Strategies Before Defibrillation
Precordial Thump
One immediate precordial thump may be considered after a monitored cardiac arrest if an electrical defibrillator is not immediately available.
Cardiopulmonary Resuscitation (CPR) before Defibrillation
A 1-1/2 to 3-minute period of CPR before attempting defibrillation may be considered in adults with out-of-hospital ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) and Emergency Medical Services (EMS) response (call to arrival) intervals >4 to 5 minutes. There is no evidence to support or refute the use of CPR before defibrillation for in-hospital cardiac arrest.
Use of Automatic External Defibrillators (AEDs)
AED Programs
Use of AEDs by trained lay and professional responders is recommended to increase survival rates in patients with cardiac arrest. Use of AEDs in public settings (airports, casinos, sports facilities, etc.) where witnessed cardiac arrest is likely to occur can be useful if an effective response plan is in place. The response plan should include equipment maintenance, training of likely responders, coordination with local EMS systems, and program monitoring. No recommendation can be made for or against personal or home AED deployment.
AED Program Quality Assurance and Maintenance
AED programs should optimize AED function (rhythm analysis and shock), battery and pad readiness, operator performance, and system performance (e.g., mock codes, time to shock, outcomes).
AED Use in Hospitals
Use of AEDs is reasonable to facilitate early defibrillation in hospitals.
Electrode-Patient Interface
Electrode Pad/Paddle Position and Size
Paddles and electrode pads should be placed on the exposed chest in an anterolateral position. Acceptable alternative positions are anteroposterior (paddles and pads) and apex posterior (pads). In large-breasted patients it is reasonable to place the left electrode pad (or paddle) lateral to or underneath the left breast. Defibrillation success may be higher with 12-cm electrodes than with 8-cm electrodes. Small electrodes (4.3 cm) may be harmful; myocardial injury can occur.
Self-Adhesive Defibrillation Pads Versus Paddles
Self-adhesive defibrillation pads are safe and effective and are an acceptable alternative to standard defibrillation paddles.
Initial Shock Waveform and Energy Levels
Biphasic Versus Monophasic Waveforms for Ventricular Defibrillation
Biphasic waveform shocks are safe and effective for termination of VF when compared with monophasic waveform shocks.
Energy Level for Defibrillation
There is insufficient evidence for or against specific selected energy levels for the first or subsequent biphasic shocks. With a biphasic defibrillator it is reasonable to use 150 J to 200 J with biphasic truncated exponential (BTE) waveforms or 120 J with the rectilinear biphasic waveform for the initial shock. With a monophasic waveform defibrillator, an initial shock of 360 J is reasonable.
Second and Subsequent Shocks
Fixed Versus Escalating Energy
Nonescalating- and escalating-energy biphasic waveform defibrillation can be used safely and effectively to terminate VF of both short and long duration.
1-Shock Protocol Versus 3-Shock Sequence
Priorities in resuscitation should include early assessment of the need for defibrillation (see National Guideline Clearinghouse [NGC] summary for the American Heart Association guideline Adult Basic Life Support), provision of CPR until a defibrillator is available, and minimization of interruptions in chest compressions. Rescuers can optimize the likelihood of defibrillation success by optimizing the performance of CPR, timing of shock delivery with respect to CPR, and the combination of waveform and energy levels. A 1-shock strategy may improve outcome by reducing interruption of chest compressions. A 3-stacked shock sequence can be optimized by immediate resumption of effective chest compressions after each shock (irrespective of the rhythm) and by minimizing the hands-off time for rhythm analysis.
Related Defibrillation Topics
Defibrillator Data Collection
Monitor/defibrillators modified to enable collection of data on compression rate and depth and ventilation rate may be useful for monitoring and improving process and outcomes after cardiac arrest.
Oxygen and Fire Risk During Defibrillation
Rescuers should take precautions to minimize sparking (by paying attention to pad/paddle placement, contact, etc) during attempted defibrillation. Rescuers should try to ensure that defibrillation is not attempted in an oxygen-enriched atmosphere.
