Synchronized cardioversion
(Redirected from Synchronized Cardioversion)
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
- Supraventricular tachycardia (SVT)
- Atrial fibrillation
- Atrial flutter
- Ventricular tachycardia with a pulse
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
- 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)
- Hold 'Shock' button until shock discharged
- 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
- Larry Mellick-live demonstration (https://www.youtube.com/watch?v=uCETUw0Bssw)
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References
- AHA 2010 ACLS Recommendations
- ↑ 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.
- ↑ 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
- ↑ 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
- ↑ 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