Synchronized cardioversion: Difference between revisions

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''See [[critical care quick reference]] for doses by weight.''
''See [[critical care quick reference]] for doses by weight.''
==Background==
*Low energy shock synchronized with peak of QRS complex
*Machine leads synchronized with patient's EKG rhythm


{{Defibrillation and cardioversion indications}}
{{Defibrillation and cardioversion indications}}
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*Defibrillator
*Defibrillator
*Consider sedation medication in conscious patient (e.g. etomidate, ketamine), but do not delay procedure in unstable patient
*Consider sedation medication in conscious patient (e.g. etomidate, ketamine), but do not delay procedure in unstable patient
**Give [[fentanyl]] 1 μg/kg before sedation, and consider slow 0.5 mg/kg [[lidocaine]] IV 1 min before sedative
**[[Etomidate]] superior to [[propofol]] in terms of recovery and hemodynamic stability<ref>Desai PM, Kane D, Sarkar MS. Cardioversion: What to choose? Etomidate or propofol. Ann Card Anaesth. 2015;18(3):306–311. doi:10.4103/0971-9784.159798.</ref>
***Etomidate 0.1 mg/kg, followed by etomidate second dose of 0.05 mg/kg just prior to shock
***VS propofol 1 mg/kg, followed by propofol second dose of 0.5 mg/kg just prior to shock


==Procedure==
==Procedure==
===Cardioversion===
===Cardioversion===
*Apply pads (anterior-posterior placement is preferred)
*Apply pads
*Select appropriate Joule setting
**Anterior-Posterior placement is preferred <ref>Kirchhof P et al. Anterior-posterior versus anterior-lateral electrode positions for external cardioversion of atrial fibrillation: A randomised trial. Lancet 2002 Oct 26; 360:1275-9</ref> but may not be as important as previously thought and most studies are for atrial fibrillation or flutter <ref>Kirkland S et al. The efficacy of pad placement for electrical cardioversion of atrial fibrillation/flutter: A systematic review. Acad Emerg Med. 2014 Jul;21(7):717-26</ref>
***Avoid placing in close proximity to implanted devices if possible <ref>Manegold J. External cardioversion of atrial fibrillation in patients with implanted pacemaker or cardioverter-defibrillator systems: A randomized comparison of monophasic and biphasic shock energy application. European Heart Journal, 28(14);1731–1738</ref>
*Select appropriate energy (Joules)
*Ensure machine is "synced" before each discharge
*Ensure machine is "synced" before each discharge
*Give sedation, if indicated
**Most machines show an indicator (arrow or dot) above each beat if appropriately synchronized
*Cardiovert
*Repeat PRN
*Ensure R or S wave is bigger than T wave
*Ensure R or S wave is bigger than T wave
**Machine may read T wave as depolarization and shock during an actual repolarization phase
**Machine may read T wave as depolarization and shock during an actual repolarization phase
**May induce shock on T and subsequent VT/VF
**May induce shock on T and subsequent VT/VF
**Move leads to avoid this
**Move leads to avoid this
*Give sedation, if indicated
**All awake and hemodynamically stable patients
*Ensure safety of environment prior to cardioversion
**Nobody touching patient
**Nobody touching equipment that is touching patient
**Consider removing supplemental oxygen
*Cardiovert
**Hold 'Shock' button until shock discharged
***Shock delayed until peak of QRS complex in synchronized cardioversion (keep holding button down)
*Repeat PRN
**May require escalating energy


===Doses===
===Doses===
Initial recommendations:
Initial recommendations:
*Tachycardia with pulse
*Tachycardia with pulse
**Narrow regular: 50-100 J
**Narrow regular (SVT): 50-100 J
**Narrow irregular
**Narrow irregular (A fib, A flutter)
***Biphasic: 120-200 J  
***Biphasic: 120-200 J (may start as low as 50 - 100 J for A flutter)
***Monophasic: 200 J
***Monophasic: 200 J
**Wide regular: 100 J
**Wide regular (VT with pulse): 100 J
**Wide irregular: [[defibrilate]] (NOT synchronized)
**Wide irregular: [[defibrilate]] (NOT synchronized)


