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What we are going to look at now is manual defibrillation. It's important to say at this stage, that you should only really be carrying out manual de-fibrillation if you have been trained and assessed as competent in recognizing life-threatening arrhythmias, namely pulseless ventricular tachycardia and ventricular fibrillation. And these are the only two rhythms that you should administer a shock to. The modern defibrillator delivers a biphasic shock across the heart in order to depolarize all the cells in there to give it a chance to start beating again on its own. Similarly to the AED, we have a set of pads which we place on the patient's chest. It's also important to say at this stage, that all this is going on while CPR is continuous and we work around each of the... Okay.

When the pads are on the chest, we can then pick up the rhythm that the heart is in by looking at the screen. The only two items that we should be shocking as I have said, are VF and pulseless VT. Different to the AED, is that with the manual defibrillation, we need to select the joulage at which we are going to shock the heart. Now, a biphasic defibrillator will deliver anywhere between 150 and 360 joules for an adult. You need to be guided by your local guidelines as to how many joules to start off. However, if you forget or you don't have access to your guidelines, just set the joulage to 360 joules every time. The biphasic defibrillation will measure the transthoracic impedance and deliver an appropriate shock for the size of the patient.

To set the joulage, we have an energy select button and we select the first joules. In this situation, we will select 200 joules. However, I'm not going to shock this mannequin at 200 joules, because it might melt. So, for the purposes of today, I'm going to set it to 30. When we've selected the appropriate energy on the machine, we can then charge, and the machine will give us a warning when we are ready to deliver the shock. It's important for us to say, "Stand clear," remove any oxygen supply and then to press the shock button. I'm shocking now. And the shock is delivered.

Following any shock, it's important that we immediately recommence chest compressions again. Even if the heart's started at this point, the chest compressions will not damage the myocardium if done correctly. We need to support the person's circulation until we get some perfusion or signs of life.