SELF/Perioperative Nursing/Defibrillation with AED

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Sudden cardiac arrest is a life-threatening emergency that requires immediate recognition and treatment. Early cardiopulmonary resuscitation (CPR) combined with prompt defibrillation using an automated external defibrillator (AED) provides the greatest opportunity to restore a perfusing cardiac rhythm and improve patient survival.

This course provides the knowledge required to safely and effectively perform defibrillation with an AED on a patient experiencing sudden cardiac arrest in the perioperative environment. Building on existing Basic Life Support (BLS) skills, the course focuses specifically on the safe operation of an AED, including recognition of cardiac arrest, identification of patients who may benefit from defibrillation, safe preparation and operation of the device, coordination with ongoing CPR, recognition of return of spontaneous circulation (ROSC), and appropriate post-resuscitation care.

Throughout the course, emphasis is placed on patient safety, effective teamwork, perioperative considerations, and practical adaptations for low-resource environments. The accompanying psychomotor skills practice complements the knowledge presented in this course by allowing learners to develop safe and consistent AED operation before applying these skills in clinical practice.

This course is intended for perioperative nurses and other members of the operating room team who may be required to operate an automated external defibrillator during the management of sudden cardiac arrest.

Learners are expected to have successfully completed Basic Life Support (BLS) training and be competent in recognizing cardiac arrest and performing high-quality cardiopulmonary resuscitation (CPR). This course does not teach CPR techniques. Instead, it builds on these prerequisite skills by focusing on the safe and effective use of an AED within the perioperative environment.

The course is designed for clinicians practicing in hospitals and surgical facilities, including low-resource settings where personnel, equipment, or advanced cardiac life support resources may be limited. Emphasis is placed on practical decision-making, patient safety, effective communication, and adapting AED use while maintaining evidence-based standards of care.

By the end of this module, you will be able to:

• Recognize the clinical features of sudden cardiac arrest and identify patients who require assessment for AED use.
• Differentiate shockable rhythms from non-shockable rhythms and explain the capabilities and limitations of an automated external defibrillator.
• Describe the indications, contraindications, precautions, and safety considerations associated with AED use.
• Explain the roles of the perioperative team and the communication required during an AED-assisted resuscitation.
• Describe the correct preparation of the patient, placement of AED pads, operation of the AED, and management of common troubleshooting situations.
• Explain how AED operation is coordinated with high-quality CPR to minimize interruptions in chest compressions and ensure safe shock delivery.
• Recognize the signs of return of spontaneous circulation (ROSC) and describe the immediate care required following rhythm analysis or defibrillation.
• Describe post-defibrillation monitoring, complication management, documentation, patient handoff, equipment readiness, and post-event quality improvement activities.

Sudden cardiac arrest (SCA) is a life-threatening emergency in which the heart suddenly stops pumping blood effectively. Without immediate treatment, circulation ceases, oxygen delivery to vital organs stops, and irreversible brain injury or death can occur within minutes. Early recognition of cardiac arrest, prompt initiation of cardiopulmonary resuscitation (CPR), and timely defibrillation when indicated provide the greatest opportunity for survival.

This course assumes that you are already trained in Basic Life Support (BLS), including recognition of cardiac arrest and delivery of high-quality CPR. Rather than teaching CPR techniques, this lesson focuses on recognizing when an automated external defibrillator (AED) is indicated and understanding how the device determines whether defibrillation is appropriate. These principles provide the foundation for the safe use of an AED throughout the remainder of this course.

When a patient collapses and is unresponsive, the nurse should immediately assess for signs of sudden cardiac arrest (SCA). This includes checking for unresponsiveness by tapping the patient and calling their name, assessing for normal breathing (not agonal gasps), and confirming the absence of a central pulse such as the carotid.

Once these findings are present, CPR should begin immediately while another clinician retrieves and prepares the AED. Early recognition and rapid intervention are essential because the likelihood of successful resuscitation decreases with every minute that effective treatment is delayed.

Recognition of cardiac arrest may differ in the perioperative environment because anesthetized patients cannot respond verbally or demonstrate purposeful movement. Instead, deterioration is often identified through patient monitoring. Oxygen desaturation, loss of waveform capnography, sudden loss of an arterial line waveform, or other evidence of circulatory collapse should immediately raise suspicion of cardiac arrest. Prompt recognition allows the perioperative team to begin CPR and prepare the AED without unnecessary delay.

Cardiac arrest in the perioperative environment often develops for different reasons than cardiac arrest in the community. While some patients experience a primary cardiac event, others arrest because of complications related to anesthesia, airway management, surgery, or medications. Recognizing these possible causes helps the perioperative team communicate effectively, anticipate ongoing management, and support treatment of reversible conditions while resuscitation continues.

