Procedure: Defibrillation by Medical Directive (2023)

Defibrillation is the treatment for ventricular fibrillation. The success of resuscitation of patients with ventricular fibrillation relates to how quickly electrical energy can be applied to the myocardium. The longer the heart fibrillates, the greater the myocardial oxygen consumption and deterioration of myocardial function. The chance of successful defibrillation is reduced as the fibrillation time increases.



Identify Life-Threatening Rhythm

A certified critical care nurses may initiate defibrillation under the following circumstances:

  • Ventricular Fibrillation (VF)
  • Pulseless Ventricular tachycardia (VT)

Note: Arterial line pressures < 60 mmHg may be associated with pulselessness. CPR should be initiated immediately.

Successful conversation of these rhythms occurs with rapid delivery of the first shock of energy.

Pulseless VT is often short-lived and deteriorates to VF.


Initiate CPR

The first responder initiates CPR until the defibrillator arrives. Use the following sequence:

  1. Initiate compressions while cart is enroute.
  2. Confirm that the patient has a shockable rhythm and defibrillate as soon as the cart arrives. If non-shockable rhythm, continue CPR per algorithm.
  3. Resume CPR following defibrillation and complete the first 2 minute cycle of compressions.
  4. Complete one full cycle of CPR even if the patient has a return ofsinus rhythm (unless the patient is actively pushing you away).
  5. Place the back board after the first full cycle of CPR. Continue with ACLS per algorithm.

Effective Compressions

Position hands on the sternum at the nipple line. Perform chest compressions at a rate of 100 - 120/minute to a depth of 5 to 6 cm (2 - 2.5 inches) of chest wall diameter. The new Zoll R series has a compression pad that provides real time feedback on the quality of CPR.

During CPR, minimize interruptions of compressions and allow for good chest recoil.

Whenever feasible, switch the person who is performing compressions after each 2 minute cycle (the effectiveness of CPR decreases beyond this).

CPR during Pregnancy:

Use the same hand positions for pregnant patients as non-pregnant (no longer recommended to move them to a more cephalic placement during pregnancy).

A second person is required to maintain continuous manual left uterine displacement with patient in the supine position (see Obstetrical Emergencies). If standing on the right of the patient, one hand is used to push the uterus towards the left. If the assistant is standing to the left of the patient, two hands are used to pull the uterus towards the left.

End-Tidal CO2

Should be initiated at the onset of bagging and intubation. ETCO2 is now displayed on screen with the Zoll R series.

End-Tidal CO2Benefits:

  • Confirm ETT placement.
  • Guide compression quality (goal for ETCO2 >20 mmHg).
  • Improved technique (e.g. prompt to identify need to switch CPR provider if < 10 mmHg).
  • Consider ROSC for an abrupt sustained increase to normal levels (35-40 mmHg) or at least 10 mmHg increase above level at onset of CPR.
  • Guide decision to terminate CPR. Levels < 10 mmHg after 20 minutes indicates low probability of ROSC. This assumes that the ETCO2 is not < 10 mmHg because of overbagging (induced hyperventilation).

Activate Code Blue

Call a code blue simultaneously with initiation of CPR. In CCTC, activated the bedside emergency call button and call for critical care physician STAT.


Prepare Patient for Defibrillation

Initial defibrillation:

Apply OneStep CPR 1 A/A Multifunctional pads. The pads should be connected to the Zoll and the package unopened. Before starting, confirm that the pads and machine have passed their self-test and are ready to open and use.

If CPR is in progress, apply the gel pads in the Anterior - Anterior position.

Anterior-Anterior Placement

Apply Pad #1 first to the left chest position. Position below the pectoral muscle as shown on pad diagram. For female patients, lift the breast and position on top of the pad once it has been applied.

Pad #2 is attached to a CPR sensor. Position the CPR sensor so that thered vertical line is mid-sternum and the blue horizontal line is aligned with the nipple. Press the right pad into position as shown on the pad diagram.

Procedure: Defibrillation by Medical Directive (1)

Procedure: Defibrillation by Medical Directive (2)

Procedure: Defibrillation by Medical Directive (3)

OneStep Multifunctional CPR A/A Pads can be used for either Anterior-Anterior or Anterior-Posterior. Pads remain connected to Zoll cable and remain unopened until use.Apply apex pad first. For female patients, lift the breast and position the pad under the breast.

Position cross bars of CPR sensor to align with the mid sternum and nipple line. The right chest pad is attached to the CPR sensor for correct positioning.

If Anterior-Posterior placement is desired, separate the right chest pad from the sensor and apply to the patients left back. Note: the posterior pad should be placed first.

