Dr.

Ali Saad, BMT department 1

Dr. Ali Saad, Biomedical Engineering Dept.
College of applied medical sciences
King Saud University

BMT414
Biomedical Engineering
Defibrillators/Cardioversion

Dr. Ali Saad, BMT department 2
Defibrillation
used to treat ventricular fibrillation (cardiac arrest) loss of coordinated contraction of muscle fibers in ventricles, death occurs in minutes if left untreated.
50,000 cardiac arrest cases occur annually in US.
defibrillation involves the application of a strong electrical shock designed to depolarize most of the heart cells simultaneously, which often reestablishes coordinated contractions and a normal sinus rhythm.
exact physical mechanism leading to ventricular fibrillation is not known. Is thought to originate from myocardial ischemia due to a complication of atheroschlerosis.
Dr. Ali Saad, BMT department 3
Defibrillation Strength Duration Curve
c
u
r
r
e
n
t

(
a
m
p
s
)

pulse duration
defibrillation
occurs
no defibrillation
Dr. Ali Saad, BMT department 4
Defibrillation Strength Duration Curve (cont.)
minimum defibrillation energy occurs for pulse durations of 3 - 10 ms (for most pulse shapes).
pulse amplitude in tens of amperes (few thousand volts).
operator selects energy delivered: 50-360 joules, depends on:
intrinsic characteristics of patient
patients disease
duration of arrhythmia
patients age
type of arrhythmia (more energy required for v. fib.)
Dr. Ali Saad, BMT department 5
External Defibrillators
For each minute elapsing between onset of ventricular fibrillation and first defibrillation, survival decreases by 10%.
defibrillators should be portable, battery operated, small size.
energy in defibrillators usually stored in large capacitors.
total energy stored in capacitor:
W CV
C C
=
1
2
2
V
c
= capacitor voltage
Dr. Ali Saad, BMT department 6
External Defibrillator
power
supply
energy
storage
patient
ECG
monitor
timing
circuitry
gate
charge
discharge
standby
switch is under
operator control
applies shock about 20 ms after
QRS complex, avoids T-wave
Dr. Ali Saad, BMT department 7
Capacitive Discharge Defibrillator
power
supply
C
L
R
lead

R
chest

10 ms
t
2kV
C: 10 F - 50 F, takes about 10s to charge
V
c
: 4,000 - 9,000 V
up to 40% of energy in C can be dissipated in L and R
i

response is slightly underdamped (depends on chest R)
V
c

+
_
V
c

Dr. Ali Saad, BMT department 8
Example
power
supply
C
R
chest

V
c

+
_
R
chest
= 95O, R
lead
= 5O, total energy stored in C is W = 300 J, want
to deliver 90% of W to heart in 8 ms. What value of C should be used?
R
lead

( ) ( )
V t V e t
C C
t R C
L
= >

0 0
/
,
V
C
(0) = initial capacitor voltage after charging
V
chest

+
_
R R R
L lead chest
= +
Dr. Ali Saad, BMT department 9
Example (cont.)
( ) ( )
V t V t
R
R R
chest C
chest
chest lead
=
+
( ) ( )
=
+
=

V e
R
R R
V e
C
t R C
chest
chest lead
C
t R C
L L
0 0
/ /
|
energy stored in capacitor at t = 0:
W V i dt V C
dV
dt
dt
C C C
C
= =
|
\

|
.
|

} }
0 0
( )
= =

}
C V dV CV
C C C
0
2
1
2
0
(1)
(2)
Dr. Ali Saad, BMT department 10
Example (cont.)
energy delivered to R
chest
:
( )
( )
W t
V t
R
dt
chest
chest
chest
t
=
}
2
0
( )
( )
W t
V e
R
dt
chest
C
t R
L
C
chest
t
=
}

|
2
2 2
0
0
/
substituting (1):
using (2):
( )
( )
0 9
1
2
0
0
2 2
2 2
0
0 008
.
/
.
=
}

CV
V e
R
dt
C
C
t R
L
C
chest
|
Dr. Ali Saad, BMT department 11
Example (cont.)
=

09 1
2 0 008
. /
( . )/
| e
R
L
C
00526
2 0 008
.
( . )/
=

e
R
L
C
C = 54.3 F
initial voltage across capacitor:
( )
300
1
2
0
2
J = CV
C
V
c
(0)=3,322.90V
solving for C:
Dr. Ali Saad, BMT department 12
Square Wave Defibrillators
power
supply
C
R
chest

V
c

+
_
V
chest

+
_
R
lead

timing
circuit
SCR1
SCR2
n during charging, SCR1 and SCR2 both open
n to defibrillate, SCR2 closes, current flows to chest
n after a fixed interval, SCR1 closes, shorts out C
V
chest

