Doi:10.1016/j.resuscitation.2005.10.008

Resuscitation (2005) 67S1, S25—S37
European Resuscitation Council Guidelines for
Resuscitation 2005
Section 3. Electrical therapies: Automated
external defibrillators, defibrillation,
cardioversion and pacing
Charles D. Deakin, Jerry P. Nolan
Introduction
the rhythm while CPR is in progress is required toprevent unnecessary delays in CPR. Waveform anal- This section presents guidelines for defibrillation ysis may also enable the defibrillator to calculate using both automated external defibrillators (AEDs) the optimal time at which to give a shock.
and manual defibrillators. All healthcare providersand lay responders can use AEDs as an integral com-ponent of basic life support. Manual defibrillation is A vital link in the chain of survival
used as part of advanced life support (ALS) therapy.
In addition, synchronised cardioversion and pacing Defibrillation is a key link in the Chain of Survival are ALS functions of many defibrillators and are also and is one of the few interventions that have been shown to improve outcome from VF/VT cardiac Defibrillation is the passage across the myocard- arrest. The previous guidelines, published in 2000, ium of an electrical current of sufficient magnitude rightly emphasised the importance of early defib- to depolarise a critical mass of myocardium and enable restoration of coordinated electrical activ- The probability of successful defibrillation and ity. Defibrillation is defined as the termination of subsequent survival to hospital discharge declines fibrillation or, more precisely, the absence of ven- rapidly with timeand the ability to deliver tricular fibrillation/ventricular tachycardia (VF/VT) early defibrillation is one of the most important at 5 s after shock delivery; however, the goal of factors in determining survival from cardiac attempted defibrillation is to restore spontaneous arrest. For every minute that passes following collapse and defibrillation, mortality increases Defibrillator technology is advancing rapidly. AED 7%—10% in the absence of bystander CPR.
interaction with the rescuer through voice prompts systems do not generally have the capability to is now established, and future technology may deliver defibrillation through traditional paramedic enable more specific instructions to be given by responders within the first few minutes of a call, voice prompt. The ability of defibrillators to assess and the alternative use of trained lay responders 0300-9572/$ — see front matter 2005 European Resuscitation Council. All Rights Reserved. Published by Elsevier Ireland Ltd.
to deliver prompt defibrillation using AEDs is now Automated external defibrillators have been widespread. EMS systems that have reduced time to tested extensively against libraries of recorded defibrillation following cardiac arrest using trained cardiac rhythms and in many trials in adults lay responders have reported greatly improved rhythm analysis. Although AEDs are not designed to 75% if defibrillation is performed within 3 min of deliver synchronised shocks, all AEDs will recom- collapse.concept has also been extended to mend shocks for VT if the rate and R-wave mor- in-hospital cardiac arrests where staff, other than doctors, are also being trained to defibrillate usingan AED before arrival of the cardiac arrest team.
In-hospital use of AEDs
When bystander CPR is provided, the reduction insurvival rate is more gradual and averages 3%—4% At the time of the 2005 Consensus Confer- per minute from collapse to defibrillation; ence, there were no published randomised trials comparing in-hospital use of AEDs with manual defibrillators. Two lower level studies of adults with in-hospital cardiac arrest from shockable All healthcare providers with a duty to perform rhythms showed higher survival-to-hospital dis- CPR should be trained, equipped, and encouraged charge rates when defibrillation was provided to perform defibrillation and CPR. Early defibrilla- through an AED programme than with manual defib- tion should be available throughout all hospitals, rillation alone.manikin study showed that outpatient medical facilities and public areas of use of an AED significantly increased the likelihood mass gathering (see Section 2). Those trained in of delivering three shocks, but increased the time AED use should also be trained to deliver at least to deliver the shocks when compared with manual external chest compressions before the arrival of defibrillators.contrast, a study of mock arrests ALS providers, to optimise the effectiveness of early in simulated patients showed that use of monitor- ing leads and fully automated defibrillators reducedtime to defibrillation when compared with manual Automated external defibrillators
Delayed defibrillation may occur when patients sustain cardiac arrest in unmonitored hospital beds Automated external defibrillators are sophisti- and in outpatient departments. In these areas sev- cated, reliable computerised devices that use voice eral minutes may elapse before resuscitation teams and visual prompts to guide lay rescuers and health- arrive with a defibrillator and deliver care professionals to safely attempt defibrillation Despite limited evidence, AEDs should be consid- in cardiac arrest victims. Automated defibrillators ered for the hospital setting as a way to facilitate have been described as ‘‘. . . the single greatest early defibrillation (a goal of <3 min from collapse), advance in the treatment of VF cardiac arrest since especially in areas where staff have no rhythm recognition skills or where they use defibrillators ogy, particularly with respect to battery capacity, infrequently. An effective system for training and and software arrhythmia analysis have enabled the retraining should be in place. Adequate numbers of mass production of relatively cheap, reliable and staff should be trained to enable achievement of the goal of providing the first shock within 3 min of AEDs by lay or non-healthcare rescuers is covered collapse anywhere in the hospital. Hospitals should monitor collapse-to-first-shock intervals and resus-citation outcomes.
Automated rhythm analysis
Automated external defibrillators have micropro-cessors that analyse several features of the ECG, Strategies before defibrillation
including frequency and amplitude. Some AEDs areprogrammed to detect spontaneous movement by Safe use of oxygen during defibrillation
the patient or others. Developing technology shouldsoon enable AEDs to provide information about In an oxygen-enriched atmosphere, sparking from frequency and depth of chest compressions dur- poorly applied defibrillator paddles can cause a ing CPR that may improve BLS performance by all caused in this way, and most have resulted in European Resuscitation Council Guidelines for Resuscitation 2005 significant burns to the patient. The risk of fire dur- Shaving the chest
ing attempted defibrillation can be minimised bytaking the following precautions.
Patients with a hairy chest have air trappingbeneath the electrode and poor electrode-to-skin • Take off any oxygen mask or nasal cannulae and electrical contact. This causes high impedance, place them at least 1 m away from the patient’s reduced defibrillation efficacy, risk of arcing (sparks) from electrode to skin and electrode • Leave the ventilation bag connected to the tra- to electrode and is more likely to cause burns cheal tube or other airway adjunct. Alterna- to the patient’s chest. Rapid shaving of the tively, disconnect any bag-valve device from the area of intended electrode placement may be tracheal tube (or other airway adjunct such as necessary, but do not delay defibrillation if a the laryngeal mask airway, combitube or laryn- shaver is not immediately available. Shaving the geal tube), and remove it at least 1 m from the chest per se may reduce transthoracic impedance patient’s chest during defibrillation.
