DEFIBRILLATOR MACHINE

BAsic TECHNICAL
TRAINING

By: Armando Darino Ngojo

Senior Biomedical Engr.
Contents
Aims & Objectives
Introduction
Principle
Anatomy and Physiology
Application
Types
Operation
Safety
Maintenance
Troubleshooting
PPM
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 Aims

Toprovide basic
understanding about
the Defibrillator Machine
To perform and understand the
basic technical troubleshooting
steps and PPM tasks
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Objectives
- as a result of completing this module, the biomedical technician / engineer should be able to:
understand the concept of the Defibrillator
including its applications
perform and identify basic problems, errors and
basic troubleshooting solutions.
Perform PPM tasks
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 History
1899 Prevost and Batelli first introduced the concept of electrical
fibrillation after noticing that large voltages applied across the
animal's heart could convert ventricular fibrillation into a
sinus rhythm.
1933 Hooker, Kouwenhoven and Langworthy published an account
of successful alternating current (AC) internal animal
defibrillation

1950s Kouwenhoven was able to defibrillate dogs by applying the

electrodes to the chest wall, that was the external electric
defibrillator.

1956 Zoll defibrillated a human subject in the same manner .

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 History
1960s Edmark and Lown et al found that direct current (DC) or pulse
defibrillators were more effective and produced fewer side
effects than AC defibrillator. The DC pulse waveform was
further improved.

1970s Experimental internal and external devices were designed to

automatically detect ventricular fibrillation.

1980s The first automatic internal defibrillator was implanted in

human

Present A lot of improvements were introduced to the defibrillator with

times the aim of improving the survival rate of the cardiac arrested
patient

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What is Defibrillator
- A device that reverses the Fibrillation of the
heart.
Fibrillation
causes the heart to stop
pumping blood, leading to brain damage.

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 Defibrillation
Defibrillation
is a process in which an electronic
device sends an electric shock to the heart to stop
an extremely rapid, irregular heartbeat, and restore
the normal heart rhythm.

Itis
a common treatment for life threatening cardiac
dysrhythmia,ventricular fibrillation, and pulse less
ventricular tachycardia.

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Principle

A high voltage electric current is

applied to the Heart muscle either
directly (Internal Defibrillator) through the
open chest or indirectly (External
Defibrillator) through the chest wall to
terminate Ventricular Fibrillation.

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Physiology of Defibrillation

If
enough current is delivered to the heart
then a majority of Ventricular cells will be
depolarized

A critical mass of cells should be

simultaneously depolarized to achieve
defibrillation

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Bio Electric Signal

Polarization

Potassium ions pumped in

Sodium ions pumped out
Depolarization

Potassium ions pumped out

Sodium ions pumped in
Repolarization

Potassium ions pumped in

Sodium ions pumped out
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Anatomy - Heart
Located between the lungs in
the middle of chest, behind
and slightly to the left of
breastbone (sternum)
Size of ones fist and shaped
like a cone.
An average heart pumps 2.4
ounces (70 milliliters) per
heartbeat. An average
heartbeat is 72 beats per
minute. Therefore an average
heart pumps 1.3 gallons (5
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Liters) per minute.
Cont
Heart is divided into four chambers

Right Atrium
Left Atrium
Right Ventricle
Left Ventricle

A wall of muscle called as a 'Septum',

separates all chambers of heart.
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Normal Cardiac Conduction
Electrical pattern ECG tracing

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Normal ECG tracing

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when
ABNORMALITIE
S
happen.
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1. Ventricular Fibrillation
Ventricular Fibrillation is a very fast, irregular
heart rhythm in the lower heart chambers
(ventricles). During VF the heart quivers and
pumps little or no blood to the body.
Consciousness is lost in seconds. If not treated
immediately, VF will cause sudden cardiac arrest

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Cardiac Arrest
Occlusion of the
coronary artery
leads to ischemia.
Ischemia leads to
infarct which
causes interruption
of normal cardiac
conduction
Infarct = VF/VT
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 SAMPLE SHOCKABLE RHYTHMS

Ventricular Fibrillation Ventricular Tachycardia

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2. Atrial Fibrillation

Atrial Fibrillation is a very fast, irregular heart

rhythm in the upper heart chambers. During AF,
the waveform is almost similar to normal
waveform but for the loss of 'P' waveform.

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AF treatment:
For Atrial fibrillation,
the shock should be
avoided to be delivered
in the T period
otherwise it will lead to
Ventricular Fibrillation

This
is achieved by
Synchronous mode
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Application
Emergency department

Anesthesiology

Cardiology

Operation theatre

Intensive care areas

Ambulance services NGOJO

Types:

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1. Manual

Clinical expertise is needed to interpret

the heart rhythm and decide whether to
charge the defibrillator and deliver the
shock to patient. Energy selection and
delivery is given to the patient manually.

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2. Automatic
These defibrillators are small, safe,
simple and lightweight with two pads
that can be applied to the patient. The
defibrillator guides the operator step-by-
step through a programmed protocol. It
records and analyses the rhythm and
instructs the user to deliver the shock
using clear voice prompts, reinforced by
displayed messages.
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3. External

External Defibrillator is the device which

delivers the high energy shock to
patients Heart externally on patient's
chest by using a Defibrillator Paddle. The
maximum energy deliver to the patient is
about 360 Joules in Monophasic & 200
Joules in Biphasic Defibrillator.