Common perioperative causes of cardiac arrest include hypoxia, airway obstruction, anesthetic complications, severe hemorrhage, medication-related cardiovascular collapse, and significant electrolyte abnormalities. These conditions may develop rapidly during surgery or anesthesia and can lead to sudden cardiovascular collapse if not recognized and managed promptly.

Although identifying the underlying cause is important, it should never delay the immediate priorities of cardiac arrest management. When a patient is unresponsive, not breathing normally, and has no definite pulse, begin CPR, apply the AED as soon as it is available, and follow the AED prompts while the anesthesia provider and surgical team investigate and manage the underlying cause.

An automated external defibrillator is specifically designed to detect and treat ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT), the two most common shockable rhythms encountered during sudden cardiac arrest.

Ventricular fibrillation is characterized by chaotic electrical activity that prevents coordinated contraction of the ventricles, while pulseless ventricular tachycardia is a rapid ventricular rhythm that fails to produce effective cardiac output. In both situations, defibrillation attempts to stop the abnormal electrical activity, allowing the heart's normal conduction system an opportunity to restore an organized rhythm.

Not all cardiac arrest rhythms respond to defibrillation. Non-shockable rhythms include asystole and pulseless electrical activity (PEA). When these rhythms are detected, the AED advises that no shock should be delivered and instructs rescuers to continue CPR while advanced resuscitation measures proceed.

Understanding the difference between shockable and non-shockable rhythms helps clinicians interpret AED prompts correctly and reinforces that the AED determines whether defibrillation is appropriate based on rhythm analysis.

Unlike a manual defibrillator, an AED automatically analyzes the patient's cardiac rhythm using built-in software. Once the pads have been correctly applied and rhythm analysis begins, the device determines whether a shock is likely to be beneficial.

If a shockable rhythm is identified, the AED charges and either advises or automatically delivers a shock depending on the model. If a non-shockable rhythm is detected, the AED advises against defibrillation and instructs rescuers to resume CPR immediately. The AED continues to reassess the patient's rhythm at regular intervals throughout the resuscitation.

The nurse should understand that the AED recommendation is based solely on rhythm analysis. Effective patient care still depends on continuous clinical assessment, adherence to established resuscitation protocols, and coordinated teamwork.

Although AEDs are highly reliable, clinicians should recognize that rhythm analysis has limitations. One important example is fine ventricular fibrillation (low-amplitude VF), which may occasionally resemble asystole and therefore be interpreted as a non-shockable rhythm.

If very fine, irregular undulations are observed on the ECG while the AED advises that no shock is indicated, the nurse should ensure that the pads have good skin contact, confirm correct pad placement once they have been applied, and continue high-quality CPR. If monitoring equipment permits, increasing the ECG gain or changing monitoring leads may make the rhythm easier to distinguish. Effective CPR also improves myocardial perfusion, which may increase the amplitude of ventricular fibrillation and allow subsequent rhythm analyses to identify a shockable rhythm.

In the perioperative environment, certain conditions, such as severe hypothermia or significant electrolyte disturbances, may alter rhythm appearance. Understanding these limitations helps clinicians interpret AED prompts within the broader clinical context while continuing evidence-based resuscitation.

• Sudden cardiac arrest is a life-threatening emergency that requires immediate recognition and treatment.
• In the perioperative environment, cardiac arrest is often recognized through changes in patient monitoring rather than patient responsiveness.
• Automated external defibrillators identify shockable rhythms by analyzing the patient's cardiac rhythm.
• Ventricular fibrillation and pulseless ventricular tachycardia are shockable rhythms.
• Asystole and pulseless electrical activity are non-shockable rhythms.
• When a shock is not advised, CPR should continue while the AED continues periodic rhythm analysis.
• Fine ventricular fibrillation may occasionally resemble asystole, making continued high-quality CPR and careful rhythm assessment especially important.

In this lesson, you learned how to recognize sudden cardiac arrest and how an AED determines whether defibrillation is appropriate. The next lesson builds on this foundation by explaining when an AED should and should not be used, together with the precautions required to ensure safe defibrillation.

Self-Assessment

Please complete the following: Recognition of Cardiac Arrest and Shockable Rhythms Quiz

Not every unresponsive patient requires defibrillation, and not every cardiac arrest rhythm benefits from an electrical shock. After recognizing sudden cardiac arrest and understanding the rhythms that an AED can treat, the next step is determining when the device should be used and how to use it safely. Appropriate patient assessment and careful attention to safety protect both the patient and the resuscitation team while ensuring the AED can accurately analyze the cardiac rhythm.

This lesson builds on the principles introduced in Topic 1 by explaining the indications for AED use, situations that require special consideration, and the precautions that should always be observed before rhythm analysis and shock delivery.