slightly and has been recommended for elective DC • If the patient is connected to a ventilator, for example in the operating room or critical careunit, leave the ventilator tubing (breathing cir- Paddle force
cuit) connected to the tracheal tube unless chestcompressions prevent the ventilator from deliv- If using paddles, apply them firmly to the chest ering adequate tidal volumes. In this case, the wall. This reduces transthoracic impedance by ventilator is usually substituted for a ventila- improving electrical contact at the electrode—skin tion bag, which can itself be left connected or interface and reducing thoracic volume.The detached and removed to a distance of at least defibrillator operator should always press firmly 1 m. If the ventilator tubing is disconnected, on handheld electrode paddles, the optimal force ensure it is kept at least 1 m from the patient being 8 kg in adultsand 5 kg in children aged or, better still, switch the ventilator off; mod- 1—8 years when using adult paddles8-kg force ern ventilators generate massive oxygen flows may be attainable only by the strongest mem- when disconnected. During normal use, when bers of the cardiac arrest team, and therefore it connected to a tracheal tube, oxygen from a ven- is recommended that these individuals apply the tilator in the critical care unit will be vented from paddles during defibrillation. Unlike self-adhesive the main ventilator housing well away from the pads, manual paddles have a bare metal plate that defibrillation zone. Patients in the critical care requires a conductive material placed between the unit may be dependent on positive end expiratory metal and patient’s skin to improve electrical con- pressure (PEEP) to maintain adequate oxygena- tact. Use of bare metal paddles alone creates high tion; during cardioversion, when the spontaneous transthoracic impedance and is likely to increase circulation potentially enables blood to remain the risk of arcing and to worsen cutaneous burns well oxygenated, it is particularly appropriate to leave the critically ill patient connected to theventilator during shock delivery.
Electrode position
Minimise the risk of sparks during defibrillation.
Theoretically, self-adhesive defibrillation pads No human studies have evaluated the electrode are less likely to cause sparks than manual pad- position as a determinant of return of spontaneous circulation (ROSC) or survival from VF/VT cardiacarrest. Transmyocardial current during defibrilla- The technique for electrode contact with
tion is likely to be maximal when the electrodes the chest
are placed so that the area of the heart that is fib-rillating lies directly between them, i.e., ventricles Optimal defibrillation technique aims to deliver in VF/VT, atria in atrial fibrillation (AF). Therefore, current across the fibrillating myocardium in the the optimal electrode position may not be the same presence of minimal transthoracic impedance.
for ventricular and atrial arrhythmias.
Transthoracic impedance varies considerably with More patients are presenting with implantable medical devices (e.g., permanent pacemaker, automatic implantable cardioverter defibrillator place external electrodes (paddles or self-adhesive (AICD)). MedicAlert bracelets are recommended for pads) in an optimal position using techniques that such patients. These devices may be damaged dur- ing defibrillation if current is discharged through electrodes placed directly over the device. Place the electrode away from the device or use an alter- have shown that anteroposterior electrode place- native electrode position as described below. On ment is more effective than the traditional antero- detecting VF/VT, AICD devices will discharge no apical position in elective cardioversion of atrial more than six times. Further discharges will occur fibrillation. Efficacy of cardioversion may be less only if a new episode of VF/VT is detected. Rarely, dependent on electrode position when using bipha- a faulty device or broken lead may cause repeated sic impedance-compensated waveforms.Either firing; in these circumstances, the patient is likely position is safe and effective for cardioversion of to be conscious, with the ECG showing a relatively normal rate. A magnet placed over the AICD willdisable the defibrillation function in these circum- Respiratory phase
stances. AICD discharge may cause pectoral musclecontraction, but an attendant touching the patient Transthoracic impedance varies during respiration, will not receive an electric shock. AICD and pacing being minimal at end expiration. If possible, defib- function should always be re-evaluated following rillation should be attempted at this phase of external defibrillation, both to check the device the respiratory cycle. Positive end-expiratory pres- itself and to check pacing/defibrillation thresholds sure (PEEP) increases transthoracic impedance and should be minimised during defibrillation. Auto- Transdermal drug patches may prevent good PEEP (gas trapping) may be particularly high in electrode contact, causing arcing and burns if the asthmatics and may necessitate higher than usual electrode is placed directly over the patch during defibrillation.emove medication patches andwipe the area before applying the electrode.
Electrode size
For ventricular arrhythmias, place electrodes (either pads or paddles) in the conventional The Association for the Advancement of Medi- sternal—apical position. The right (sternal) elec- cal Instrumentation recommends a minimum elec- trode is placed to the right of the sternum, below trode size of for individual electrodes and the the clavicle. The apical paddle is placed in the mid- sum of the electrode areas should be a mini- axillary line, approximately level with the V6 ECG electrode or female breast. This position should impedance, but excessively large electrodes may be clear of any breast tissue. It is important that result in less transmyocardial current flow.
this electrode is placed sufficiently laterally. Other adult defibrillation, both handheld paddle elec- trodes and self-adhesive pad electrodes 8—12 cm in diameter are used and function well. Defib- each electrode on the lateral chest wall, one rillation success may be higher with electrodes on the right and the other on the left side (bi- of 12-cm diameter compared with those of 8-cm one electrode in the standard apical position and Standard AEDs are suitable for use in children the other on the right or left upper back; over the age of 8 years. In children between 1 and one electrode anteriorly, over the left pre- 8 years, use paediatric pads with an attenuator cordium, and the other electrode posterior to the to reduce delivered energy, or a paediatric mode, heart just inferior to the left scapula.
if they are available; if not, use the unmodified It does not matter which electrode (apex/ machine, taking care to ensure that the adult pads sternum) is placed in either position.
do not overlap. Use of AEDs is not recommended in Transthoracic impedance has been shown to be minimised when the apical electrode is not placedover the female breast.shaped Coupling agents
apical electrodes have a lower impedance whenplaced longitudinally rather than transversely.
If using manual paddles, gel pads are preferable The long axis of the apical paddle should therefore to electrode pastes and gels because the latter be orientated in a craniocaudal direction.
can spread between the two paddles, creating the Atrial fibrillation is maintained by functional potential for a spark. Do not use bare electrodes re-entry circuits anchored in the left atrium. As without a coupling material, because this causes the left atrium is located posteriorly in the tho- high transthoracic impedance and may increase the rax, an anteroposterior electrode position may be severity of any cutaneous burns. Do not use med- more efficient for external cardioversion of atrial ical gels or pastes of poor electrical conductivity European Resuscitation Council Guidelines for Resuscitation 2005 (e.g., ultrasound gel). Electrode pads are preferred with immediate defibrillation. In contrast, a sin- to electrode gel because they avoid the risk of gle randomised study in adults with out-of-hospital smearing gel between the two paddles and the sub- VF or VT failed to show improvements in ROSC or sequent risk of arcing and ineffective defibrillation.
survival following 1.5 min of paramedic animal studies of VF lasting at least 5 min, CPR Pads versus paddles
before defibrillation improved haemodynamics andsurvival.may not be possible to extrapo- Self-adhesive defibrillation pads are safe and effec- late the outcomes achieved by paramedic-provided tive and are preferable to standard defibrillation CPR, which includes intubation and delivery of 100% paddles.Consideration should be given to use oxygen,those that may be achieved by laypeo- of self-adhesive pads in peri-arrest situations and ple providing relative poor-quality CPR with mouth- in clinical situations where patient access is diffi- cult. They have a similar transthoracic impedance It is reasonable for EMS personnel to give a period of about 2 min of CPR (i.e., about five cycles at and enable the operator to defibrillate the patient 30:2) before defibrillation in patients with pro- from a safe distance rather than leaning over the longed collapse (>5 min). The duration of collapse patient (as occurs with paddles). When used for ini- is frequently difficult to estimate accurately, and it tial monitoring of a rhythm, both pads and paddles may be simplest if EMS personnel are instructed to enable quicker delivery of the first shock compared provide this period of CPR before attempted defib- with standard ECG electrodes, but pads are quicker rillation in any cardiac arrest they have not wit- nessed. Given the relatively weak evidence avail- When gel pads are used with paddles, the elec- able, individual EMS directors should determine trolyte gel becomes polarised and thus is a poor whether to implement a CPR-before-defibrillation conductor after defibrillation. This can cause spu- strategy; inevitably, protocols will vary depending rious asystole that may persist for 3—4 min when used to monitor the rhythm; a phenomenon not Laypeople and first responders using AEDS should deliver the shock as soon as possible.
a gel pad/paddle combination, confirm a diagnosis There is no evidence to support or refute CPR of asystole with independent ECG electrodes rather before defibrillation for in-hospital cardiac arrest.
