood pressure, pulse and respirations
frequently until stable.
- Initiate IV
- Monitor for
burns. Treat if indicated.
Include neurologic, respiratory and cardiovascular
assessment before and after defibrillation. All code
related information should be completed on the code
education. Assess understanding of past, current and
altered LOC occurs following defibrillation. Cerebral
anoxia or emboli may develop as a post-procedure
centers of the brain may be depressed as a result of
may develop after defibrillation .
dysrhythmias are indicative of myocardial
irritability, and if antidysrhythmic therapy is not
administered, recurrence of ventricular dysrhythmias
current in contact with subcutaneous tissue can cause
loss of skin integrity.
- Provides a
record of pre-procedure patient status, nursing
interventions, post-procedure patient status, and
both expected and unexpected outcomes. Serves as a
legal medical record of the events.
patient and family for both expected and unexpected
- Check all
equipment for proper grounding to prevent current
temporary pacemaker and other electrical equipment.
- Do not
defibrillate directly over an implanted pacemaker.
Defibrillation may result in damage to equipment.
patient and family as necessary after defibrillation.
defibrillator of remaining electrical current
immediately; never set charged defibrillator paddles
down. Prepare equipment for future use.
patient with CPR as appropriate.
- Check possible
causes of failure to convert ventricular dysrhythmias:
- Debris on
paddles which impairs conductivity
amplitude fibrillatory waves, which can be
associated with long-standing ventricular
fibrillation, acidosis and hypoxia; this requires
CPR measures prior to defibrillation.
wires and faulty equipment.
- Recognize the
following differences for internal defibrillation:
sterile internal defibrillator paddles.
sterile gel pads between myocardium and
defibrillator to prescribed voltage; a
significantly lower (15-30 joules) energy level
- Recognize the
following changes for pacemaker defibrillation:
- Turn off
temporary external pacemaker.
placing defibrillator paddles over permanent
pulse generator or electrode.
- Cardiac arrest
Pulmonary or systemic emboli
arrest Equipment malfunction
- Altered skin
Cardiac Life Support, 1994 American Heart Association.
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page last updated 07/25/10