An automated external defibrillator should be used when a patient is unresponsive, is not breathing normally (or is only gasping), and has no central pulse, indicating sudden cardiac arrest. Once these findings are confirmed, CPR should begin immediately while another clinician retrieves and prepares the AED.

The AED is specifically designed to detect ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT), the two shockable rhythms discussed in Topic 1. After the pads are applied and rhythm analysis begins, the AED determines whether defibrillation is indicated. If a shockable rhythm is detected, the device advises or delivers a shock depending on its design. If a non-shockable rhythm is detected, it instructs rescuers to continue CPR.

In the perioperative environment, rapid recognition of cardiac arrest relies on both clinical assessment and continuous patient monitoring. The AED should be incorporated into the resuscitation process as soon as cardiac arrest is recognized, while ensuring that high-quality CPR continues with minimal interruption.

Although AEDs are designed to simplify defibrillation, several patient-related factors should be recognized before applying the pads.

Medication patches should not remain beneath an AED pad because they may interfere with electrical current and increase the risk of skin burns. If a medication patch is present at the intended pad site, it should be carefully removed before pad application, taking appropriate precautions to avoid medication exposure.

The patient's chest should be as dry as possible before the pads are applied. Moisture from perspiration, blood, irrigation fluids, or surgical skin preparation solutions may reduce pad adhesion and interfere with effective electrical contact. Quickly drying the skin improves pad adhesion and helps ensure effective rhythm analysis and shock delivery.

Excessive chest hair may also reduce pad adhesion by preventing full contact between the electrode and the skin. If a razor is immediately available, the intended pad sites should be shaved rapidly before pad application. If shaving equipment is unavailable and delaying treatment would postpone defibrillation, the pads should be applied firmly without unnecessary delay.

Certain implanted medical devices also require attention during pad placement. If a pacemaker or implantable cardioverter-defibrillator (ICD) is visible or palpable beneath the skin, the AED pad should be placed slightly away from the device to avoid positioning the electrode directly over the implant while maintaining the recommended current pathway across the heart.

Safe defibrillation depends on protecting both the patient and every member of the resuscitation team.

Immediately before rhythm analysis and again before shock delivery, all rescuers must avoid physical contact with the patient, bed, or attached equipment that could conduct electrical current. The clinician operating the AED should clearly announce "Clear" and perform a deliberate visual check to confirm that no one is touching the patient before allowing rhythm analysis or delivering a shock.

Whenever possible, oxygen sources that are delivering high concentrations of oxygen directly across the patient's chest should be moved away from the immediate shock area in accordance with local protocols while maintaining adequate oxygenation. This reduces the potential fire risk associated with electrical defibrillation in oxygen-enriched environments.

In the operating room, additional attention should be given to attached monitoring cables, intravenous tubing, invasive lines, surgical drapes, and other equipment surrounding the patient. These should be organized so they do not interfere with safe AED operation or delay treatment.

The perioperative environment presents challenges that are uncommon in other clinical settings. Surgical drapes, monitoring equipment, invasive lines, electrosurgical equipment, and multiple team members may all be present when cardiac arrest occurs.

During resuscitation, effective communication allows the team to coordinate patient access while maintaining as much of the sterile environment as is safely possible. Equipment should be moved only as necessary to allow prompt AED application and safe defibrillation. When patient positioning or the surgical field limits access to the standard pad locations, alternative pad placement may be required. The principles of pad placement and alternative configurations will be discussed in the next lesson.

Throughout the event, patient safety remains the priority. Team members should anticipate potential hazards, communicate clearly, and work together to minimize delays while maintaining safe resuscitation practices.

In settings where AEDs are limited, nurses should know the location of the nearest functioning device before an emergency occurs and ensure that access routes remain unobstructed.

If shaving equipment is unavailable, pads should be applied firmly despite chest hair rather than delaying defibrillation. Likewise, if towels or gauze are unavailable, any clean absorbent material may be used to dry excessive moisture from the chest before pad placement.

When staffing is limited, team members should clearly assign responsibilities so that CPR continues while the AED is retrieved and prepared. Effective teamwork and early role allocation help minimize interruptions to patient care even when resources are constrained.

• An AED should be used when sudden cardiac arrest has been recognized and CPR has begun.
• The AED determines whether defibrillation is indicated by analyzing the patient's cardiac rhythm.
• Medication patches, wet skin, excessive chest hair, and implanted cardiac devices require consideration before pad application.
• Everyone must remain clear of the patient during rhythm analysis and shock delivery.
• Perioperative environments present additional challenges because of equipment, monitoring devices, surgical drapes, and restricted patient access.
• In low-resource settings, prompt treatment should not be unnecessarily delayed when ideal equipment or supplies are unavailable.