We recommend shock delivery as soon as possiblefollowing in-hospital cardiac arrest (see Section 4b Fibrillation waveform analysis
The importance of early uninterrupted external It is possible to predict, with varying reliability, chest compression is emphasised throughout these the success of defibrillation from the fibrillation guidelines. In practice, it is often difficult to ascer- waveform.optimal defibrillation waveforms tain the exact time of collapse and, in any case, and the optimal timing of shock delivery can be CPR should be started as soon as possible. The res- determined in prospective studies, it should be pos- cuer providing chest compressions should interrupt sible to prevent the delivery of unsuccessful high- chest compressions only for rhythm analysis and energy shocks and minimise myocardial injury. This shock delivery, and should be prepared to resume technology is under active development and inves- chest compressions as soon as a shock is delivered.
When two rescuers are present, the rescuer operat-ing the AED should apply the electrodes while CPR CPR versus defibrillation as the initial
is in progress. Interrupt CPR only when it is nec- treatment
essary to assess the rhythm and deliver a shock.
The AED operator should be prepared to deliver a Although the previous guidelines have recom- shock as soon as analysis is complete and the shock mended immediate defibrillation for all shockable is advised, ensuring all rescuers are not in contact rhythms, recent evidence has suggested that a with the victim. The single rescuer should practice period of CPR before defibrillation may be bene- coordination of CPR with efficient AED operation.
ficial after prolonged collapse. In clinical studieswhere response times exceeded 4—5 min, a periodof 1.5—3 min of CPR by paramedics or EMS physi- One-shock versus three-shock sequence
cians before shock delivery improved ROSC, sur-vival to hospital discharge1-year survival There are no published human or animal studies for adults with out-of-hospital VF or VT, compared comparing a single-shock protocol with a three- stacked-shock protocol for treatment of VF car-diac arrest. Animal studies show that relativelyshort interruptions in external chest compressionto deliver rescue perform rhythmanalysisare associated with post-resuscitationmyocardial dysfunction and reduced survival.
Interruptions in external chest compression alsoreduce the chances of converting VF to anotherof CPR performance during out-in-hospitalarrest hasshown that significant interruptions are common,with external chest compressions comprising nomore than 51%total CPR time.
In the context of a three-shock protocol being recommended in the 2000 guidelines, interruptionsin CPR to enable rhythm analysis by AEDs were Figure 3.1 Monophasic damped sinusoidal waveform
significant. Delays of up to 37 s between delivery of shocks and recommencing chest compressionshave been ith first shock efficacy of of repetitive shocks, which in turn limits myocardial cardiovert VF successfully is more likely to suggest After a cautious introduction a decade ago, the need for a period of CPR rather than a fur- defibrillators delivering a shock with a biphasic ther shock. Thus, immediately after giving a single waveform are now preferred. Monophasic defibril- shock, and without reassessing the rhythm or feel- lators are no longer manufactured, although many ing for a pulse, resume CPR (30 compressions:2 ven- remain in use. Monophasic defibrillators deliver cur- tilations) for 2 min before delivering another shock rent that is unipolar (i.e., one direction of cur- (if indicated) (see Section 4c). Even if the defibril- rent flow). There are two main types of monopha- lation attempt is successful in restoring a perfusing sic waveform. The commonest waveform is the rhythm, it is very rare for a pulse to be palpable monophasic damped sinusoidal (MDS) waveform immediately after defibrillation, and the delay in trying to palpate a pulse will further compromise flow. The monophasic truncated exponential (MTE) the myocardium if a perfusing rhythm has not been waveform is electronically terminated before cur- restored.one study of AEDs in out-of-hospital VF cardiac arrest, a pulse was detected in only 2.5% rillators, in contrast, deliver current that flows in (12/481) of patients with the initial post shock pulse a positive direction for a specified duration before check, though a pulse was detected sometime after reversing and flowing in a negative direction for the the initial shock sequence (and before a second remaining milliseconds of the electrical discharge.
There are two main types of biphasic waveform: the a perfusing rhythm has been restored, giving chest compressions does not increase the chance of VF recurring.the presence of post-shock asystole sic defibrillators compensate for the wide varia- tions in transthoracic impedance by electronically This single shock strategy is applicable to both monophasic and biphasic defibrillators.
Waveforms and energy levels
Defibrillation requires the delivery of sufficientelectrical energy to defibrillate a critical mass ofmyocardium, abolish the wavefronts of VF andenable restoration of spontaneous synchronisedelectrical activity in the form of an organisedrhythm. The optimal energy for defibrillation isthat which achieves defibrillation while causing theminimum of myocardial of an Figure 3.2 Monophasic truncated exponential wave-
appropriate energy level also reduces the number European Resuscitation Council Guidelines for Resuscitation 2005 The optimal current for defibrillation using amonophasic waveform is in the range of 30—40 A.
Indirect evidence from measurements during car-dioversion for atrial fibrillation suggest that the cur-rent during defibrillation using biphasic waveformsis in the range of 15—20 A.Future technologymay enable defibrillators to discharge according totransthoracic current: a strategy that may lead togreater consistency in shock success. Peak currentamplitude, average current and phase duration allneed to be studied to determine optimal values, Figure 3.3 Biphasic truncated exponential waveform
and manufacturers are encouraged to explore fur- ther this move from energy-based to current-baseddefibrillation.
adjusting the waveform magnitude and duration.
The optimal ratio of first-phase to second-phase First shock
duration and leading-edge amplitude has not been First-shock efficacy for long-duration cardiac arrest established. Whether different waveforms have dif- using monophasic defibrillation has been reported fering efficacy for VF of differing durations is also as 54%—63% for a 200-J monophasic truncated All manual defibrillators and AEDs that allow using a 200-J monophasic damped sinusoidal (MDS) manual override of energy levels should be labelled to indicate their waveform (monophasic or bipha- of this waveform, the recommended initial energy sic) and recommended energy levels for attempted level for the first shock using a monophasic defib- defibrillation of VF/VT. First-shock efficacy for rillator is 360 J. Although higher energy levels risk long-duration VF/VT is greater with biphasic than a greater degree of myocardial injury, the bene- fits of earlier conversion to a perfusing rhythm are the former is recommended whenever possible.
paramount. Atrioventricular block is more common Optimal energy levels for both monophasic and with higher monophasic energy levels, but is gen- biphasic waveforms are unknown. The recommen- erally transient and has been shown not to affect dations for energy levels are based on a consensus following careful review of the current literature.
studies demonstrated harm caused by attempted Although energy levels are selected for defibril- lation, it is the transmyocardial current flow that There is no evidence that one biphasic wave- achieves defibrillation. Current correlates well with form or device is more effective than another. First- the successful defibrillation and cardioversion.
shock efficacy of the BTE waveform using 150—200 Jhas been reported as 86%—98%.shock efficacy of the RLB waveform using 120 J is upto 85% (data not published in the paper but sup-plied by personnel initialbiphasic shock should be no lower than 120 J forRLB waveforms and 150 J for BTE waveforms. Ide-ally, the initial biphasic shock energy should be atleast 150 J for all waveforms.
