Cardioversion (Training Physician)

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External direct current cardioversion (DCC) is the application of a brief pulse of direct electrical current across the chest wall of a patient with an appropriate rapid dysrhythmia, causing momentary depolarization of most cardiac cells. Synchronized cardioversion refers to an electrical energy discharge synchronized with the QRS complex, avoiding energy delivery in the early phase of repolarization when the ventricular myocardium is susceptible to ventricular fibrillation (VF). Unsynchronized cardioversion refers to an unsynchronized discharge of energy and is only recommended for extremely unstable patients. DCC is usually effective almost immediately, has few side effects, and is often more successful than pharmacological therapy.

  • Unstable patient with reentrant tachycardia
  • Stable patient with supraventricular tachycardia
  • Sinus tachycardia
  • Atrial fibrillation lasting longer than 36-48 hours without appropriate anticoagulation therapy
  • Digoxin toxicity
  • Junctional and multifocal atrial tachycardia
  • ECG monitor/defibrillator
    • Paddles and pads
    • Conductive materials
  • Resuscitation supplies (adjuncts to defibrillation)
    • Intravenous access
    • Advanced airway management equipment
    • Antidysrythmic drugs
  • Procedural sedation drugs
  • The heart lies behind the sternum with the base at about the third intercostal space, just to the right of the sternum, and the apex in the fifth intercostal space, inferior to the nipple and usually just medial to the nipple.
  • Anteroposterior placement (for self-adhesive defibrillator electrode pads)
    • Anterior pad: just to the left of the sternum at the point of maximum impulse (PMI)
    • Posterior pad: to the left of the spine, just below the left scapula
  • Anterolateral placement (for pads or paddles)
    • Left lateral pad: left fourth or fifth intercostal space, midaxillary line
    • Right anterior pad: to the right of the sternal margin, second or third intercostal space

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  • Clinical pearls providing practical clinical tips from medical experts
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  • Verify the postshock rhythm on the monitor.
  • Verify that the airway is patent, and continue oxygen administration through high-flow reservoir mask.
  • Monitor the patient closely until the sedative has worn off.
  • Record blood pressure immediately following procedure.
  • Obtain 12-lead ECG within 15 minutes of the procedure.
  • Ventricular fibrillation and other dysrhythmias (see Defibrillation for further details)
  • Respiratory failure (see Basic Airway Management for further details)
  • Cardioverter sensor unable to identify the R waves in low amplitude QRS tachycardia
  • Permanent cardiac pacemaker or AICD dysfunction
  • Skin burns
  • Excessive sedation
  • Increase in serum myoglobin and CK/CK-MB levels
  • Injuries to health care personnel
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