Having learned when an AED should be used and the precautions that ensure safe defibrillation, the next lesson focuses on team communication, emergency response activation, and the coordinated actions that allow the resuscitation team to work efficiently during cardiac arrest.

Self-Assessment

Please complete the following: Indications, Contraindications, and Safety Precautions for AED Use Quiz

Successful resuscitation depends on more than the correct operation of an automated external defibrillator. During sudden cardiac arrest, every member of the perioperative team must communicate clearly, understand their responsibilities, and coordinate their actions to minimize delays in treatment. Effective teamwork allows high-quality CPR, AED preparation, rhythm analysis, defibrillation, and advanced interventions to occur simultaneously rather than sequentially.

This lesson explains how effective communication supports safe AED use, the importance of early emergency response activation, and the responsibilities of perioperative team members throughout a cardiac arrest event.

Once sudden cardiac arrest is recognized, the emergency response system should be activated immediately while CPR begins. Delaying activation postpones the arrival of additional personnel, advanced equipment, and advanced life support interventions.

Whenever possible, one team member should remain focused on delivering high-quality CPR while another retrieves and powers on the AED. Additional personnel should be assigned specific responsibilities as they arrive, allowing resuscitation activities to continue without unnecessary interruption.

In the operating room, emergency activation should follow local institutional protocols. Early notification allows anesthesia providers, surgeons, additional nursing staff, and emergency response teams to mobilize rapidly and prepare for advanced resuscitative care.

Clear role assignment improves efficiency and reduces confusion during cardiac arrest. Whenever staffing permits, responsibilities should be assigned as early as possible.

Typical responsibilities may include:

• Performing continuous chest compressions.
• Operating the AED.
• Managing the airway and ventilation.
• Administering medications as directed.
• Recording events and interventions.
• Coordinating equipment and additional resources.

In smaller facilities or low-resource environments, fewer clinicians may be available. Team members may therefore perform multiple responsibilities while maintaining clear communication regarding changes in role or task.

During resuscitation, instructions should be communicated clearly and confirmed by the receiving team member. This process, often referred to as closed-loop communication, reduces misunderstanding and helps ensure that important actions are completed promptly.

For example:

Leader:

"Retrieve the AED."

Team member:

"Retrieving the AED."

Leader:

"Begin rhythm analysis."

AED operator:

"Beginning rhythm analysis."

By confirming both the instruction and its completion, the team maintains situational awareness and reduces the likelihood of missed or duplicated actions.

Effective communication becomes especially important during rhythm analysis and shock delivery.

Before rhythm analysis, the AED operator should clearly instruct the team to stop chest compressions only for the brief period required for rhythm analysis.

Immediately before rhythm analysis and again before shock delivery, the operator should loudly announce "Clear" while visually confirming that no one is touching the patient, bed, or attached equipment.

After rhythm analysis or shock delivery, communication should focus on immediately resuming CPR or recognizing signs of return of spontaneous circulation (ROSC), depending on the AED prompts and the patient's condition.

Throughout the event, concise, standardized communication reduces delays and improves patient safety.

As additional clinicians arrive, clear communication becomes essential to coordinate advanced interventions.

The nurse should communicate significant clinical findings, including the time cardiac arrest was recognized, CPR initiation, AED application, rhythm analyses, shocks delivered, and any observed patient responses. This information allows advanced care providers to make timely decisions regarding airway management, medication administration, and ongoing resuscitation.

In the perioperative environment, continuous monitoring may provide early indications of return of spontaneous circulation. If these signs are observed, the nurse should promptly communicate them to the anesthesia provider so circulation can be assessed according to established resuscitation protocols.

In low-resource settings, fewer personnel may require individuals to alternate between several responsibilities during the resuscitation. Clear communication becomes even more important when staffing is limited.

Before emergencies occur, facilities should establish simple role assignments appropriate to the number of available staff. During cardiac arrest, clinicians should communicate role changes clearly to ensure that CPR, AED operation, airway management, and patient monitoring continue without unnecessary interruption.

Even with limited personnel, effective communication helps maintain patient safety and supports coordinated resuscitation.

• Early activation of the emergency response system allows additional personnel and resources to arrive promptly.
• Clear role assignment improves the efficiency of resuscitation.
• Closed-loop communication reduces misunderstandings and confirms that important actions have been completed.
• Standardized verbal communication, including announcing "Clear," promotes safety during rhythm analysis and shock delivery.
• Accurate communication with advanced care providers supports ongoing resuscitation and post-resuscitation care.
• Effective teamwork becomes even more important in low-resource environments where fewer clinicians may be available.