Manufacturers should display the effective wave- form dose range on the face of the biphasic device.
If the provider is unaware of the effective doserange of the device, use a dose of 200 J for thefirst shock. This 200 J default energy has been cho-sen because it falls within the reported range ofselected doses that are effective for first and subse-quent biphasic shocks and can be provided by everybiphasic manual defibrillator available today. It isa consensus default dose and not a recommended Figure 3.4 Rectilinear biphasic waveform (RLB).
ideal dose. If biphasic devices are clearly labelled and providers are familiar with the devices they use Blind defibrillation
in clinical care, there will be no need for the default200 J dose. Ongoing research is necessary to firmly Delivery of shocks without a monitor or an ECG establish the most appropriate initial settings for rhythm diagnosis is referred to as ‘‘blind’’ defibril- both monophasic and biphasic defibrillators.
lation. Blind defibrillation is unnecessary. Handheldpaddles with ‘‘quick-look’’ monitoring capabilities Second and subsequent shocks
on modern manually operated defibrillators arewidely available. AEDs use reliable and proven deci- With monophasic defibrillators, if the initial shock has been unsuccessful at 360 J, second and sub-sequent shocks should all be delivered at 360 J.
Spurious asystole and occult ventricular
With biphasic defibrillators there is no evidence to fibrillation
support either a fixed or escalating energy proto-col. Both strategies are acceptable; however, if the Rarely, coarse VF can be present in some leads, with first shock is not successful and the defibrillator is very small undulations seen in the orthogonal leads, capable of delivering shocks of higher energy, it which is called occult VF. A flat line that may resem- is rational to increase the energy for subsequent ble asystole is displayed; examine the rhythm in shocks. If the provider is unaware of the effective two leads to obtain the correct diagnosis. Of more dose range of the biphasic device and has used the importance, one study noted that spurious asystole, default 200 J dose for the first shock, use either a flat line produced by technical errors (e.g., no an equal or higher dose for second or subsequent power, leads unconnected, gain set to low, incor- shocks, depending on the capabilities of the device.
rect lead selection, or polarisation of electrolyte If a shockable rhythm (recurrent ventricular fib- gel (see above)), was far more frequent than occult rillation) recurs after successful defibrillation (with or without ROSC), give the next shock with the There is no evidence that attempting to defib- energy level that had previously been successful.
rillate true asystole is beneficial. Studies inchildrenadultsfailed to show bene-fit from defibrillation of asystole. On the contrary, Other related defibrillation topics
repeated shocks will cause myocardial injury.
Defibrillation of children
Precordial thump
Cardiac arrest is less common in children. Aetiology There are no prospective studies that evaluate is generally related to hypoxia and trauma.
use of precordial (chest) thump. The rationale for VF is relatively rare compared with adult cardiac giving a thump is that the mechanical energy of arrest, occurring in 7%—15% of paediatric and ado- the thump is converted to electrical energy, which children include trauma, congenital heart disease, The electrical threshold of successful defibrillation long QT interval, drug overdose and hypothermia.
increases rapidly after the onset of the arrhythmia, Rapid defibrillation of these patients may improve and the amount of electrical energy generated falls below this threshold within seconds. A precordial The optimal energy level, waveform and shock thump is most likely to be successful in convert- sequence are unknown but, as with adults, bipha- ing VT to sinus rhythm. Successful treatment of sic shocks appear to be at least as effective as, VF by precordial thump is much less likely: in all and less harmful than, monophasic shocks.
the reported successful cases, the precordial thump The upper limit for safe defibrillation is unknown, but doses in excess of the previously recommended maximum of 4 J kg−1 (as high as 9 J kg−1) have less VT was converted to a perfusing rhythm by defibrillated children effectively without signifi- a precordial thump, there are occasional reports of thump causing deterioration in cardiac rhythm, energy level for manual monophasic defibrillation such as rate acceleration of VT, conversion of VT is 4 J kg−1 for the initial shock and for subsequent shocks. The same energy level is recommended for Consider giving a single precordial thump when manual biphasic defibrillation.with adults, if cardiac arrest is confirmed rapidly after a wit- a shockable rhythm recurs, use the energy level for nessed, sudden collapse and a defibrillator is not defibrillation that had previously been successful.
immediately to hand. These circumstances are European Resuscitation Council Guidelines for Resuscitation 2005 most likely to occur when the patient is monitored.
randomised study comparing escalating monophasic Precordial thump should be undertaken immedi- energy levels to 360 J and biphasic energy levels to ately after confirmation of cardiac arrest and only 200 J found no difference in efficacy between the by healthcare professionals trained in the tech- two waveforms.initial shock of 120—150 J, nique. Using the ulnar edge of a tightly clenched escalating if necessary, is a reasonable strategy fist, a sharp impact is delivered to the lower half of the sternum from a height of about 20 cm, followedby immediate retraction of the fist, which creates Atrial flutter and paroxysmal
supraventricular tachycardia
Cardioversion
require less energy than atrial fibrillation forcardioversion.Give an initial shock of 100-J If electrical cardioversion is used to convert atrial monophasic or 70—120 J biphasic waveform. Give or ventricular tachyarrhythmias, the shock must be subsequent shocks using stepwise increases in synchronised to occur with the R wave of the elec- trocardiogram rather than with the T wave: VF canbe induced if a shock is delivered during the rel- Ventricular tachycardia
ative refractory portion of the cardiac cycle.Synchronisation can be difficult in VT because of The energy required for cardioversion of VT the wide-complex and variable forms of ventricular depends on the morphological characteristics and arrhythmia. If synchronisation fails, give unsynchro- rate of the arrhythmia.entricular tachycardia nised shocks to the unstable patient in VT to avoid with a pulse responds well to cardioversion using prolonged delay in restoring sinus rhythm. Ventric- initial monophasic energies of 200 J. Use biphasic ular fibrillation or pulseless VT requires unsynchro- energy levels of 120—150 J for the initial shock.
nised shocks. Conscious patients must be anaes- Give stepwise increases if the first shock fails to thetised or sedated before attempting synchronised Atrial fibrillation
Consider pacing in patients with symptomatic Biphasic waveforms are more effective than bradycardia refractory to anticholinergic drugs or other second-line therapy (see Section 4f). Immedi- ate pacing is indicated, especially when the block is rillator in preference to a monophasic defibrillator.
at or below the His—Purkinje level. If transthoracicpacing is ineffective, consider transvenous pacing.
Monophasic waveforms
Whenever a diagnosis of asystole is made, check theECG carefully for the presence of P waves, because A study of electrical cardioversion for atrial fib- this may respond to cardiac pacing. Do not attempt rillation indicated that 360-J MDS shocks were pacing for asystole; it does not increase short-term more effective than 100-J or 200-J MDS shocks.
