How to use an external defibrillator (Automated External Defibrillator - AED) in a patient with an Implantable Cardioverter-Defibrillator (ICD)?

Using External Defibrillators in Patients with ICDs

When using an external defibrillator (AED) in a patient with an implantable cardioverter-defibrillator (ICD), position the defibrillation pads or paddles as far as possible from the pulse generator and place them in an anterior-posterior location to minimize potential damage to the ICD device. 1

Initial Assessment and Approach

• First, determine if the patient has an ICD by checking for scars, palpating for the device, or reviewing available medical information 1
• If the patient's ICD is actively delivering shocks (visible muscle contractions similar to external defibrillation), allow 30-60 seconds for the ICD to complete its treatment cycle before attaching an AED 1
• For patients with ICDs, pad/paddle placement should not delay defibrillation if it is clinically indicated 1

Proper Pad Placement Technique

• Position defibrillation pads or paddles as far as possible from the pulse generator (at least 8 cm away) 1
• Place pads/paddles perpendicular to the major axis of the ICD by using an anterior-posterior position whenever possible 1
• Avoid placing pads or paddles directly over the ICD device 1
• Both anteroposterior and anterolateral pad positions are acceptable in patients with ICDs 1
• Use standard adult-sized electrode pads (8-12 cm in diameter) 1

Emergency Defibrillation Protocol for ICD Patients

For patients with magnet-disabled ICD therapies:

1. Terminate all sources of electromagnetic interference (EMI) 1
2. Remove the magnet to re-enable the ICD's antitachycardia therapies 1
3. Observe the patient and monitors for appropriate ICD therapy 1
4. If the above steps fail to restore ICD function, proceed with external defibrillation using proper pad placement 1

For patients with programming-disabled ICD therapies:

1. Terminate all sources of EMI 1
2. Re-enable therapies through programming if the programmer is immediately available 1
3. Observe the patient and monitors for appropriate ICD therapy 1
4. If the above steps fail to restore ICD function, proceed with external defibrillation 1

Energy Settings and Technical Considerations

• Use a clinically appropriate energy output regardless of the presence of an ICD 1
• If it is technically impossible to place the pads/paddles in optimal locations, defibrillate the patient in the quickest possible way and be prepared to provide pacing through other routes if needed 1
• Ensure the defibrillation pads make good contact with the skin; remove excess chest hair if necessary but do not delay defibrillation 1
• Do not place AED electrode pads directly on top of transdermal medication patches, as they may block energy delivery 1

Post-Defibrillation Management

• After successful resuscitation, the ICD should be interrogated as soon as possible to assess for any damage or programming changes 1
• Continuously monitor cardiac rate and rhythm and have backup pacing and defibrillation equipment immediately available 1
• Restore all antitachyarrhythmic therapies in the ICD 1
• Consultation with a cardiologist or pacemaker-ICD service may be necessary to ensure proper device function 1

Common Pitfalls to Avoid

• Do not delay defibrillation in a life-threatening situation due to concerns about the ICD 1
• Do not assume the ICD will automatically treat all life-threatening arrhythmias, especially if it has been disabled or is malfunctioning 1
• Be aware that pacemaker spikes with unipolar pacing may confuse AED software and prevent proper VF detection 1
• Remember that the presence of an ICD does not contraindicate the use of an external defibrillator when clinically indicated 1