Anterior-Posterior Placement

TheOneStep CPR 1 A/A Multifunctional pads can be used for anterior - posterior placement. Separate the right chest pad from the CPR sensor. Apply the right chest pad to the left posterior chest first (to prevent wrinkling of the anterior pads. Apply the apex pad as shown above. Apply the apex pad as shown above.

Procedure: Defibrillation by Medical Directive (4)

Procedure: Defibrillation by Medical Directive (5)

Procedure: Defibrillation by Medical Directive (6)

Identify the checkmark in the window display. This confirms that the pads and machine are functioning prior to use.The purple display identifies the quality and depth of CPR.End Tidal CO2 confirms adequacy of CPR and endotracheal tube placement.

ECG Electrodes

Apply the Zoll ECG electrodes. The One Step Multifunctional pads can monitor, shock and pace, but they cannot read the ECG at the same time that they pace or cardiovert. The ECG must be connected to the Zoll to provide sending and rhythm feedback.

Paddles are no longer available on the Crash Carts.

Prepare Patient:

  • Side rails.
  • Bed and patient flat.
  • Chest exposed. When time permits, hair should be clipped (not shaved).
  • Confirm gel pads in correct position and pressed onto skin.
  • Ensure paddles have no contact with metal jewelry, pharmacologicalpatches (e.g., fentanyl, nitroglycerin) or transparent dressings..

Position for Pacemaker/Defibrillator Pads:


OneStep CPR 1 A/A Multifunctional pads are attached and ready to open and apply on all Crash Carts. When the unopened package is connected to the Zoll R, they perform ongoing self-tests to ensure functionality. The package must remain unopened for the self-test to work. Confirm that the pads and machine are functional prior to use by confirming the check mark is visible in the display window.

The CPR A/A pads can be applied either in the Anterior-Posterior position or Anterior-Anterior, however, during CPR they should be applied Anterior-Anterior for speed.

When pads are applied Anterior-Posterior, apply the posterior pad first to avoid wrinkling of the anterior pad.

Do no place pads over ECG electrodes. Arcing will occur if shock is delivered too close to electrodes.


Prepare Defibrillator:

  1. Continue CPR while preparing defibrillator.
  2. Turn Defibrillator on and ensure dial is set to "Defib".
  3. Confirm the default charge is 200 joules.
  4. Charge the pads. The paddles can be charged using the "Charge" button on the front of the monitor.

Ensure the pads do not come in contact with ECG leads.

The only treatment for fibrillation is delivering electrical current immediately to the myocardium. Biphasic defibrillators are more successful at converting VF with the first shock.


Maintain Environment Safety

Ensure that there is no contact with any metal objects and no one is in contact with the patient or bed. Call "All Clear".


Deliver Shock

Discharge energy by simultaneously depressing the SHOCK button on the paddles or monitor (second person).

Deliver shock following exhalation.

Air filled lungs decrease electrical conduction. Patient may be in a respiratory arrest.


Continue CPR

  • Do not check for pulse. Immediately return to CPR for 2 minutes.
  • Do not stop compressions for rescue breathing. Second provider delivers 1 rescue breath by face mask/ETT every 6 seconds.
  • Charge padsto 200 Joules before 2 minutes of CPR is completed. After the first shock is delivered, you can change to multipurpose pads for subsequent defibrillations.

Continue CPR immediately after shock; this provides myocardial oxygenation which improves shock success.

Higher respiratory rates increase intrathoracic pressure which decreases perfusion of organs.


If multipurpose pads have been charged and are no longerrequired, do not discharge the energy into the machine or the air. To safely discharge the pads, turn the dial on the machine from "defib"to "monitor" to discharge the energy. Confirm that the energy has been discharged before removing the pads from the chest.


Reassess Rhythm

  • Quickly reassess rhythm at the end of 2-minute CPR cycle to ensure that patient has not returned to VF or VT.
  • If patient is in VT/VF, proceed to deliver the next shock (as above) at 200 Joules
  • Resume CPR after completion of the shock
10.Administer Epinephrine

While CPR is being performed, administer epinephrine 1 mg IV direct after the second defibrillation.

A certified critical care nurse may give epinephrine 1 mg IV direct after the second defibrillation shock has been delivered by Medical Directive. The certified critical care nurse may repeat epinephrine 1 mg IV direct every 3 minutes until Return of Spontaneous Circulation (ROSC).

If the patient does not have IV access, epinephrine may also be given by a certified critical care nurse by Medical Directive down the endotracheal tube.