Although a first shock of 360-J reduces overallenergy requirements for cardioversion, 360 J maycause greater myocardial damage than occurs with References
lower monophasic energy levels, and this must betaken into consideration. Commence cardioversion 1. American Heart Association in collaboration with Inter- of atrial fibrillation using an initial energy level of national Liaison Committee on Resuscitation. Guide-lines 2000 for Cardiopulmonary Resuscitation and Emer- 200 J, increasing in a stepwise manner as necessary.
gency Cardiovascular Care, Part 6: Advanced Cardiovas-cular Life Support: Section 2: Defibrillation. Circulation Biphasic waveforms
2. Larsen MP, Eisenberg MS, Cummins RO, Hallstrom AP.
More data are needed before specific recommen- Predicting survival from out-of-hospital cardiac arrest: a dations can be made for optimal biphasic energy graphic model. Ann Emerg Med 1993;22:1652—8.
3. Valenzuela TD, Roe DJ, Cretin S, Spaite DW, Larsen levels. First-shock efficacy of a 70-J biphasic wave- MP. Estimating effectiveness of cardiac arrest interven- form has been shown to be significantly greater than tions: a logistic regression survival model. Circulation that with a 100-monophasic waveform.
4. Waalewijn RA, de Vos R, Tijssen JGP, Koster RW. Survival ysis in infants and children. Ann Emerg Med 2003;42:185— models for out-of-hospital cardiopulmonary resuscitation from the perspectives of the bystander, the first responder, 21. Cecchin F, Jorgenson DB, Berul CI, et al. Is arrhythmia and the paramedic. Resuscitation 2001;51:113—22.
detection by automatic external defibrillator accurate for 5. Myerburg RJ, Fenster J, Velez M, et al. Impact of children? Sensitivity and specificity of an automatic exter- community-wide police car deployment of automated nal defibrillator algorithm in 696 pediatric arrhythmias.
external defibrillators on survival from out-of-hospital car- diac arrest. Circulation 2002;106:1058—64.
22. Zafari AM, Zarter SK, Heggen V, et al. A program encour- 6. Capucci A, Aschieri D, Piepoli MF, Bardy GH, Iconomu aging early defibrillation results in improved in-hospital E, Arvedi M. Tripling survival from sudden cardiac resuscitation efficacy. J Am Coll Cardiol 2004;44:846—52.
arrest via early defibrillation without traditional edu- 23. Destro A, Marzaloni M, Sermasi S, Rossi F. Automatic exter- nal defibrillators in the hospital as well? Resuscitation 7. van Alem AP, Vrenken RH, de Vos R, Tijssen JG, Koster RW.
24. Domanovits H, Meron G, Sterz F, et al. Successful automatic Use of automated external defibrillator by first responders external defibrillator operation by people trained only in in out of hospital cardiac arrest: prospective controlled basic life support in a simulated cardiac arrest situation.
8. Valenzuela TD, Bjerke HS, Clark LL, et al. Rapid defibrilla- 25. Cusnir H, Tongia R, Sheka KP, et al. In hospital cardiac tion by nontraditional responders: the Casino Project. Acad arrest: a role for automatic defibrillation. Resuscitation 9. Swor RA, Jackson RE, Cynar M, et al. Bystander CPR, 26. Kaye W, Mancini ME, Richards N. Organizing and imple- ventricular fibrillation, and survival in witnessed, unmon- menting a hospital-wide first-responder automated exter- itored out-of-hospital cardiac arrest. Ann Emerg Med nal defibrillation program: strengthening the in-hospital chain of survival. Resuscitation 1995;30:151—6.
10. Holmberg M, Holmberg S, Herlitz J. Effect of bystander 27. Miller PH. Potential fire hazard in defibrillation. JAMA cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients in Sweden. Resuscitation 2000;47:59—70.
28. Hummel IIIrd RS, Ornato JP, Weinberg SM, Clarke AM. Spark- 11. Monsieurs KG, Handley AJ, Bossaert LL. European Resus- generating properties of electrode gels used during defib- citation Council Guidelines 2000 for Automated External rillation. A potential fire hazard. JAMA 1988;260:3021—4.
Defibrillation. A statement from the Basic Life Support and 29. Fires from defibrillation during oxygen administration.
Automated External Defibrillation Working Group (1) and approved by the Executive Committee of the European 30. Lefever J, Smith A. Risk of fire when using defibrillation in Resuscitation Council. Resuscitation 2001;48:207—9.
an oxygen enriched atmosphere. Medical Devices Agency 12. Cummins RO, Eisenberg M, Bergner L, Murray JA. Sensitivity accuracy, and safety of an automatic external defibrillator.
31. Ward ME. Risk of fires when using defibrillators in an oxygen enriched atmosphere. Resuscitation 1996;31:173.
13. Davis EA, Mosesso Jr VN. Performance of police first 32. Theodorou AA, Gutierrez JA, Berg RA. Fire attributable responders in utilizing automated external defibrillation to a defibrillation attempt in a neonate. Pediatrics on victims of sudden cardiac arrest. Prehosp Emerg Care 33. Kerber RE, Kouba C, Martins J, et al. Advance prediction of 14. White RD, Vukov LF, Bugliosi TF. Early defibrillation by transthoracic impedance in human defibrillation and car- police: initial experience with measurement of critical dioversion: importance of impedance in determining the time intervals and patient outcome. Ann Emerg Med success of low-energy shocks. Circulation 1984;70:303—8.
34. Kerber RE, Grayzel J, Hoyt R, Marcus M, Kennedy J.
15. White RD, Hankins DG, Bugliosi TF. Seven years’ experi- Transthoracic resistance in human defibrillation. Influence ence with early defibrillation by police and paramedics of body weight, chest size, serial shocks, paddle size in an emergency medical services system. Resuscitation and paddle contact pressure. Circulation 1981;63:676— 16. Wik L, Kramer-Johansen J, Myklebust H, et al. Quality of 35. Sado DM, Deakin CD, Petley GW, Clewlow F. Comparison cardiopulmonary resuscitation during out-of-hospital car- of the effects of removal of chest hair with not doing so diac arrest. JAMA 2005;293:299—304.
before external defibrillation on transthoracic impedance.
17. Abella BS, Alvarado JP, Myklebust H, et al. Quality of cardiopulmonary resuscitation during in-hospital cardiac 36. Deakin CD, Sado DM, Petley GW, Clewlow F. Differen- tial contribution of skin impedance and thoracic volume 18. Kerber RE, Becker LB, Bourland JD, et al. Automatic exter- to transthoracic impedance during external defibrillation.
nal defibrillators for public access defibrillation: recom- mendations for specifying and reporting arrhythmia analy- 37. Deakin C, Sado D, Petley G, Clewlow F. Determining the sis algorithm performance, incorporating new waveforms, optimal paddle force for external defibrillation. Am J Car- and enhancing safety. A statement for health professionals from the American Heart Association Task Force on Auto- 38. Deakin C, Bennetts S, Petley G, Clewlow F. What is the opti- matic External Defibrillation, Subcommittee on AED Safety mal paddle force for paediatric defibrillation? Resuscitation and Efficacy. Circulation 1997;95:1677—82.
