Principle of defibrillation Normal heart has a synchronized activation sequence starting from the sinoatrial node, conducted down

to the ventricles through the conduction system. In an abnormal rhythm known as ventricular fibrillation, the ventricles stand still due to multiple wavelets of activation known as ventricular fibrillation. Ventricular fibrillation is fatal, unless promptly corrected by direct current shock using a defibrillator. Defibrillator shock simultaneously depolarizes a large portion of the ventricular cells so that the fibrillary cannot be sustained. This gives a chance for the sinoatrial node, the regular pacemaker to take over the sequential activation of the heart.

Principle of Early Defibrillation

Early defibrillation is critical to survival from cardiac arrest for several reasons: (1) the most frequent initial rhythm in witnessed sudden cardiac arrest is VF; (2) the most effective treatment for VF is electrical defibrillation; (3) the probability of successful defibrillation diminishes rapidly over time; and (4) VF tends to convert to asystole within a few minutes.25
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Many adults in VF can survive neurologically intact even if The performance of CPR while awaiting the arrival of

defibrillation is performed as late as 6 to 10 minutes after sudden cardiac arrest, particularly if CPR is provided.25
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the AED appears to prolong VF, contributing to preservation of heart and brain function.3940 Basic CPR, however, is unlikely to convert VF to a normal rhythm. The speed with which defibrillation is performed is the major determinant of the success of resuscitative arrest.38 approximately delayed. attempts 7% to 10% for with treatment every
41

of that

VF

cardiac is When

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Survival rates after VF cardiac arrest decrease minute defibrillation

44 45 46

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(See Figure 1. ) A survival rate as high as 90% has

been reported when defibrillation is achieved within the first minute of collapse.43

defibrillation is delayed, survival rates decrease to approximately 50% at 5 minutes, approximately 30% at 7 minutes, approximately 10% at 9 to 11 minutes, and approximately 2% to 5% beyond 12 minutes.25
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One historical observational

study suggests that survival may be improved if CPR is performed by first responders for 1 minute before defibrillation when defibrillation is delayed 4 minutes57 and no bystander CPR is performed.

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Figure 1. Composite data illustrating relationship between probability of survival to hospital discharge (indicated as success in figure) after VF cardiac arrest and interval between collapse and defibrillation. Based on data from Reference 41 .

Survival rates from cardiac arrest can be remarkably high if the event is witnessed. For example, when people in supervised cardiac rehabilitation programs experience a witnessed cardiac arrest, defibrillation is usually performed within minutes; in 4 studies of cardiac arrest in this setting, 90 of 101 victims (89%) were resuscitated.43 survival rate reported for a defined out-of-hospital population. Communities with no out-of-hospital ACLS services but with early defibrillation programs have reported improved survival rates among patients with cardiac arrest when survival rates for EMT care with and without AEDs were compared.47
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This is the highest

The most impressive

results were reported by King County, Washington, where the survival rate of patients with VF improved from 7% to 26%,47 and rural Iowa, where the survival rate rose from 3% to 19%.48 More modest results have been observed in rural communities in southeastern Minnesota,49 northeastern Minnesota,50 and Wisconsin.51 After implementation of early defibrillation programs by EMS personnel in 5 European regions, survival to discharge from VF cardiac arrest was as high as 27% to 55%.58 Clearly prognosis.38 the earlier defibrillation occurs, the better the
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Emergency personnel have only a few minutes

after a victims collapse to reestablish a perfusing rhythm. CPR can sustain a patient for a short time but cannot directly restore an organized rhythm. Restoration of an adequate perfusing rhythm requires defibrillation and advanced cardiovascular care, which must be administered within a few minutes of the initial arrest.37 The use of AEDs increases the range of personnel who can use a defibrillator, shortening the time between collapse and defibrilla-tion.47
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This exciting prospect accounts for the addition of this

intervention as an integral component of BLS. Early defibrillation (shock within 5 minutes of EMS call receipt) is a high-priority goal of EMS care. Every community should assess its capability to provide this intervention and institute whatever measures are necessary to make this recommendation a reality.