Performing Emergency Manual External Defibrillation (Asynchronous)

Goal: The procedure is performed correctly without adverse effect to the patient; and the patient regains signs of circulation.

1. Assess responsiveness. If the patient is not responsive, call for help and pull call bell, and call the facility emergency response number. Call for the AED. Put on gloves, if available. Perform cardiopulmonary resuscitation (CPR) until the defibrillator and other emergency equipment arrive.

2. Turn on the defibrillator.

3. If the defibrillator has “quick-look” capability, place the paddles on the patient’s chest. Otherwise, connect the monitoring leads of the defibrillator to the patient and assess the cardiac rhythm.

4. Expose the patient’s chest, and apply conductive pads at the paddle placement positions. For anterolateral placement, place one pad to the right of the upper sternum, just below the right clavicle, and the other over the fifth or sixth intercostal space at the left anterior axillary line. ‘Hands-free’ defibrillator pads can be used with the same placement positions, if available. For anteroposterior placement, place the anterior paddle directly over the heart at the precordium, to the left of the lower sternal border. Place the flat posterior paddle under the patient’s body beneath the heart and immediately below the scapulae (but not on the vertebral column).

5. Set the energy level for 360 J (joules) for an adult patient when using a monophasic defibrillator. Use clinically appropriate energy levels for biphasic defibrillators, beginning with 150 to 200 J (AHA, 2005b).

6. Charge the paddles by pressing the charge buttons, which are located either on the machine or on the paddles themselves.

7. Place the paddles over the conductive pads and press firmly against the patient’s chest, using 25 pound (11 kg) of pressure. If using hands-off pads, do not touch the paddles.

8. Reassess the cardiac rhythm.

9. If the patient remains in VF or pulseless VT, instruct all personnel to stand clear of the patient and the bed, including the operator.

10. Discharge the current by pressing both paddle charge buttons simultaneously. If using remote defibrillator pads, press the discharge or shock button on the machine.

11. 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 move, you are too exhausted to continue, or a physician discontinues CPR. Advanced care providers will indicate when a pulse check or other therapies are appropriate.

12. If necessary, prepare to defibrillate a second time. Energy level on the monophasic defibrillator should remain at 360 J for subsequent shocks (AHA, 2005b).

13. Announce that you are preparing to defibrillate and follow the procedure described above.

14. 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.
b. If signs of circulation are present, check breathing. If breathing is inadequate, assist breathing. Start rescue breathing (one breath every 5 seconds).
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, breath sounds, and skin color and temperature.
e. Obtain baseline ABG levels and a 12-lead ECG, if ordered.
f. Provide supplemental oxygen, ventilation, and medications, as needed.

15. Check the chest for electrical burns and treat them, as ordered, with corticosteroid- or lanolin-based creams. If using ‘hands-free’ pads, keep pads on in case of recurrent ventricular tachycardia or ventricular fibrillation.

16. Remove gloves, if used. Perform hand hygiene.

17. Prepare the defibrillator for immediate reuse.