19. Dickey W, Dalzell GW, Anderson JM, Adgey AA. The accu- 39. Panacek EA, Munger MA, Rutherford WF, Gardner SF. Report racy of decision-making of a semi-automatic defibrillator of nitropatch explosions complicating defibrillation. Am J during cardiac arrest. Eur Heart J 1992;13:608—15.
20. Atkinson E, Mikysa B, Conway JA, et al. Specificity and 40. Wrenn K. The hazards of defibrillation through nitroglycerin sensitivity of automated external defibrillator rhythm anal- patches. Ann Emerg Med 1990;19:1327—8.
European Resuscitation Council Guidelines for Resuscitation 2005 41. Pagan-Carlo LA, Spencer KT, Robertson CE, Dengler A, Bir- and nonparametric classification of ventricular fibrillation kett C, Kerber RE. Transthoracic defibrillation: importance in patients with out-of-hospital cardiac arrest. Circulation of avoiding electrode placement directly on the female breast. J Am Coll Cardiol 1996;27:449—52.
60. Eftestol T, Wik L, Sunde K, Steen PA. Effects of cardiopul- 42. Deakin CD, Sado DM, Petley GW, Clewlow F. Is the ori- monary resuscitation on predictors of ventricular fibrilla- entation of the apical defibrillation paddle of impor- tion defibrillation success during out-of-hospital cardiac tance during manual external defibrillation? Resuscitation arrest. Circulation 2004;110:10—5.
61. Weaver WD, Cobb LA, Dennis D, Ray R, Hallstrom AP, Copass 43. Kirchhof P, Borggrefe M, Breithardt G. Effect of electrode MK. Amplitude of ventricular fibrillation waveform and out- position on the outcome of cardioversion. Card Electro- come after cardiac arrest. Ann Intern Med 1985;102:53—5.
62. Brown CG, Dzwonczyk R. Signal analysis of the human elec- 44. Kirchhof P, Eckardt L, Loh P, et al. Anterior-posterior ver- trocardiogram during ventricular fibrillation: frequency sus anterior-lateral electrode positions for external car- and amplitude parameters as predictors of successful coun- dioversion of atrial fibrillation: a randomised trial. Lancet tershock. Ann Emerg Med 1996;27:184—8.
63. Callaham M, Braun O, Valentine W, Clark DM, Zegans C. Pre- 45. Botto GL, Politi A, Bonini W, Broffoni T, Bonatti R. Exter- hospital cardiac arrest treated by urban first-responders: nal cardioversion of atrial fibrillation: role of paddle posi- profile of patient response and prediction of outcome tion on technical efficacy and energy requirements. Heart by ventricular fibrillation waveform. Ann Emerg Med 46. Alp NJ, Rahman S, Bell JA, Shahi M. Randomised comparison 64. Strohmenger HU, Lindner KH, Brown CG. Analysis of of antero-lateral versus antero-posterior paddle positions the ventricular fibrillation ECG signal amplitude and fre- for DC cardioversion of persistent atrial fibrillation. Int J quency parameters as predictors of countershock success 47. Mathew TP, Moore A, McIntyre M, et al. Randomised com- 65. Strohmenger HU, Eftestol T, Sunde K, et al. The predictive parison of electrode positions for cardioversion of atrial value of ventricular fibrillation electrocardiogram signal fibrillation. Heart 1999;81:576—9.
frequency and amplitude variables in patients with out- 48. Walsh SJ, McCarty D, McClelland AJ, et al. Impedance com- of-hospital cardiac arrest. Anesth Analg 2001;93:1428—33.
pensated biphasic waveforms for transthoracic cardiover- 66. Podbregar M, Kovacic M, Podbregar-Mars A, Brezocnik M.
sion of atrial fibrillation: a multi-centre comparison of Predicting defibrillation success by ‘genetic’ programming antero-apical and antero-posterior pad positions. Eur Heart in patients with out-of-hospital cardiac arrest. Resuscita- 49. Deakin CD, McLaren RM, Petley GW, Clewlow F, Dalrymple- 67. Menegazzi JJ, Callaway CW, Sherman LD, et al. Ventricular Hay MJ. Effects of positive end-expiratory pressure on fibrillation scaling exponent can guide timing of defibrilla- transthoracic impedance—–implications for defibrillation.
tion and other therapies. Circulation 2004;109:926—31.
68. Povoas HP, Weil MH, Tang W, Bisera J, Klouche K, Barbatsis 50. American National Standard: Automatic External Defibril- A. Predicting the success of defibrillation by electrocardio- lators and Remote Controlled Defibrillators (DF39). Arling- graphic analysis. Resuscitation 2002;53:77—82.
ton, Virgina: Association for the Advancement of Medical 69. Noc M, Weil MH, Tang W, Sun S, Pernat A, Bisera J. Electro- cardiographic prediction of the success of cardiac resusci- 51. Deakin CD, McLaren RM, Petley GW, Clewlow F, Dalrymple- tation. Crit Care Med 1999;27:708—14.
Hay MJ. A comparison of transthoracic impedance using 70. Strohmenger HU, Lindner KH, Keller A, Lindner IM, Pfen- standard defibrillation paddles and self-adhesive defibril- ninger EG. Spectral analysis of ventricular fibrillation and lation pads. Resuscitation 1998;39:43—6.
closed-chest cardiopulmonary resuscitation. Resuscitation 52. Stults KR, Brown DD, Cooley F, Kerber RE. Self-adhesive monitor/defibrillation pads improve prehospital defibrilla- 71. Noc M, Weil MH, Gazmuri RJ, Sun S, Biscera J, Tang W.
tion success. Ann Emerg Med 1987;16:872—7.
Ventricular fibrillation voltage as a monitor of the effec- 53. Kerber RE, Martins JB, Kelly KJ, et al. Self-adhesive preap- tiveness of cardiopulmonary resuscitation. J Lab Clin Med plied electrode pads for defibrillation and cardioversion. J 72. Lightfoot CB, Nremt P, Callaway CW, et al. Dynamic nature 54. Kerber RE, Martins JB, Ferguson DW, et al. Exper- of electrocardiographic waveform predicts rescue shock imental evaluation and initial clinical application of outcome in porcine ventricular fibrillation. Ann Emerg Med new self-adhesive defibrillation electrodes. Int J Cardiol 73. Marn-Pernat A, Weil MH, Tang W, Pernat A, Bisera J. Opti- 55. Perkins GD, Roberts C, Gao F. Delays in defibrillation: influ- mizing timing of ventricular defibrillation. Crit Care Med ence of different monitoring techniques. Br J Anaesth 74. Hamprecht FA, Achleitner U, Krismer AC, et al. Fibrilla- 56. Bradbury N, Hyde D, Nolan J. Reliability of ECG monitor- tion power, an alternative method of ECG spectral analysis ing with a gel pad/paddle combination after defibrillation.
for prediction of countershock success in a porcine model of ventricular fibrillation. Resuscitation 2001;50:287— 57. Chamberlain D. Gel pads should not be used for monitoring ECG after defibrillation. Resuscitation 2000;43:159—60.
75. Amann A, Achleitner U, Antretter H, et al. Analysing ven- 58. Callaway CW, Sherman LD, Mosesso Jr VN, Dietrich TJ, Holt tricular fibrillation ECG-signals and predicting defibrillation E, Clarkson MC. Scaling exponent predicts defibrillation success during cardiopulmonary resuscitation employing success for out-of-hospital ventricular fibrillation cardiac N(alpha)-histograms. Resuscitation 2001;50:77—85.
arrest. Circulation 2001;103:1656—61.