Epinephrine may be ordered earlier by a physician during the cardiac arrest. This will requirean order as it is outside the Medical Directive.

Epinephrine can increase cerebral and coronary perfusion pressures by alpha vasoconstriction.Delivery of drug during compressions minimizes interruptions to CPR.


Consider Causes for Non-Responsiveness

Return to step # 8-9.
Troubleshoot for possible causes of non-responsive VT/VF (e.g. electrolyte disturbance, hypoxemia, MI).

Consider H's and T's

Hydrogen ions
Tension pneumothorax
Thrombosis: coronary/pulmonary
Consider adrenal endocrine (adrenal insufficiency, hypoglycemia)


Administer Antiarrhythmic

While CPR is being performed, administer amiodarone 300 mg IV direct per amiodarone procedure.

If contraindicated, administer lidocaine 1 mg/kg per defibrillation procedure under medical directive.

A certified critical care nurse may give lidocaine by Medical Directive if amiodarone is contraindicated at a total bolus dose of 1.5 mg/kg (preloaded syringe).

An order is required to initiate an amiodarone or lidocaine infusion.


Return to Steps 8-10

Maintain ABC’s.
Continue to treat possible causes of arrhythmia.

Return to Step #11 Administer Epinenphrine

Continue CPR as per step # 9 followed then by step # 10.


Obstetrical Considerations

The priority during resuscitation of the pregnant patient is the mother. Activate Code OB STAT and early(as soon as patient shows signs of deterioration in condition). Code OB is available at Victoria Hospital only. At UH, page a general surgeon STAT for perimortem cesarean:

Follow standard ACLS algorithms with the following modifications:

  • Hand position in the same location as for the non-pregnant patient (it is no longer recommended to position the hands closer to the head)
  • Perform CPR in the supine position with one person assigned to manually display the uterus toward the patient's left.
    • Use two hand uterine "pull"technique if standing on patient's left side or one hand "push" if standing on patients right side.
  • All IVs above the diaphragm
  • Consider calcium chloride if patient was receiving magnesium sulphate
  • Remove fetal monitor (external and internal) prior to defibrillation
  • The goal is to start perimortem C-section at 4 minutes during cardiac arrest

Causes for Maternal Cardiac Arrest (Beauchops)

B Bleeding/DIC
E Embolism cardiac/pulmonary/ amniotic
A Anaesthetic complications
U Uterine atony
C Cardiac disease: MI/ischemia/aortic dissection/cardiomyopathy
H Hypertension/preeclampsia/eclampsia
O Review standard ACLS guidelines (Hs and Ts)
P Placental abruptio, previa
S Sepsis



Document in cardiac arrest record.


Order Requirements

The medical directive for ACLS provides theauthority to initiate interventions.

The RN who initiates the medical directive should be identified in the cardiac arrest record.

Last Update: November 5, 2018, February 10, 2020 (KK/BM); Reviewed January 22, 2021, Revised January 30, 2023


What is the procedure of defibrillation? ›

The act of defibrillation delivers an electrical shock across the chest, either by placing a pair of manual paddles on the chest or through the application of adhesive “hands-free” pads. Current defibrillators typically utilize a biphasic waveform that needs a lower energy level to achieve effective defibrillation.

What are the 4 universal steps for operating an AED? ›

The “Universal AED”: Common Steps to Operate All AEDs
  • Step 1: POWER ON the AED. The first step in operating an AED is to turn the power on. ...
  • Step 2: Attach electrode pads. ...
  • Step 3: Analyze the rhythm. ...
  • Step 4: Clear the victim and press the SHOCK button.
Aug 22, 2000

Are nurses allowed to defibrillate? ›

It is not one of the controlled acts authorized to all nurses. However, nurses may perform the act of applying a form of energy in one of two scenarios: Through delegation: when someone authorized to perform the act can transfer the authority to a nurse or nurses through a delegation process or.

How long does a defibrillator procedure take? ›

How long does the procedure take? Inserting a pacemaker or defibrillator takes about 3 hours. After several years (usually 7 to 8 years), the battery in the device will begin to get low and the doctor will need to replace the device. Often the leads are still fine and can stay in place.

What is the first step when using a defibrillator? ›

STEP 1: Turn on the AED.

As soon as an AED arrives to the victim, press the “Power” button to turn on the device. From the moment the device is powered on, a voice will begin to guide you and provide directions.

What are five 5 Safety Considerations When Using an AED? ›

AED Precautions
  • Do Not touch the victim while defibrillating. ...
  • Do Not use alcohol to wipe the victim's chest dry. ...
  • Do Not use an AED in a moving vehicle. ...
  • Do Not use an AED on a victim who is in contact with water. ...
  • Do Not use an AED on a victim lying on a conductive surface.