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4. Internal

Internal defibrillator consist of sterilized

internal Handle/Paddle through which
shock is delivered directly to the heart.

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5. AED
Automatic External Defibrillator
AED can be classified as either fully automatic or
semiautomatic. In fully automatic models
disposable paddles are kept connected to the
patient whilst the AED analyzes the ECG rhythm ,
decides and determines whether a defibrillation
counter-shock is needed. Then the device
automatically charges and discharges.
Semi Automatic AED analyze the patient's ECG
and notify the operator when defibrillation is
indicated. The operator then activates defibrillator
and discharge.

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AED
Semi Automatic Fully Automatic

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6. ICD
Implantable Cardioverter Defibrillator

If it detects an abnormally fast heart rhythm,

it either electrically paces the heart very fast
or delivers a small electrical shock to the
heart to convert the heart rhythm back to
normal. The rapid pacing is not felt by the
patient but the electrical shock, if used, is felt
as a strong jolt in the chest. The ICD is used
to treat life-threatening heart rhythms that
lead to sudden death.
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ICD

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7. Pacemaker

A pacemaker is an electronic stimulator

that produces periodic electric stimulation
to the heart

It is classified into two types:

Internal Pacemaker
External Pacemaker

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 Internal Pacemaker

Battery operated
device that is implanted
inside the patients
body to pace the Heart

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External Pacemaker

This is used to pace

the heart temporally.
It may use leads or
electrodes for the
stimulation

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What is Joule?
It
is the unit of energy delivered by the
Defibrillator

Itmeans - The energy released in one

second by a current of one ampere through
a resistance of one ohm

Also called as watt-second

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- The delivered energy is in the range of 50-
360 joules and depends on:
intrinsic characteristics of patient
patients disease
duration of arrhythmia
patients age
type of arrhythmia (more energy required for
VF)
type of the machine used
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Operating Principle

Monophasic Defibrillator

Bi- Phasic Defibrillator

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Monophasic Defibrillator
Delivers its current in one forward
direction (positive)

Requireshigher escalating energy levels

(200-300J) to convert VF/ pulse-less VT

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Bi Phasic Defibrillator

The Biphasic waveform type defibrillator

delivers the current in one direction during
the first phase and in opposite direction
during the second phase.

Biphasic waveform shocks of 200 J are

safe, equivalent or higher efficiency than
damped sinusoidal waveform shocks of 360
J.
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Generation of bi-phasic waveform

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Waveform Comparison

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Operation

Defibrillator: Normal and

Synchronous Mode
Monitor
Recorder
Pacemaker
NIBP
SPO2
CO2 NGOJO
1. Manual Defibrillation

Switch 'ON' the Machine

Wait for initialisation and self test

Make sure it is not in SYNC Mode

Apply gel to the paddles

Place them properly on the chest

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 Cont

Select 'ENERGY' to be delivered( energy in

Joules)

Press 'CHARGE' button

Waitfor Charging to complete. This is usually

denoted by a continuous /long beep sound.

Applypressure to the paddles ( 12 Kg of

pressure) NGOJO
Cont

Make sure all the personnel are away from

the patient
Press both 'DISCHARGE' button
simultaneously
Observe patient and monitor ECG
If required, defibrillate again
When finished, turn off and clean the
paddles
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2. Synchronization Mode
Wait for initialization and self test
.

Connect ECG leads to get a tall R wave

Select 'SYNC / CARDIOVERSION' mode.
.

Checkfor sync marker on the QRS

waveform
.

If
possible sedate the patient and
maintain airway NGOJO
Cont
Apply gel on the paddles and place it
properly on chest
Select 'ENERGY' to be delivered( energy in
Joules)
Press 'CHARGE' button
Wait for the Charge to be completed. This is
usually denoted by a continuous /long beep
sound.
Press both 'DISCHARGE' button
simultaneously and hold till energy is
delivered. NGOJO
Cont

Check patient condition and Heart

rhythm
.

If required, defibrillate again

.

Monitor the patient for few hours

.

Switch off and clean the paddles

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3. Internal Defibrillation
Connect the Internal Paddles to the
machine
Place one paddle over the apex of the left
ventricles and the other over the base of
the right ventricles
Switch on the machine
Select Energy
Charge and Discharge
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What are the types of Paddles?

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 Paddle Placement
There are two notable methods of
paddle placement recommended by
AHA

Anterior- Anterior

Anterior-Posterior

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Paddle Placement
Anterior- Anterior
Place one paddle near
the second or the third
right sternal border and
the other on the
cardiac apex.

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Paddle Placement
Anterior-Posterior
- One paddle on
sternum and the
other on the left
infra-scapular
region

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Important Factors: 1.Time
Early defibrillation allows more success
or the longer period of VF, the less
success of defibrillation.