Having learned how communication and teamwork support safe resuscitation, the next lesson explains how to prepare the patient, operate the AED, position the pads correctly, and manage common troubleshooting situations during defibrillation.

Self-Assessment

Please complete the following: Team Communication and Emergency Response Activation Quiz

Once sudden cardiac arrest has been recognized, the emergency response has been activated, and cardiopulmonary resuscitation (CPR) is underway, attention turns to preparing and operating the automated external defibrillator (AED). Proper AED setup allows the device to analyze the patient's cardiac rhythm accurately and, when appropriate, deliver life-saving defibrillation with minimal interruption to chest compressions.

This lesson explains the correct sequence for preparing the AED, preparing the patient, applying the electrode pads, performing rhythm analysis, recognizing and managing common troubleshooting situations, and adapting AED operation to the perioperative environment.

Once the AED is retrieved, the nurse should immediately open the unit and power it on either by pressing the designated power button or lifting the lid, depending on the model design. The device should be positioned where the operator can easily see the display, hear the voice prompts, and access the controls without interfering with ongoing resuscitation.

The electrode pads should be removed promptly from their sealed package and inspected before use. Confirm that the adhesive is intact, the conductive gel remains moist, and the packaging has not been damaged. If replacement pads are immediately available and the original pads are damaged, contaminated, or dried out, they should be replaced before application.

Throughout AED preparation, CPR should continue without interruption whenever possible while another team member prepares the device.

Before applying the AED pads, expose the patient's chest sufficiently to identify the correct pad positions.

Inspect the skin to ensure the intended pad sites are clean and dry. If the patient's chest is moist from perspiration, blood, irrigation fluid, or surgical skin preparation solution, quickly dry the skin using available absorbent material to improve pad adhesion and electrical contact.

If significant chest hair is present, shave the intended pad sites if a razor is immediately available and doing so will not significantly delay defibrillation. When shaving equipment is unavailable, apply the pads firmly without unnecessary delay.

If a medication patch is present where a pad will be placed, remove the patch before pad application using appropriate precautions to avoid medication exposure.

When a pacemaker or implantable cardioverter-defibrillator (ICD) is present, position the pad slightly away from the implanted device while maintaining the recommended electrical pathway across the heart.

Correct pad placement allows electrical current to pass effectively through the myocardium.

The recommended adult pad configuration is the anterolateral position.

Place one pad on the upper right chest below the clavicle and to the right of the sternum.

Place the second pad on the left lateral chest wall below the axilla.

This anterolateral configuration provides an effective electrical pathway across the myocardium and is recommended for most adult patients.

Press each pad firmly against the skin to achieve complete contact and eliminate trapped air pockets that could reduce electrical conduction.

Once both pads have been applied, connect the electrode cable securely to the AED if it is not already pre-connected. Confirm that the connection is secure before rhythm analysis begins.

Occasionally, the standard anterolateral position cannot be used.

During perioperative procedures, surgical drapes, operative sites, monitoring equipment, or patient positioning may obstruct the recommended left lateral pad position.

When this occurs, an anterior-posterior configuration may be used by placing one pad on the anterior chest and the other on the patient's back according to the manufacturer's recommendations.

Regardless of the pad configuration used, the objective is to maintain an effective electrical pathway through the heart while avoiding unnecessary delays in treatment.

Once the pads have been connected, the AED automatically begins rhythm analysis or instructs the operator to initiate rhythm analysis, depending on the model.

During rhythm analysis, chest compressions should be paused only for the brief period required for the AED to analyze the rhythm.

The operator should clearly announce "Clear" while visually confirming that no one is touching the patient, bed, or attached equipment before rhythm analysis proceeds.

If the AED detects a shockable rhythm, it will charge and advise or automatically deliver a shock, depending on the model.

If a non-shockable rhythm is detected, the AED will advise that no shock should be delivered and instruct rescuers to resume CPR immediately.

Immediately following rhythm analysis or shock delivery, CPR should resume without unnecessary delay, following the AED prompts and established Basic Life Support (BLS) protocols.

Interruptions to chest compressions should be kept as short as possible while the AED prepares for subsequent rhythm analyses or additional shocks.

In the operating room, continuous monitoring using ECG, arterial line pressure, and waveform capnography may provide early indications of return of spontaneous circulation (ROSC) while CPR is ongoing. If these indicators appear, the nurse should immediately alert the anesthesia provider, who may direct a brief pause to confirm the return of circulation according to established resuscitation protocols.

Although AEDs provide clear voice prompts, certain conditions may reduce the accuracy of rhythm analysis or delay effective treatment.

Poor pad adhesion may result from wet skin, excessive chest hair, damaged pads, or incomplete skin contact.