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*[[PALS (Main)]]
*[[PALS (Main)]]
*[[Defibrillation]]
*[[Defibrillation]]
*[[In-Training Exam Review]]


==External Links==
==External Links==
*[https://www.merckmanuals.com/professional/cardiovascular-disorders/arrhythmias-and-conduction-disorders/direct-current-dc-cardioversion-defibrillation?query=synchronized%20cardioversion Merk Manual - Direct-Current Cardioversion-Defibrillation]
===Videos===
*Larry Mellick-live demonstration (https://www.youtube.com/watch?v=uCETUw0Bssw)
{{#widget:YouTube|id=T7Zv9vLdWtE}}


==References==
==References==

Latest revision as of 11:55, 24 July 2021

See critical care quick reference for doses by weight.

Background

  • Low energy shock synchronized with peak of QRS complex
  • Machine leads synchronized with patient's EKG rhythm

Indications

It is important to note that the procedure and indications differ between defibrillation and cardioversion

Defibrillation (Unsynchronized Cardioversion)

Synchronized Cardioversion

Contraindications

  • None

Equipment Needed

  • Defibrillator
  • Consider sedation medication in conscious patient (e.g. etomidate, ketamine), but do not delay procedure in unstable patient
    • Give fentanyl 1 μg/kg before sedation, and consider slow 0.5 mg/kg lidocaine IV 1 min before sedative
    • Etomidate superior to propofol in terms of recovery and hemodynamic stability[1]
      • Etomidate 0.1 mg/kg, followed by etomidate second dose of 0.05 mg/kg just prior to shock
      • VS propofol 1 mg/kg, followed by propofol second dose of 0.5 mg/kg just prior to shock

Procedure

Cardioversion

  • Apply pads
    • Anterior-Posterior placement is preferred [2] but may not be as important as previously thought and most studies are for atrial fibrillation or flutter [3]
      • Avoid placing in close proximity to implanted devices if possible [4]
  • Select appropriate energy (Joules)
  • Ensure machine is "synced" before each discharge
    • Most machines show an indicator (arrow or dot) above each beat if appropriately synchronized
  • Ensure R or S wave is bigger than T wave
    • Machine may read T wave as depolarization and shock during an actual repolarization phase
    • May induce shock on T and subsequent VT/VF
    • Move leads to avoid this
  • Give sedation, if indicated
    • All awake and hemodynamically stable patients
  • Ensure safety of environment prior to cardioversion
    • Nobody touching patient
    • Nobody touching equipment that is touching patient
    • Consider removing supplemental oxygen
  • Cardiovert
    • Hold 'Shock' button until shock discharged
      • Shock delayed until peak of QRS complex in synchronized cardioversion (keep holding button down)
  • Repeat PRN
    • May require escalating energy

Doses

Initial recommendations:

  • Tachycardia with pulse
    • Narrow regular (SVT): 50-100 J
    • Narrow irregular (A fib, A flutter)
      • Biphasic: 120-200 J (may start as low as 50 - 100 J for A flutter)
      • Monophasic: 200 J
    • Wide regular (VT with pulse): 100 J
    • Wide irregular: defibrilate (NOT synchronized)

Complications

See Also

External Links

Videos

{{#widget:YouTube|id=T7Zv9vLdWtE}}

References

  • AHA 2010 ACLS Recommendations
  1. ↑ Desai PM, Kane D, Sarkar MS. Cardioversion: What to choose? Etomidate or propofol. Ann Card Anaesth. 2015;18(3):306–311. doi:10.4103/0971-9784.159798.
  2. ↑ Kirchhof P et al. Anterior-posterior versus anterior-lateral electrode positions for external cardioversion of atrial fibrillation: A randomised trial. Lancet 2002 Oct 26; 360:1275-9
  3. ↑ Kirkland S et al. The efficacy of pad placement for electrical cardioversion of atrial fibrillation/flutter: A systematic review. Acad Emerg Med. 2014 Jul;21(7):717-26
  4. ↑ Manegold J. External cardioversion of atrial fibrillation in patients with implanted pacemaker or cardioverter-defibrillator systems: A randomized comparison of monophasic and biphasic shock energy application. European Heart Journal, 28(14);1731–1738
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