76. Brown CG, Griffith RF, Van Ligten P, et al. Median 59. Eftestol T, Sunde K, Aase SO, Husoy JH, Steen PA. Predict- frequency—–a new parameter for predicting defibrillation ing outcome of defibrillation by spectral characterization success rate. Ann Emerg Med 1991;20:787—9.
77. Amann A, Rheinberger K, Achleitner U, et al. The predic- 93. Rea TD, Shah S, Kudenchuk PJ, Copass MK, Cobb LA. Auto- tion of defibrillation outcome using a new combination of mated external defibrillators: to what extent does the algo- mean frequency and amplitude in porcine models of car- rithm delay CPR? Ann Emerg Med 2005;46:132—41.
diac arrest. Anesth Analg 2002;95:716—22.
94. Hess EP, White RD. Ventricular fibrillation is not pro- 78. Cobb LA, Fahrenbruch CE, Walsh TR, et al. Influence voked by chest compression during post-shock organized of cardiopulmonary resuscitation prior to defibrillation in rhythms in out-of-hospital cardiac arrest. Resuscitation patients with out-of-hospital ventricular fibrillation. JAMA 95. Joglar JA, Kessler DJ, Welch PJ, et al. Effects of repeated 79. Wik L, Hansen TB, Fylling F, et al. Delaying defibrillation to electrical defibrillations on cardiac troponin I levels. Am J give basic cardiopulmonary resuscitation to patients with out-of-hospital ventricular fibrillation: a randomized trial.
96. van Alem AP, Chapman FW, Lank P, Hart AA, Koster RW. A prospective, randomised and blinded compari- 80. Jacobs IG, Finn JC, Oxer HF, Jelinek GA. CPR before defibril- son of first shock success of monophasic and biphasic lation in out-of-hospital cardiac arrest: a randomized trial.
waveforms in out-of-hospital cardiac arrest. Resuscitation Emerg Med Australas 2005;17:39—45.
81. Berg RA, Hilwig RW, Kern KB, Ewy GA. Precountershock 97. Carpenter J, Rea TD, Murray JA, Kudenchuk PJ, Eisenberg cardiopulmonary resuscitation improves ventricular fibril- MS. Defibrillation waveform and post-shock rhythm in out- lation median frequency and myocardial readiness for suc- of-hospital ventricular fibrillation cardiac arrest. Resusci- cessful defibrillation from prolonged ventricular fibrilla- tion: a randomized, controlled swine study. Ann Emerg Med 98. Morrison LJ, Dorian P, Long J, et al. Out-of-hospital car- diac arrest rectilinear biphasic to monophasic damped sine 82. Berg RA, Hilwig RW, Ewy GA, Kern KB. Precountershock defibrillation waveforms with advanced life support inter- cardiopulmonary resuscitation improves initial response vention trial (ORBIT). Resuscitation 2005;66:149—57.
to defibrillation from prolonged ventricular fibrillation: 99. Kerber RE, Martins JB, Kienzle MG, et al. Energy, current, a randomized, controlled swine study. Crit Care Med and success in defibrillation and cardioversion: clinical studies using an automated impedance-based method of 83. Kolarova J, Ayoub IM, Yi Z, Gazmuri RJ. Optimal timing for energy adjustment. Circulation 1988;77:1038—46.
electrical defibrillation after prolonged untreated ventric- 100. Koster RW, Dorian P, Chapman FW, Schmitt PW, O’Grady ular fibrillation. Crit Care Med 2003;31:2022—8.
SG, Walker RG. A randomized trial comparing monophasic 84. Berg RA, Sanders AB, Kern KB, et al. Adverse hemo- and biphasic waveform shocks for external cardioversion of dynamic effects of interrupting chest compressions for atrial fibrillation. Am Heart J 2004;147:e20.
rescue breathing during cardiopulmonary resuscitation 101. Martens PR, Russell JK, Wolcke B, et al. Optimal Response for ventricular fibrillation cardiac arrest. Circulation to Cardiac Arrest study: defibrillation waveform effects.
85. Kern KB, Hilwig RW, Berg RA, Sanders AB, Ewy GA.
102. Weaver WD, Cobb LA, Copass MK, Hallstrom AP. Ventricu- Importance of continuous chest compressions during lar defibrillation: a comparative trial using 175-J and 320-J cardiopulmonary resuscitation: improved outcome dur- shocks. N Engl J Med 1982;307:1101—6.
ing a simulated single lay-rescuer scenario. Circulation 103. Tang W, Weil MH, Sun S, et al. The effects of biphasic and conventional monophasic defibrillation on 86. Yu T, Weil MH, Tang W, et al. Adverse outcomes of inter- postresuscitation myocardial function. J Am Coll Cardiol rupted precordial compression during automated defibril- lation. Circulation 2002;106:368—72.
104. Gliner BE, Jorgenson DB, Poole JE, et al. Treatment of out- 87. Eftestol T, Sunde K, Steen PA. Effects of interrupting pre- of-hospital cardiac arrest with a low-energy impedance- cordial compressions on the calculated probability of defib- compensating biphasic waveform automatic external defib- rillation success during out-of-hospital cardiac arrest. Cir- rillator. The LIFE Investigators. Biomed Instrum Technol 88. Valenzuela TD, Kern KB, Clark LL, et al. Interruptions 105. White RD, Blackwell TH, Russell JK, Snyder DE, Jorgenson of chest compressions during emergency medical systems DB. Transthoracic impedance does not affect defibrillation, resuscitation. Circulation 2005;112:1259—65.
resuscitation or survival in patients with out-of-hospital 89. van Alem AP, Sanou BT, Koster RW. Interruption of car- cardiac arrest treated with a non-escalating biphasic wave- diopulmonary resuscitation with the use of the automated form defibrillator. Resuscitation 2005;64:63—9.
external defibrillator in out-of-hospital cardiac arrest. Ann 106. Kuisma M, Suominen P, Korpela R. Paediatric out-of-hospital cardiac arrests: epidemiology and outcome. Resuscitation 90. Bain AC, Swerdlow CD, Love CJ, et al. Multicenter study of principles-based waveforms for external defibrillation.
107. Sirbaugh PE, Pepe PE, Shook JE, et al. A prospective, population-based study of the demographics, epidemi- 91. Poole JE, White RD, Kanz KG, et al. Low-energy impedance- ology, management, and outcome of out-of-hospital compensating biphasic waveforms terminate ventricular fibrillation at high rates in victims of out-of-hospital car- diac arrest. LIFE Investigators. J Cardiovasc Electrophysiol 108. Hickey RW, Cohen DM, Strausbaugh S, Dietrich AM. Pedi- atric patients requiring CPR in the prehospital setting. Ann 92. Schneider T, Martens PR, Paschen H, et al. Multicenter, randomized, controlled trial of 150-J biphasic shocks com- 109. Appleton GO, Cummins RO, Larson MP, Graves JR. CPR and pared with 200- to 360-J monophasic shocks in the resusci- the single rescuer: at what age should you ‘‘call first’’ tation of out-of-hospital cardiac arrest victims. Optimized rather than ‘‘call fast’’? Ann Emerg Med 1995;25:492—4.