Dry the chest, shave excessive hair when appropriate, press the pads firmly against the skin, and replace defective pads if replacement pads are immediately available.

If the AED reports poor electrode contact, inspect both pads to ensure they remain fully attached to the chest and confirm that the electrode cable is securely connected.

Correct the problem before allowing rhythm analysis to continue.

Very fine ventricular fibrillation (low-amplitude VF) may occasionally resemble asystole.

If the ECG demonstrates very fine, irregular baseline undulations while the AED advises that no shock is indicated, carefully inspect the rhythm, ensure good pad contact, and continue high-quality CPR. If monitoring equipment permits, increasing the ECG gain or changing monitoring leads may make the rhythm easier to distinguish. Improved myocardial perfusion resulting from effective CPR may increase the amplitude of ventricular fibrillation, allowing subsequent rhythm analyses to identify a shockable rhythm.

If the AED reports a low battery, device malfunction, or another equipment fault that cannot be corrected immediately, another AED should be obtained while CPR continues without interruption.

AED operation in the operating room requires awareness of the surrounding surgical environment.

Pads should not interfere with the surgical site, electrosurgical return electrode, invasive lines, monitoring cables, or other essential equipment whenever this can be avoided without delaying treatment.

If the recommended left lateral pad position is obstructed by sterile drapes or the operative field, the anterior-posterior pad configuration should be considered.

Throughout the resuscitation, clear communication among the perioperative team is essential to coordinate CPR, AED operation, patient monitoring, and advanced interventions while maintaining patient safety.

In facilities where replacement pads, razors, or additional AEDs are limited, treatment should not be unnecessarily delayed while attempting to obtain ideal equipment.

If shaving equipment is unavailable, apply the pads firmly despite chest hair. If towels or gauze are unavailable, use any available clean absorbent material to dry excessive moisture from the chest before pad placement.

Facilities should routinely identify the location of the nearest functioning AED, ensure that access routes remain unobstructed so the device can be retrieved without unnecessary delay, and confirm that replacement pads and batteries are available whenever possible.

• Power on the AED immediately after it is retrieved.
• Inspect the pads before use and ensure they are intact and ready for application.
• Prepare the patient's chest before applying the pads.
• Use the standard anterolateral pad position whenever possible.
• Use an anterior-posterior configuration when the standard position is not feasible.
• Pause chest compressions only for rhythm analysis and shock delivery.
• Resume CPR immediately after rhythm analysis or shock delivery unless return of spontaneous circulation has been confirmed according to established protocols.
• Recognize and correct common problems such as poor pad adhesion, poor electrical contact, fine ventricular fibrillation, and equipment faults.
• During perioperative resuscitation, ensure that pads do not interfere with the surgical field or essential equipment while maintaining an effective electrical pathway through the heart.

In this lesson, you learned how to prepare the AED, prepare the patient, apply the electrode pads, perform rhythm analysis, and manage common operational problems. The next lesson explains how AED operation is coordinated with high-quality CPR to minimize interruptions in chest compressions and maximize the effectiveness of defibrillation.

Self-Assessment

Please complete the following: AED Setup Quiz

Successful defibrillation depends not only on delivering a shock when indicated but also on minimizing interruptions to cardiopulmonary resuscitation (CPR). While the AED analyzes the patient's rhythm and advises treatment, rescuers must work together to ensure that chest compressions are interrupted only when necessary. Efficient coordination between CPR and AED operation improves myocardial and cerebral perfusion and increases the likelihood of successful defibrillation.

This lesson explains how CPR and AED use should be coordinated throughout a resuscitation, the importance of minimizing pauses in chest compressions, and the role of the AED in guiding ongoing treatment.

Once CPR has begun and the AED has been prepared, both interventions should proceed together. Whenever possible, one rescuer should continue chest compressions while another prepares and operates the AED.

Chest compressions should continue throughout AED preparation and pad application whenever they do not interfere with safe pad placement. Only the brief interruptions required for rhythm analysis and shock delivery should interrupt compressions.

Maintaining this coordinated approach minimizes delays in treatment while allowing the AED to perform accurate rhythm analysis.

Interruptions in chest compressions reduce blood flow to the heart and brain and may decrease the effectiveness of subsequent defibrillation.

The AED operator should anticipate each stage of AED use so that rhythm analysis and shock delivery occur efficiently. Team members should be prepared to resume CPR immediately after the AED completes rhythm analysis or after a shock has been delivered unless return of spontaneous circulation has been confirmed according to established resuscitation protocols.

Good communication and role allocation help reduce unnecessary pauses throughout the resuscitation.

Modern AEDs provide voice and visual prompts that guide rescuers through each stage of resuscitation.

The operator should listen carefully to each prompt and follow the instructions exactly. Team members should avoid performing actions that conflict with the AED prompts or delay the resuscitation sequence.

