Recommended Energy Levels for Cardiac Arrest Life Support

Energy Recommendations by Defibrillator Type

The American Heart Association recommends initial sequence energies of 200 J, 200 J, and 360 J for the three stacked shocks when using a monophasic defibrillator 1
Subsequent shocks after the initial three-shock sequence should use 360 J, as recommended by the American Heart Association 1
If a coordinated rhythm appears briefly but then deteriorates, either continuing with 360 J or reverting to 200 J is acceptable, according to the American Heart Association 2
For biphasic truncated exponential (BTE) waveforms, the initial shock should be 150 J or greater, as recommended by the American Heart Association 3, 4
For rectilinear biphasic (RLB) waveforms, the initial shock should be 120 J or greater, as recommended by the American Heart Association 3, 4
For subsequent biphasic shocks, the same initial energy level is acceptable, but it is reasonable to increase the energy level when possible, according to the American Heart Association 5

With modern defibrillators, charging times are sufficiently short for three shocks to be delivered within one minute, as noted by the American Heart Association 1
Pulse checks should only be performed after a shock if the waveform changes to one compatible with cardiac output, as recommended by the American Heart Association 1
If ventricular fibrillation (VF) or ventricular tachycardia (VT) with identical waveform persists after the first shock, proceed immediately to the second shock without checking for a pulse, according to the American Heart Association 1

Proper paddle placement is crucial, with one paddle below the right clavicle in the mid-clavicular line and the other over the lower left ribs in the mid-anterior axillary line, as recommended by the American Heart Association 2
Ensure adequate contact with the chest wall and proper use of conductive gel to maximize current delivery, according to the American Heart Association 2
In female patients, place the second paddle firmly on the chest wall just outside the position of the normal cardiac apex, avoiding breast tissue, as recommended by the American Heart Association 2

Modern guidelines have shifted from the three stacked shocks approach to a single shock strategy followed by immediate CPR resumption, as recommended by the American Heart Association 4, 6
This change was made to minimize interruptions to chest compressions and because of the greater efficacy of biphasic shocks, according to the American Heart Association 4

Myocardial injury, both functionally and morphologically, may be greater with increasing energies, as noted by the American Heart Association 1
The most recent evidence suggests a trend toward single shock protocols in modern practice, with immediate resumption of chest compressions after the shock, as recommended by the American Heart Association 3, 4