Response to Cardiac Arrest (ORCA) Investigators. Circula- 110. Ronco R, King W, Donley DK, Tilden SJ. Outcome and cost at a children’s hospital following resuscitation for out-of- European Resuscitation Council Guidelines for Resuscitation 2005 hospital cardiopulmonary arrest. Arch Pediatr Adolesc Med 129. Gertsch M, Hottinger S, Hess T. Serial chest thumps for the treatment of ventricular tachycardia in patients with coro- 111. Losek JD, Hennes H, Glaeser P, Hendley G, Nelson DB.
nary artery disease. Clin Cardiol 1992;15:181—8.
Prehospital care of the pulseless, nonbreathing pediatric 130. Krijne R. Rate acceleration of ventricular tachycardia after patient. Am J Emerg Med 1987;5:370—4.
a precordial chest thump. Am J Cardiol 1984;53:964—5.
112. Mogayzel C, Quan L, Graves JR, Tiedeman D, Fahrenbruch 131. Sclarovsky S, Kracoff OH, Agmon J. Acceleration of ven- C, Herndon P. Out-of-hospital ventricular fibrillation in chil- tricular tachycardia induced by a chest thump. Chest dren and adolescents: causes and outcomes. Ann Emerg 132. Yakaitis RW, Redding JS. Precordial thumping during cardiac 113. Safranek DJ, Eisenberg MS, Larsen MP. The epidemiol- resuscitation. Crit Care Med 1973;1:22—6.
ogy of cardiac arrest in young adults. Ann Emerg Med 133. Lown B. Electrical reversion of cardiac arrhythmias. Br 114. Berg RA, Chapman FW, Berg MD, et al. Attenuated adult 134. Mittal S, Ayati S, Stein KM, et al. Transthoracic cardiover- biphasic shocks compared with weight-based monophasic sion of atrial fibrillation: comparison of rectilinear biphasic shocks in a swine model of prolonged pediatric ventricular versus damped sine wave monophasic shocks. Circulation fibrillation. Resuscitation 2004;61:189—97.
115. Tang W, Weil MH, Jorgenson D, et al. Fixed-energy bipha- 135. Page RL, Kerber RE, Russell JK, et al. Biphasic versus sic waveform defibrillation in a pediatric model of cardiac monophasic shock waveform for conversion of atrial fibril- arrest and resuscitation. Crit Care Med 2002;30:2736—41.
lation: the results of an international randomized, double- 116. Clark CB, Zhang Y, Davies LR, Karlsson G, Kerber RE. Pedi- blind multicenter trial. J Am Coll Cardiol 2002;39:1956—63.
atric transthoracic defibrillation: biphasic versus monopha- 136. Joglar JA, Hamdan MH, Ramaswamy K, et al. Initial energy sic waveforms in an experimental model. Resuscitation for elective external cardioversion of persistent atrial fib- rillation. Am J Cardiol 2000;86:348—50.
117. Gurnett CA, Atkins DL. Successful use of a biphasic wave- 137. Alatawi F, Gurevitz O, White R. Prospective, randomized form automated external defibrillator in a high-risk child.
comparison of two biphasic waveforms for the efficacy and safety of transthoracic biphasic cardioversion of atrial fib- 118. Atkins DL, Jorgenson DB. Attenuated pediatric electrode rillation. Heart Rhythm 2005;2:382—7.
pads for automated external defibrillator use in children.
138. Pinski SL, Sgarbossa EB, Ching E, Trohman RG. A comparison of 50-J versus 100-J shocks for direct-current cardioversion 119. Gutgesell HP, Tacker WA, Geddes LA, Davis S, Lie JT, McNa- of atrial flutter. Am Heart J 1999;137:439—42.
mara DG. Energy dose for ventricular defibrillation of chil- 139. Kerber RE, Kienzle MG, Olshansky B, et al. Ventricular tachycardia rate and morphology determine energy and 120. Cummins RO, Austin Jr D. The frequency of ‘occult’ ventric- current requirements for transthoracic cardioversion. Cir- ular fibrillation masquerading as a flat line in prehospital cardiac arrest. Ann Emerg Med 1988;17:813—7.
140. Hedges JR, Syverud SA, Dalsey WC, Feero S, Easter R, Shultz 121. Losek JD, Hennes H, Glaeser PW, Smith DS, Hendley G. Pre- B. Prehospital trial of emergency transcutaneous cardiac hospital countershock treatment of pediatric asystole. Am pacing. Circulation 1987;76:1337—43.
141. Barthell E, Troiano P, Olson D, Stueven HA, Hendley G. Pre- 122. Martin DR, Gavin T, Bianco J, et al. Initial countershock in hospital external cardiac pacing: a prospective, controlled the treatment of asystole. Resuscitation 1993;26:63—8.
clinical trial. Ann Emerg Med 1988;17:1221—6.
123. Kohl P, King AM, Boulin C. Antiarrhythmic effects of acute 142. Cummins RO, Graves JR, Larsen MP, et al. Out-of-hospital mechanical stiumulation. In: Kohl P, Sachs F, Franz MR, edi- transcutaneous pacing by emergency medical technicians tors. Cardiac mechano-electric feedback and arrhythmias: in patients with asystolic cardiac arrest. N Engl J Med form pipette to patient. Philadelphia: Elsevier Saunders; 143. Ornato JP, Peberdy MA. The mystery of bradyasystole 124. Befeler B. Mechanical stimulation of the heart; its thera- during cardiac arrest. Ann Emerg Med 1996;27:576— peutic value in tachyarrhythmias. Chest 1978;73:832—8.
144. Niemann JT, Adomian GE, Garner D, Rosborough JP. Endo- Siegert K. Terminierung von Kammertachykardien durch cardial and transcutaneous cardiac pacing, calcium chlo- ride, and epinephrine in postcountershock asystole and (‘‘Termination of Ventricular Tachycardias by Mechan- bradycardias. Crit Care Med 1985;13:699—704.
ical Cardiac Pacing by Means of Precordial Thumps’’).
145. Quan L, Graves JR, Kinder DR, Horan S, Cummins RO.
Transcutaneous cardiac pacing in the treatment of out- 126. Caldwell G, Millar G, Quinn E. Simple mechanical meth- of-hospital pediatric cardiac arrests. Ann Emerg Med ods for cardioversion: Defence of the precordial thump and cough version. Br Med J 1985;291:627—30.
146. Dalsey WC, Syverud SA, Hedges JR. Emergency department 127. Morgera T, Baldi N, Chersevani D, Medugno G, Camerini F.
use of transcutaneous pacing for cardiac arrests. Crit Care Chest thump and ventricular tachycardia. Pacing Clin Elec- 147. Knowlton AA, Falk RH. External cardiac pacing during in- 128. Rahner E, Zeh E. Die Regularisierung von Kammertachykar- hospital cardiac arrest. Am J Cardiol 1986;57:1295—8.
akordialen Faustschlag. (‘‘The Regulariza- 148. Ornato JP, Carveth WL, Windle JR. Pacemaker insertion for tion of Ventricular Tachycardias by Precordial Thumping’’).
prehospital bradyasystolic cardiac arrest. Ann Emerg Med

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