Misuse of "Quick-Look" Defibrillator Paddles
Hazard [Health Devices Feb 1988;17(2):68-9]
A hospital reported to us a case in which misuse of a
defibrillator/monitor equipped with external "quick-look"* paddles
led to injury of a nursing assistant, who had held the paddles to her own chest to check
the defibrillator's ECG monitor. While positioning the paddles, she accidentally charged
and discharged the defibrillator, shocking herself and receiving burns at the paddle
contact sites. In addition, she suffered recurring cardiac arrhythmias, possibly from the
shock. In the same hospital, misuse of the rapid ECG-monitoring feature on the quick-look
paddle resulted when users substituted the paddle tracings for routine diagnostic ECGs.
The hospital encouraged this practice to save the cost of disposable ECG electrodes and
may have influenced the assistant's actions.
The hospital also stated that other inadvertent discharges occurred when
manufacturers' technicians placed paddles on themselves to check the defibrillator's ECG
monitor, rather than connecting the patient lead cable to an ECG simulator.
Lack of familiarity with defibrillators, accidental discharge of
defibrillators, or inappropriate use of the quick-look paddles may injure or kill a user
The quick-look paddle feature is designed for initial, rapid ECG
assessment during cardiac resuscitation only. Most defibrillator/monitors have paddles
with this feature, but their monitors typically accept a 3- or 5-lead patient ECG cable as
well. ECG monitoring through these leads is the correct way to obtain short-term ECG data
(e.g., during patient transport, after defibrillation) as well as a recommended method of
determining whether defibrillation is needed. The leads may also be used to check monitor
operation during device inspection or repair.
Some units also have hard-copy recorders that can produce
diagnostic-quality (0.05-100 Hz bandwidth) ECG tracings. However, if quick-look paddles
are used in this mode, their tracings will not be of diagnostic quality because of the
limited bandwidth (typically 0.5-40 Hz) of the paddle monitoring feature. Substituting
paddle tracings for routine diagnostic ECGs could result in misdiagnosis and inappropriate
Manufacturers recommend using the quick-look paddle monitoring feature for
immediate ECG assessment only. Users should then connect the patient to the
defibrillator's ECG monitor with ECG leads for short-term monitoring. Unless it is
designed specifically for recording diagnostic ECGs (i.e., includes a diagnostic ECG mode
used with an appropriate patient cable for recording full diagnostic multiple-lead ECGs),
a defibrillator's ECG monitor should not be used for routine diagnostic ECGs. Most
manufacturers also recommend using a patient ECG lead cable for synchronized
cardioversion. If an ECG is taken through the paddles for this purpose, electrical
artifacts are generated on the ECG waveform that can inhibit correct triggering.
Safe and effective use of quick-look paddles and their
rapid-ECG-monitoring feature requires proper user training. Hospitals should not permit
unqualified personnel to operate, inspect, or service defibrillator/monitors. ECG
electrode cost-saving policies should not encourage misuse of the monitoring feature or
- Warn defibrillator/monitor users that they should never test paddles or monitoring operation by
applying external defibrillator paddles to their chest.
- Ensure that only trained personnel use these devices. These paddles deliver dangerous electrical
shocks. Never charge the unit until ready to defibrillate a patient or
discharge the defibrillator into a test load. Use the quick-look paddle
monitoring feature for initial, rapid ECG assessment during an emergency or
a resuscitation attempt only. If the defibrillator's ECG monitor does not
appear to be functioning properly during rapid ECG assessment through the
paddles, connect the ECG leads to the patient to obtain an ECG. If the
monitor still does not function, use another unit.
- Do not perform short-term or routine ECG monitoring
using the quick-look paddle monitoring feature; use the ECG leads supplied
with the device for such applications and for synchronized cardioversion.
When full diagnostic tracings are required, use a standard
electrocardiograph or a defibrillator/monitor with a diagnostic ECG mode and
the special cable and monitoring electrodes required.
- To test the quick-look paddle monitoring feature, clinical engineering
personnel should connect or contact the paddles to an ECG simulator. Be sure
the defibrillator is discharged and turned off if you have to touch the
paddle electrode surfaces or ECG circuit, and keep the defibrillator off and
uncharged while testing the ECG function. Use a patient lead cable and a
simulator that does not require applying the ECG signal to the paddles to
check the defibrillator's ECG monitor operation.
* The generic term "quick-look" as used
in this discussion should not be confused with the trade name Quik-Look used by
Physio-Control for this model of defibrillator paddles.
User error: Incorrect clinical use
Support system failure: Failure to train
Mechanism of Injury or Death
Burn; Electrical shock/electrocution