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Determinants of Successful Defibrillation

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Determinants of Successful Defibrillation Heart 1998;80:405–407 405 BRIEF REVIEW Heart: first published as 10.1136/hrt.80.4.405 on 1 October 1998. Downloaded from Determinants of successful defibrillation G W N Dalzell Ventricular defibrillation by electric counter Other approaches have included the use of shock is the definitive treatment for cardiac telemedicine technology. Transtelephonic con- arrest due to ventricular fibrillation (VF). Ven- trol of defibrillation using standard telephone tricular defibrillation is the fundamental cor- land lines was shown to be eVective in 1988,5 nerstone to a successful outcome. As most and later extended to use with a cellular deaths from VF occur out of hospital, often in device.6 Transtelephonic defibrillation in pa- patients without pre-existent recognised car- tients with collapse out of hospital due to VF diac disease, the major public health issue provides defibrillation more rapidly, and oVers remains the widespread application of external control and performance of defibrillation by defibrillation. This article therefore concen- remotely sited trained hospital personnel. trates exclusively on transthoracic counter In 1993 the American Heart Association shock, while recognising clinically relevant Task Force on Automatic External Defibrilla- recent developments in internal defibrillation tion was asked to consider how access to defi- that are applicable to a small proportion of the brillation might be achieved more rapidly in total population at risk. patients facing sudden cardiac death. The Electrical defibrillation occurs when a suY- report from the first public access defibrillation cient mass of excitable cells is simultaneously conference7 highlighted the challenge of pro- depolarised by an adequate intracardiac ducing lightweight, inexpensive, small, easy to current,1 thereby extinguishing activation use, durable, maintenance free devices. In the fronts within a critical myocardial mass. A United States, less than 50% of emergency threshold current density must be attained medical technicians and only 20% of public within the myocardium to achieve defibrilla- safety personnel are adequately prepared to tion. The electrical circuit formed during defi- treat sudden cardiac death. Only 41% of emer- http://heart.bmj.com/ brillation includes impedance of two gency medical technicians are equipped with electrode–electrolyte–tissue interfaces and of automatic external defibrillators. The second the intervening tissues. The main determinants public access defibrillation conference empha- of intracardiac current flow during electric sised the components of public access defibril- counter shock are the energy selected and trans- lation and steps already taken, including thoracic impedance (TTI) of the patient. The broadening the range of people who can act as development of methods to predict TTI in first responders.8 American legislation (the advance of a defibrillatory counter shock2 has Cardiac Arrest Survival Act) is being intro- been a significant aid, enabling novel tech- duced in an attempt to pave the way for univer- on September 30, 2021 by guest. Protected copyright. niques for defibrillation to emerge and closer sal access to emergency cardiac care. examination of factors involved in determining the success or failure of counter shocks. New techniques Clinical needs drive the design of new devices. Recent research has identified areas of defibril- Early defibrillation lator design that may be of benefit if incorpo- Early defibrillation is one, if not the major, pri- rated into mainstream commercially available ority of the new global guidelines recently devices. One example is current based defibril- reported in the advisory statements of the lation. Use of a fixed energy level during International Liaison Committee on defibrillation results in a variable range of gen- Resuscitation.3 erated transthoracic currents, as TTI varies The fundamental importance of early defi- significantly between patients. A microproces- brillation as a major predictor of outcome in sor controlled current based defibrillator auto- patients with VF has been known since matically measures TTI and calculates the portable direct current defibrillators were energy required to develop a selected current. introduced in the 1960s. This clinical observa- This system enables rapid delivery of an accu- Regional Medical tion drove hardware development leading to rately calibrated preselected transthoracic cur- 9 Cardiology Centre, the manufacture of automatic external defibril- rent to patients with VF. This device was as Royal Victoria lators that are commercially available today, eVective as conventional defibrillators using a Hospital, Belfast BT12 which themselves were dependent on the fixed