When the AED advises that no shock is indicated, CPR should be resumed immediately while awaiting the next rhythm analysis.

When a shock is advised, rescuers should follow the AED prompts, ensure that everyone is clear of the patient, and resume CPR promptly after shock delivery.

Successful AED use requires continuous communication among all members of the resuscitation team.

The individual performing chest compressions should be informed before compressions are briefly paused for rhythm analysis. Likewise, the AED operator should clearly announce when CPR should resume.

Throughout the resuscitation, team members should communicate clearly, anticipate the next step, and work together to minimize delays between AED prompts and patient care.

In the perioperative environment, CPR and AED operation occur alongside anesthesia management, surgical activities, and continuous patient monitoring.

The perioperative team should coordinate these simultaneous activities to minimize interruptions while maintaining patient safety. Continuous physiologic monitoring may provide additional clinical information during resuscitation, but AED prompts and established resuscitation protocols should continue to guide treatment.

When surgical drapes, equipment, or personnel limit access to the patient, the team should communicate clearly and reposition only what is necessary to allow safe CPR and AED operation without unnecessary delays.

Many perioperative patients receive supplemental oxygen through an anesthesia circuit, face mask, nasal cannula, or breathing device. Oxygen itself does not cause fire, but oxygen-enriched environments greatly increase the risk of combustion if a spark occurs during defibrillation.

Before rhythm analysis and shock delivery, quickly identify any oxygen source near the patient's chest. If it can be done safely without delaying defibrillation or compromising ventilation, move oxygen delivery equipment away from the path of the shock according to local protocol. Ensure oxygen tubing is not lying across the chest or directly beneath the AED pads. Continue to provide oxygenation whenever possible while minimizing fire risk.

Immediately before the AED analyzes the rhythm or delivers a shock, confirm that the patient is clear of personnel, oxygen equipment has been managed appropriately, and all team members understand it is safe to proceed. After the shock has been delivered, restore oxygen delivery as required and immediately resume CPR or continue post-ROSC care according to the patient's condition.

In low-resource settings, a limited number of healthcare workers may need to alternate between performing CPR and operating the AED.

Whenever possible, responsibilities should be assigned before rhythm analysis begins so that CPR resumes immediately after each AED prompt.

Even with limited personnel, maintaining clear communication and minimizing interruptions to chest compressions remain essential priorities throughout the resuscitation.

• CPR should continue while the AED is prepared and the pads are applied whenever possible.
• Interrupt chest compressions only for rhythm analysis and shock delivery.
• Resume CPR immediately after rhythm analysis or shock delivery unless circulation has been confirmed according to established protocols.
• Follow the AED voice prompts throughout the resuscitation.
• Clear communication helps minimize unnecessary interruptions.
• Effective coordination between CPR and AED operation improves the efficiency of resuscitation, including in low-resource environments.

You have now learned how to coordinate AED operation with ongoing CPR while minimizing interruptions in chest compressions. The next lesson explains the care required after AED use, including recognizing return of spontaneous circulation, ongoing monitoring, patient handover, and post-event responsibilities.

Self-Assessment

Please complete the following: Coordinating AED Use with Cardiopulmonary Resuscitation Quiz

The use of an automated external defibrillator (AED) does not end when a shock is delivered or when the device advises that no shock is indicated. Throughout the resuscitation and following return of spontaneous circulation (ROSC), the patient requires ongoing assessment, monitoring, and supportive care. The perioperative team must communicate effectively, prepare for continued treatment, document the event accurately, and restore the AED to operational readiness for future emergencies.

This lesson explains the nurse's responsibilities following AED use, including recognizing ROSC, providing post-resuscitation care, assessing the patient for AED-related injuries, completing documentation, restoring equipment readiness, and participating in post-event review.

Return of spontaneous circulation (ROSC) is the restoration of effective cardiac activity and circulation following cardiac arrest.

Possible signs of ROSC include:

• Return of a palpable carotid pulse.
• Improvement in blood pressure, including the return of an arterial line waveform if present.
• Spontaneous breathing or purposeful movement.
• Increasing end-tidal carbon dioxide (EtCO₂).
• Improvement in other physiologic parameters observed on continuous monitoring.

In the perioperative environment, continuous ECG, arterial pressure monitoring, and waveform capnography may provide early indications that circulation has returned before other clinical signs become obvious.

If ROSC is suspected, immediately communicate the findings to the anesthesia provider or resuscitation team leader so that circulation can be confirmed according to established resuscitation protocols.

Following ROSC, the patient requires continuous monitoring and supportive care.

Provide supplemental oxygen as indicated and continuously monitor cardiac rhythm, oxygen saturation, ventilation, blood pressure, and other vital signs while preparing for ongoing post-resuscitation management.