Early initiation of CPR improves the

success rate
> 8 mins neurological damage sets in
> 10 mins survival probability becomes
very low

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2. Energy Level
AHA Recommendation for Adults
First shock 200 j
Second shock 200 j to 300 j
Third and above shocks 360 j

AHA Recommendation For Paeds

First shock 2 joules per Kg
Subsequent shock double the energy

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3. Paddle Size
Adult paddles should be 8 to 13
cm in diameter
Child paddles should be 4.5 cm in
diameter
Infants use Anterior Posterior
position

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4. Skin To Paddle Interface
Use the right gel
Too little gel increases possibility of
burn
Too much gel causes electric current
to arc from one electrode to another
If
disposable paddles are used check
the expire date
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Block Diagram of a typical Defibrillator machine

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Power Supply
Stepup transformers used to
convert 240 VAC to 5000 VAC
This is converted to DC by rectifier
Inbattery mode the DC is converted
to AC by inverter

This AC is amplified and then again

rectified to DC.
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Capacitor Most important
part of
Defibrillator
Stores large
energy which can
be discharged in a
short burst

Unitof
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measurement is
Farad
Inductor
Coils of wire that
produce a magnetic
field when current
flow through them
Used to prolong the
duration of current
flow
Unit of measurement
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is Henry
Safety

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Safety - General

The Defibrillator generates High voltage. It

must be operated by trained, professional
and qualified personnel only.
Never use defibrillator with improper
grounding or electrical leak socket.
Keep away the Defibrillator from any x-ray,
Ultrasonic or other electronic instruments.

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Cont
Check the patient lead wire, cable and
paddles for any damage or mishandling,
otherwise replace the same immediately.

Recommend using proper size and

placement of recording paper.

Clean the print head regularly for clear

printout
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Safety - Monitoring

Use only the specified patient cable as

recommended by manufacturer.

Place the patient cable in proper winding

position or hang on to patient cable arm
attached with Defibrillator trolley

Use good ECG electrodes to monitor ECG

waveform.
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Cont

Don't use damaged patient cable.

Confirm there is no ECG waveform

because of electrical interference or
defective patient cable. This may
misinterpreted as QRS in synchronize
mode.

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Safety - Defibrillation

Excessive Gels can cause arcing of the

current along the chest wall
Malfunction of permanent pacemakers
can result from placing defibrillator
pads or paddles near the pacemaker
Defibrillationin the absence of an ECG
rhythm (ie, 'blind defibrillation') to be
avoided NGOJO
Cont

A shock can be accidentally delivered

to other rescuers
The initial three shocks should be
delivered in sequence, without
interruption for CPR, medication
administration, or pulse checks.
Iftransthoracic impedance is high, a
low energy shock (< 100 J) may fail to
generate enough current to achieve
successful defibrillation.
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 Cont

Alcohol should never be used as

conducting material for paddles because
serious burns can result.
Never discharge the Defibrillator in Air
to check its performance
Never discharge with paddles shorted
Always clean the paddles after use
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Maintenance - Cleaning

For Exterior surface of defibrillator and

battery /battery well or compartment
Isopropyl alcohol(70% in water)
Mild soap and water
Chlorine bleach (3% in water)
While cleaning take care that solution
should not go inside the defibrillator. Use
soft cloth for cleaning display, to prevent
scratching.
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Maintenance - Cleaning
For Paddles, pads, Electrodes & cables

Disposable pads & monitoring Electrodes

do not require cleaning.
The paddles, paddle cable and patient
cable, may cleaned with
Alcohol free hand soap
Chlorine bleach solution 10%in water
Isopropyl Alcohol
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Maintenance - Cleaning

Internal Paddles / Cables

Internal Paddle Handle/ Cable / Electrodes

can be cleaned ultrasonically, autoclave
or steam sterilized but follow the
manufacturer's instruction for
sterilization procedure

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 PRECAUTIONS
The paddles used in the procedure should not be
placed:-
on a woman's breasts
over an internal pacemaker patients.

Before the paddle is used, a gel must be applied

to the patient's skin

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 RISKS IN DEFIBRILLATION

Skin burns from the defibrillator

paddles are the most common
complication of defibrillation.

Other risks include injury to the

heart muscle,
abnormal heart rhythms, and
blood clots.
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 TROUBLESHOOTING
Attach the external and internal paddles if the monitor
reads, "No paddles."

Check to ensure that the leads are securely attached if

the monitor reads, "No leads.

Connect the unit to AC power if the message reads,

"Low battery."

Verify that the Energy Select control settings are

correct if the defibrillator does not charge.
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 TROUBLESHOOTING
Change the electrodes and make sure that
the electrodes adapter cable is properly
connected if you receive a message of
"PACER FAILURE." Restart the pacer.

Close the recorder door and the paper roll if

the monitor message reads, "Check
recorder.
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PPM (Planned Preventive Maintenance)

Qualitative Task

PPM Task

Quantitative Task

Electrical Safety Test

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Test tool: Defibrillator Analyzer

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Defibrillator Analyzer
Basic Functions

Measures output energy

Measures cardioversion delay time
Measures output of pacemakers
Simulates range of ECG waveforms
Provides clinical training

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Practical Training
and
Assessment

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Questions!!!

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THA
NK
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