energy protocol, but was superior in 6BA, UK development of self adhesive electrocardio- delivering less energy and current per shock. G W N Dalzell graph (ECG) defibrillator pads4 for easy use by Research in internal defibrillation has con- Correspondence to: minimally trained personnel during cardiac firmed the superior eYcacyofdiVerent wave- Dr Dalzell. arrest. forms for ventricular defibrillation.10 The 406 Dalzell biphasic waveform produces experimentally propriate electrode placement is the most lower defibrillation thresholds than the com- frequently encountered error in the use of monly employed monophasic waveform for automatic external defibrillators. The increas- Heart: first published as 10.1136/hrt.80.4.405 on 1 October 1998. Downloaded from transthoracic defibrillation.11 Superior eYcacy ingly widespread use of self adhesive ECG with biphasic waveforms was reported in the defibrillator pads is the result of the high qual- recently published multicentre, prospective, ity ECG signal for monitoring during cardiac randomised comparison of monophasic (Ed- arrest, adhesive qualities ensuring consistently mark) versus biphasic (Gurvich) waveforms for accurate electrode placement, increased opera- transthoracic cardioversion/defibrillation of pa- tor safety, less artefact, and quicker delivery of tients in the electrophysiology laboratory.12 shocks.15 Their development was an essential Patients were randomised in a blinded fashion step for the development and use of automatic to receive either a monophasic or biphasic external defibrillators by minimally trained waveform for the initial shock conversion of personnel. However, whether their perform- induced VF, monomorphic ventricular tachy- ance is equivalent to that of hand held paddles cardia, polymorphic ventricular tachycardia, or remains doubtful. ventricular flutter. Delivered energies for the The relation between electrode size and TTI Edmark and Gurvich waveforms were 215 and was confirmed using three diVerent combina- 171 J, respectively. The first shock for all tions of electrode pad size in patients with VF.16 arrhythmias was successful in 85.2% of pa- As the combined electrode area increased then tients with monophasic waveforms compared TTI decreased, accompanied by improved with 97.6% with biphasic waveforms. There success rates for first and cumulative shocks. was also a higher first shock success rate for While this was a recognised phenomenon with patients with VF (78.6% v 100%), which was hand held paddles, these results suggested for achieved at a significantly lower energy level the first time in humans that even larger self than with the monophasic waveform. Interest- adhesive electrodes may be of benefit. Optimal ingly, average patient impedance was 81 Ù, electrode size and shape remain to be deter- higher than in other studies, and ascribed to the mined. use of self adhesive electrodes. What percentage of transthoracic current Many mechanisms have been postulated to during defibrillation traverses the heart? Ler- explain the lower defibrillation thresholds with man and Deale17 have suggested that as little as biphasic waveforms. Blanchard and Ideker13 4% may reach the myocardium. This relatively have extensively discussed these mechanisms. small percentage is a result of parallel pathways One mechanism suggests that lower impedance such as those in the thoracic cage and lungs in the second phase of biphasic shock aids cur- which shunt current around the heart. How- rent flow during reversed polarity in the second ever, considerable variability in current per- phase. Other mechanisms include: the ability centage was reported, ranging between 1% and to stimulate myocardium, detrimental eVects 10%. This variation may be explained by http://heart.bmj.com/ in regions of high potential gradient, eVects on diVerent thoracic geometry, which may, along sodium channels, and the induction of new with relative resistance per unit length (resis- action potentials or a prolongation of the tivities) of thoracic tissues, determine current refractory period. While a few mechanisms flow in the thoracic volume conductor.17 may be incorrect, several others may together Individual patient related factors are impor- contribute to the general superiority of the tant. There is a strong correlation between TTI biphasic waveform. The beneficial eVect of the and body composition as expressed by body second phase of the biphasic waveform may mass index, percentage body fat, and skinfold on September 30, 2021 by guest. Protected copyright. possibly arise from rapid restoration of the thickness.18 This relation is likely to be related transmembrane potential to a level close to that to the high resistivity of fat tissue, as that which existed just before the shock, rather than between TTI and weight alone is not as strong. from changing the transmembrane potential
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