Prepare for additional interventions directed by advanced care providers, including advanced airway management, intravenous or intraosseous access, vasoactive medications, diagnostic investigations, and transfer to an appropriate level of care according to local protocols.

The AED pads should generally remain attached while the patient is being monitored, as recurrent ventricular arrhythmias may occur and additional defibrillation may become necessary.

If ROSC has not occurred, continue CPR by following the AED prompts and established Basic Life Support (BLS) and Advanced Life Support (ALS) protocols. Pause chest compressions only when instructed by the AED for rhythm analysis or shock delivery.

Once the patient has been stabilized, inspect the skin beneath the AED pads for burns, blistering, erythema, or other evidence of pad-related injury.

Mild skin redness is relatively common following defibrillation and often resolves without treatment. However, deeper burns or significant skin injury may require wound care and further medical evaluation.

The AED pads should generally remain attached until the patient is stable and the risk of recurrent defibrillation has passed. Once they are removed, gently cleanse the skin to remove any remaining adhesive while avoiding unnecessary skin trauma.

Any pad-related injury or complication should be documented according to institutional policy.

Clear communication following resuscitation ensures continuity of patient care.

Provide a structured handover to the receiving healthcare team that includes:

• Time cardiac arrest was recognized.
• Time CPR was initiated.
• Time the AED was applied.
• Number of rhythm analyses performed.
• Number of shocks delivered.
• Whether ROSC occurred.
• Patient response throughout the resuscitation.
• Treatments provided before transfer.

Complete documentation as soon as practical while ensuring that patient care remains the priority.

Documentation should also include any complications observed during or after resuscitation, including pad-related burns, skin trauma, or other AED-related injuries.

After the resuscitation has concluded, prepare the AED for future use.

Dispose of used electrode pads and other single-use accessories according to local infection prevention and waste management procedures.

Clean the AED according to the manufacturer's recommendations, replace opened or used electrode pads, verify battery status, and confirm that the device has successfully completed its self-test before returning it to service.

Any malfunction or equipment problem identified during the resuscitation should be reported according to institutional policy so that the device can be repaired or replaced before it is needed again.

In facilities where AED availability is limited, responsibility for restoring and checking the device should be clearly assigned to ensure that the AED remains ready for the next emergency.

Following the resuscitation, the perioperative team should participate in a structured debrief whenever feasible.

The discussion should review:

• Recognition of cardiac arrest.
• Emergency response activation.
• Team communication.
• AED operation.
• Coordination of AED use with CPR.
• Challenges encountered.
• Opportunities to improve future emergency responses.

Patients who achieve ROSC should continue to receive appropriate post-resuscitation care and be transferred to the operating room recovery area, intensive care unit, or another appropriate level of care according to their clinical condition and institutional protocols.

Communication with the patient's family should occur according to institutional policy and the responsibilities of the healthcare team.

Structured debriefing promotes continuous quality improvement, strengthens team performance, and helps identify equipment or system issues requiring correction.

In low-resource settings, replacement AED pads, batteries, or technical support may not be immediately available.

Following AED use, inspect the device carefully, replace consumable items whenever possible, and verify that it remains operational for future emergencies.

If replacement supplies cannot be obtained immediately, the facility should establish a contingency plan for accessing another functioning AED while awaiting replacement equipment.

Even where resources are limited, accurate documentation, effective communication, proper equipment maintenance, and structured team debriefing remain essential components of high-quality post-resuscitation care. If electronic documentation systems or synchronized clocks are unavailable, record the sequence of events and key times manually as accurately as possible to support patient care, clinical handover, and post-event review.

• Recognize the clinical signs that may indicate return of spontaneous circulation.
• Continue patient monitoring and supportive care following AED use.
• Leave the AED pads in place while ongoing monitoring continues and recurrent defibrillation remains possible.
• Assess the skin for pad-related burns or other injuries after the patient has been stabilized.
• Provide a structured handover and complete accurate documentation, including any AED-related complications.
• Restore the AED to operational readiness by cleaning the device, replacing used consumables, checking the battery, and confirming successful self-testing.
• Participate in team debriefing and quality improvement activities after the event.
• Maintain AED readiness and contingency plans in low-resource environments.

You have now completed the knowledge component of this module. The following assessments will evaluate your understanding of AED use, team coordination, and post-resuscitation responsibilities before you begin practical skills training.

Self-Assessment

Please complete the following: Post-Resuscitation Care and Follow-up Quiz

Cumulative Test

Please complete the following: Defibrillation with AED Cumulative Assessment

Cumulative Test

Please complete the following: Clinical Decision-Making Assessment Defibrillation with AED