Dr. Ali Saad, BMT department 13
Defibrillation Electrodes
n metal, 70-100 cm
2
surface area
n must be coupled to skin using conductive material
(otherwise can burn patient)
n two types:
n hand-held: conductive gel must be manually applied,
reusable.
n adhesive: adhesive conducting material holds electrode
to skin, disposable
Dr. Ali Saad, BMT department 14
Electrode Placement
anterior wall placement
front-to-back placement
Dr. Ali Saad, BMT department 15
Automatic External Defibrillators (AEDs)
n Two modes of operation:
n Automatic: AED recognizes specific arrhythmias via
signal processing algorithms, applies shock as
needed. No manual control.
n Semi-automatic: operator must confirm shock
advisory from AED to deliver the shock.
n Less operator training needed
Dr. Ali Saad, BMT department 16
(a) Basic circuit diagram for a capacitivedischarge type of
cardiac defibrillator. (b) A typical waveform of the discharge
pulse. The actual waveshape is strongly dependent on the
values of L, C, and the torso resistance R
L
.
Dr. Ali Saad, BMT department 17
Electrodes used in cardiac defibrillation (a) A
spoon-shaped internal electrode that is applied
directly to the heart. (b) A paddle-type electrode that
is applied against the anterior chest wall.
Dr. Ali Saad, BMT department 18
Hand-held transthoracic electrode
(From Tacker Jr. 1980).



Button
Dr. Ali Saad, BMT department 19
Some examples of the pre-applied adhesive electrodes
(From Tyco/Healthcare Kendall - LTP 2001)



Dr. Ali Saad, BMT department 20
LIFEPAK 500 Automatic External
Defibrillator (AED) weighs 3 kg and is
portable (Medtronic inc. 2001).

Dr. Ali Saad, BMT department 21
Cardioversion
Cardioversion is also a shock supplied to treat other types of arrhythmias such as:
atrial fibrillation
ventricular tachycardia (rapid heart rate)
these types of arrhythmias are not life threatening but do result in reduced cardiac output
it is important that the cardioversion pulse not coincide with a T-wave otherwise ventricular fibrillation may result.
Dr. Ali Saad, BMT department 22
A cardioverter The defibrillation pulse in this
case must be synchronized with the R wave of
the ECG so that it is applied to a patient shortly
after the occurrence of the R wave.
Dr. Ali Saad, BMT department 23
Implantable cardioverter defibrillator (ICD) (Medtronic inc.,
2001).

Dr. Ali Saad, BMT department 24






Electrode
Lead wire
Electrode
Electrode
Lead wire
(a) (b) (c)
Electrodes for the automatic implantable cardioverter defibrillator
(ICD). (a and b:modified from Tacker Jr. 1994, c: modified from
Owens et al., 1990)
Dr. Ali Saad, BMT department 25
A defibrillator provides a 5 ms pulse
of 20 A to a 50 O load.
Thus the energy delivered is
E = P = I
2
Rt = (20 A)
2
(50 O)(0.005 s)
= 100 J.


Dr. Ali Saad, BMT department 26
Defibrillator Safety
n Shock for treating atrial flutter or atrial fibrillation should
not be applied during T-wave.
n Operator should be careful not to touch electrodes during
defibrillation.
n Other personnel should remain clear of patient and any
metal objects contacting patient during defibrillation.
Dr. Ali Saad, BMT department 27
Defibrillator Case Study
CardioServe
Dr. Ali Saad, BMT department 28
Case Study (cont.)
Instrument type: Portable defibrillator with monitor
Operation modes: Non-synchronized, synchronized, HR
monitoring
Energy levels
External defibrillation: 2, 5, 7, 10, 20, 30, 50, 70, 100, 150, 200,
300, 360 J
Capacitor charging time: To 360J from power line or fully
charged battery typically 8 seconds. To 200J typically 4
seconds.
Waveform: Damped sinusoidal halfwave (Edmark)
Synchronized delay: From R-wave trigger to pulse discharge
approximately 40 ms
Pulse output: Isolated
Safety discharge: Capacitor discharge via internal load
resistance

Dr. Ali Saad, BMT department 29
Case Study (cont.)
Defibrillation electrodes
Hard paddles: Hard paddles (80 cm
2
) with charge/shock and printer
buttons. Pediatric adapter (17 cm2).
Pads: Adapter cable for adult and pediatric pads. Buttons for
charge/shock and printer on the defibrillator.
Synchronization
Signal: With ECG signal of either polarity
ECG acquisition: Via hard paddles/pads or ECG patient cable. Via ECG
patient cable up to 7 leads are selectable.
ECG Monitor
Input: ECG via 3 or 5 leadwire cable or defibrillation hard paddles or
pads
Frequency response: 0.5 to 100 Hz (ECG patient cable)
Isolation: Class CF according to IEC. Input protected against high voltage
defibrillator pulses.
Common mode rejection: >110 dB RL referred to ground
Dr. Ali Saad, BMT department 30
Implantable Defibrillators
n Treat v. fibrillation, tachycardia
n Usually incorporated as part of an implanted cardiac
pacemaker (typically VVI).
n Defibrillation threshold: J (n = 102), biphasic pulse
n Defibrillation electrodes also transvenous.
n Must detect arrhythmia prior to defibrillation:
n HR
n PR, RR interval stability
n more sophisticated electrogram analysis (EE 5345)
98 66 . .
Dr. Ali Saad, BMT department 31
References for Defibrillation
n Willis A Tacker, External Defibrillators, in The
Biomedical Engineering Handbook, J. Bronzino (ed) CRC
Press, 1995.
n M. Neuman, in Webster (ed), Medical Instrumentation:
Application and Design, Houghton Mifflin, 1992.
n