Do you need to remove a bra when using a defibrillator? ›

Any clothing or jewellery that could interfere with the pads should be removed or cut away, as the pads must be attached to bare skin. You will also need to remove clothing containing metal from the area where the pads are attached, such as an underwired bra.

Do you do CPR before or after AED? ›

Always call 911 first before administering CPR or using an AED. The timing of the use of an AED first depends on how accessible an AED is. If an AED is immediately accessible, get the AED and use it right away. However, in all likelihood, there will not be an AED close enough and CPR should be started first.

How many times can you shock a patient with an AED? ›

5. How many times can a person be defibrillated? In short; a person can be shocked as many times as necessary, however, with each shock that fails to return the heart to a normal rhythm, the chances of survival decreases.

What safety and maintenance procedures are required for an AED? ›

Keep Your AED Properly Maintained
  • Place your AED in a visible and unobstructed location.
  • Verify the battery installation is correct.
  • Check the status / service indicator light.
  • Note the absence of the visual/ audio service alarm.
  • Inspect exterior components and sockets for cracks.

What are the 4 special situations you should look for before using an AED? ›

The most common special considerations when using an AED involve pediatric patients, patients who are wet or moist, patients with excessive hair, patients with a medication patch, or patients who have a device that could get in the way when you're trying to deliver a shock.

Who can perform defibrillation? ›

Anyone can use a defibrillator and you don't need training. Once you turn it on, it will give clear instructions on how to attach the defibrillator pads. The device checks the heart rhythm and will only tell you to shock if it's needed.

Can you defibrillate a DNR patient? ›

So if a patient has a DNR order in place, emergency services will refrain from using a defibrillator, as this equipment is designed to restore cardiac function.

What are defibrillator laws? ›

Is it a legal requirement to have a defibrillator in the workplace? The simple answer is that there is no specific legal requirement with regard to employers having to provide defibrillators in the workplace.

Is getting a defibrillator a major surgery? ›

The procedure to implant a defibrillator does not require open heart surgery, and most people go home within 24 hours. Before the surgery, medication may be given to make you sleepy and comfortable. Generally, the procedure is performed under local anesthesia.

Are you awake during defibrillator surgery? ›

You will receive a sedative in your IV before the procedure to help you relax. However, you will likely remain awake during the procedure. The ICD insertion site will be cleansed with antiseptic soap. Sterile towels and a sheet will be placed around this area.

How long do you stay in the hospital after a defibrillator? ›

After the Procedure

Most people who have an ICD implanted are able to go home from the hospital in 1 day. Most quickly they return to their normal activity level. Full recovery takes about 4 to 6 weeks.

What do they say before using a defibrillator? ›

Once the pads are placed correctly the machine will say, “analyzing heart rhythm, do not touch the patient.” It is important to make sure no one is touching the patient at this time. Look up and down the body. Loudly state, “Stand clear.” If the machine determines a shock is needed, it will say, “Shock Advised.

How many cycles of CPR do you need for a defibrillator? ›

If prompted to begin CPR, follow the cycle of 30 compressions and 2 rescue breaths. After five cycles allow the AED to analyze the rhythm again. Continue CPR until help arrives or until the AED announces rhythm restored.

What are the 3 positions for defibrillation pads? ›

Simply, they go on the front (anterior) of the chest, one above the right nipple, and the other on the left side of the chest below the left breast area. The only exception is for paediatrics, where one is placed on the back chest wall (posterior) and the other on the front (anterior) left chest wall.

Can you use a defibrillator on someone with no pulse? ›

If the person is not breathing and has no pulse or has an irregular heartbeat, prepare to use the AED as soon as possible.

What is the correct rate of compression per 2 minutes? ›

Give 30 compressions followed by 2 breaths, known as “30:2”. Aim for 5 sets of 30:2 in about 2 minutes (if only doing compressions about 100 – 120 compressions per minute).

What action should you take immediately after an AED shock? ›

The main action you should take immediately after providing an AED shock is to leave the device on and attached. The device will continue to provide instructions, analyze the patient's heart, and provide further shocks if needed.

What can you not do after a defibrillator? ›

Keep your incision completely dry for 4 to 5 days. After that, you may take a shower and pat it dry. Always wash your hands before touching the wound. For 4 to 6 weeks, do not lift your arm higher than your shoulder on the side of your body where your ICD was placed.

