Synchronized cardioversion: Difference between revisions

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==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
*Repeat PRN
**May require escalating energy


===Doses===
===Doses===

Revision as of 14:03, 1 March 2019

See critical care quick reference for doses by weight.

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

Procedure

Cardioversion

  • Apply pads
    • Anterior-Posterior placement is preferred [1] but may not be as important as previously thought and most studies are for atrial fibrillation or flutter [2]
      • Avoid placing in close proximity to implanted devices if possible [3]
  • 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
  • Repeat PRN
    • May require escalating energy

Doses

Initial recommendations:

  • Tachycardia with pulse
    • Narrow regular: 50-100 J
    • Narrow irregular
      • Biphasic: 120-200 J
      • Monophasic: 200 J
    • Wide regular: 100 J
    • Wide irregular: defibrilate (NOT synchronized)

Complications

See Also

External Links

References

  • AHA 2010 ACLS Recommendations
  1. ↑ 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
  2. ↑ 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
  3. ↑ 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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