Takeaway: Use analogy of fighting fires to help them understand the 3 components important to

defibrillation. All 3 parts are important to have to give the patient the best chance for the best
possible outcome.
Describe each, using analogy, start talking about high rise building/high impedance patient
Fire hose analogy for FIRE/EMS customers: Successful defibrillation with a high impedance
patient is similar to trying to put a fire out on a third story building with a fire hose, You need:
enough water---flowing with enough----force---for a long enough--- time--- to be able to put the
fire out.
i.e. Water = amount of water available to put fire out (Current) Pressure =force pushing water to
reach top floors of high rise building(Voltage)Time = how long until water runs dry(Time or
duration)
Takeaway message: Make sure to point out that 70-80 ohm
averageimpedance from AHA is HOSPITAL setting, not EMS.
The range of impedance that they will likely see goes past 150
ohms.
Average impedance from Guidelines is hospital setting, your
setting is different (EMS), here is an actual range from over
700 patients in out of hospital setting. Zoll often references the
50 ohm patient-show them where that is on the scale.
Takeaway: Biphasic works differently than monophasic,
industry standard for ICD.

Defibrillation is the termination of a lethal irregular cardiac

rhythm called ventricular fibrillation (VF). This rhythm is the
most common cause of Sudden Cardiac Arrest (SCA). A brief
pulse of electrical current is sent to a heart in ventricular
fibrillation to stop the VF, that is, to de-fibrillate the heart.

A biphasic waveform is a new way to deliver this pulse of

electrical current. Monophasic waveform defibrillators preceded
This slide shows a very familiar study, the Higgins study for those
who has been with us since year 2000. This graph illustrates the
40% difference between monophasic peak current and biphasic
peak current.
Fortunately, even monophasic waveforms with the higher peak
currents have not been shown to cause damage to the heart at
traditional energy levels.
This slide shows a very familiar study, the Higgins study for those
who has been with us since year 2000. This graph illustrates the
40% difference between monophasic peak current and biphasic
peak current.
Fortunately, even monophasic waveforms with the higher peak
currents have not been shown to cause damage to the heart at
traditional energy levels.
This slide shows a very familiar study, the Higgins study for those
who has been with us since year 2000. This graph illustrates the
40% difference between monophasic peak current and biphasic
peak current.
Fortunately, even monophasic waveforms with the higher peak
currents have not been shown to cause damage to the heart at
traditional energy levels.
Takeaway: Were you ever concerned with 100 joules
monophasic?
Here you can see 360 joules compared to 100 joules, you can
see the current is similar, was 100 joules shock of concern to
you in your practice? Again remind them, there is NO clinical
evidence of damage with biphasic, all studies done with
extremely high doses of monophasic (up to 3200 joules!)

Actually our highest biphasic (360 joules) shock is virtually the

same current as 100 joules monophasic.
Biphasic waveforms are more effective yet much gentler than monophasic
waveforms. Any fear of damaging the heart through use of 360J is not
supported by science. The AHA recognized this science and supports the
fact that energy levels to 360J in humans does not cause injury. They further
note that energy levels up to 9J/kg have been successful in pediatric
patients with no adverse effects. We will discuss the new energy levels for
pediatric patients in a later slide.
Here are the 2010 energy recommendations for adult VF. Essentially no
change from 2005. Start anywhere between 120J and 200J. Repeat the
same or escalate. Starting at 200J and escalating to 360J is only available
from Physio-Control (vs Philips and ZOLL).
The AHA Guidelines for CPR and ECC with treatment recommendations is
also known as the ILCOR consensus on science. This represents the
collective conclusions and recommendations of ILCOR, a group that
includes representatives from the AHA, ERC, Heart and Stroke Foundation
of Canada, Australian and New Zealand Committee on Resuscitation
(ANZCOR), Resuscitation Council of South Africa (RCSA) and Asia (RSA),
and the Inter American Heart Foundation (IAHF). They concluded after
reviewing the evidence that higher energy levels are associated with higher
Philips recommended cardiac arrest dose range is 150-150-150J. To give a
6J/kg dose for the 79 lb (36kg) patient who is in refractory VF, you are
beyond the maximum energy capability of Philips and ZOLL manual
defibrillators. Both stop at 200J in manual mode and Philips stops at 150J in
AED mode. What about children weighing 85 lbs? 90 Lbs? 110 lbs (7 th grade
boys and older)? Why limit the recommended energy levels for pediatric
patients?

For cardioversion, use a starting dose of 0.5 to 1J/kg. If that fails, the dose
should be increased to 2J/kg.1 Even with cardioversion in pediatric patients
there is recognition that increasing the energy dose will increase shock
AHA increased their recommended dose for initial shock in Adult AF from
100J in 2005 (Guidelines 2005 for CPR and ECC. Circulation 2005;
112(24): IV-42) to 120J in the 2010 guidelines and now recommends if a
first shock fails, providers should increase the dose. In 2005, subsequent
shocks were as needed.
Although unchanged from AHA 2005, this repeated and important guideline
indicates a dosing inconsistency when low energy defibrillators are involved.
There are no dilemmas with Physio-Control. This is an unnecessary patient
issue that doesnt exist with LIFEPAK devices.
The evidence from all the independent AF studies clearly show that joule for
joule the different biphasic waveforms perform equally at the same energy
levels. This fact was recognized by the AHA in the 2005 and 2010
Guidelines which state there was no evidence supporting the superiority of
one biphasic waveform over another.
No study has shown that any one waveform at the same energy level has
shown superior results. But studies have shown that increasing the energy
dose does improve shock success and that plenty of low energy shocks
show room for improvement.
The guidelines also gave special mention to the fact that their was no new
data for the rectilinear waveform (used by ZOLL Medical) since the 2005