The first shock setting should be 200 joules followed by a second shock of 300 joules. One defibrillator paddle is positioned to the right of the sternum below the clavicle. The other paddle is placed to the left of the left nipple with the center of the paddle in the mid-axillary line. An appropriate gel is one that has a low impedance. Because gel spreads during chest compression, shocks may arc across the chest surface thus, the gel must be toweled off. Conducting gel pads should be used but must be changed between shocks. Heavy arm pressure should be applied to each paddle applied to the chest and defibrillation should take place when the victim’s phase of ventilation is in full expiration. In the UK the lower paddle is placed over the points designated as V4 and V5 for the ECG, that is, a little outside the position of the normal apex beat. The paddle should be placed at least five inches away from a pacemaker generator.
The area around the patient should be checked so that no personnel are directly or indirectly in contact with the patient. The operator must not touch the patient when the shock is delivered. Deliver countershock by depress¬ing both paddle discharge buttons simultaneously. If no skeletal muscle contraction is observed, check the equipment.

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