What to avoid if you have a defibrillator? ›

Don't dangle headphones round your neck or within 3cm (1in) of your ICD. Don't put mobile or cordless phones, or MP3 players within 15cm (6in) of your ICD. Don't wear magnetic fasteners near your ICD. Don't use a TENS machine for pain relief, and keep electric-pulse body-toning tools below your stomach.

Can you touch someone with an internal defibrillator? ›

It is important to understand that if you receive a shock from an implantable defibrillator, it will not cause harm to anyone else who might be touching you. Anti-tachycardia pacing is an alternative method of stopping ventricular arrhythmias and is available in most ICDs.

What happens if you do CPR on someone with a pulse? ›

The physicians and scientists at the Sarver Heart Center, have found that the old saying "Never perform CPR on beating heart" is not valid. According to these professionals, the chances that a bystander could harm a person by pressing on their chest are slim to none, even if the heart is working normally.

What rhythm is not shockable? ›

The two nonshockable rhythms are pulseless electrical activity (PEA) and asystole and the two shockable rhythms are pulseless ventricular tachycardia and ventricular fibrilation.

How many rounds of CPR before pulse check? ›

Every 2 minutes of CPR you will check for a pulse. Attach an AED as soon as it becomes available, it is best to wait for the natural pause between cycles of CPR while breaths are being delivered.

Do you continue CPR after defibrillation? ›

Aim: Current consensus guidelines for cardiopulmonary resuscitation (CPR) recommend that chest compressions resume immediately after defibrillation attempts and that rhythm and pulse checks be deferred until completion of 5 compression:ventilation cycles or minimally for 2min.

Can you continue CPR while the AED delivers a shock? ›

The AED will allow you to provide CPR for two minutes. After two minutes, the AED will tell you to stand clear so it can start analyzing to determine if a second shock is needed. After a second shock, the AED will allow you to provide two more minutes of CPR.

What happens if you accidentally get shocked by an AED? ›

EFFECTS OF ACCIDENTAL SHOCK. Defibrillators are designed to affect electrical activity in the patient's heart, and potentially can affect the caregiver's heart as well. Earlier reports describe a tingling sensation and electrical burns in those who are shocked.

What are three 3 safety procedures when using an AED automated external defibrillator? ›

Safety Precautions

Check for danger before touching the victim. Wear protective gloves such as disposable latex or nitrile examination gloves. Use the provided resuscitation mask when giving Cardio Pulmonary Resuscitation (CPR). Dry the victim's chest if it is wet.

How often does a defibrillator need to be checked? ›

Defibrillators need servicing by professionals regularly, at the very least once a year. Checking it over yourself is OK, but sometimes you may not be able to spot any issues that are not obvious.

How often does an AED need to be checked? ›

Someone should be responsible for performing AED maintenance checks at least monthly and these checks should be logged. Here are some things to look for when doing an AED Maintenance check: Is the Active Status Indicator light on your AED flashing green?

What are the 7 steps of using an AED? ›

The AED protocol has seven basic steps:
  • Check unresponsiveness.
  • Call 9-1-1 or the local emergency number (if applicable) and retrieve the AED.
  • Open the airway and check for breathing. ...
  • Check for a pulse. ...
  • Attach the AED electrode pads.
  • Analyze the heart rhythm. ...
  • Press the "shock" button, if advised.

What should you check before delivering a shock using an AED? ›

Home automated external defibrillator (AED)
  • Check to see if the person is breathing and has a pulse.
  • If you cannot feel a pulse and the person is not breathing, call for emergency help. ...
  • Turn on the AED . ...
  • Deliver the shock. ...
  • Start CPR .

What are the 4 steps to using the automated external defibrillator? ›

Connect the pads to the defibrillator if they are not already connected. Stand clear of the patient while the AED searches for a shockable rhythm. Follow the AED's audible instructions. Press the “Shock” button only if instructed, or allow the AED to shock automatically for automatic AED models.

What is the procedure to shock heart into rhythm? ›

Cardioversion is a medical procedure that uses quick, low-energy shocks to restore a regular heart rhythm. It's a treatment for certain types of irregular heartbeats (arrhythmias), including atrial fibrillation (A-fib). Sometimes cardioversion is done using medications.

Do you remove oxygen during defibrillation? ›

Oxygen / PEEP and respiratory cycle: As discussed above free flowing oxygen must be removed during defibrillation. However, if attached to an LMA / ETT this may be left attached.

When should a defibrillator be used before or after CPR? ›

CPR should be performed if the patient is non-responsive and not breathing and an AED should be applied after performing CPR. If the AED does not bring the patient back to consciousness CPR should be re-administered.


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