Elective Cardioversion for Atrial Fibrillation

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  • Persistent atrial fibrillation or atrial flutter as part of a rhythm control strategy, with or without anti-arrhythmic drug therapy
  • Digitalis toxicity
  • Hypokalemia
  • Duration of atrial fibrillation or flutter > 48 hours and no prophylactic anticoagulation
  • Biphasic defibrillator
  • Self-adhesive, low-impedance, and disposable defibrillation patch electrodes
  • IV catheter, IV tubing, IV fluids for IV access
  • Short-acting anesthetic drugs for anesthesia/sedation An anesthesiologist should be consulted for procedures involving patients in whom deep sedation or anesthesia pose significant risks of airway obstruction or inability to intubate.
  • Advanced airway management equipment: positive-pressure ventilation bag and mask, oral or nasal airway, endotracheal tubes of graduated sizes, laryngoscope
  • Oxygen source and airway suction capability
  • Code cart including anti-arrhythmic drugs
  • 12-lead ECG machine and electrodes
  • An anterior-posterior electrode configuration is preferred.
    • The anterior patch electrode is placed just to the right of the sternum at the 3rd intercostal space.
    • The posterior patch electrode is placed at the angle of the left scapula.
  • An anterolateral electrode configuration can be used if cardioversion is unsuccessful with the anterior-posterior configuration.
    • The right anterior patch electrode is placed to the right of the sternum over the 2nd and 3rd intercostal spaces.
    • The lateral patch electrode is placed beneath the left breast at the mid-axillary line, directly against the chest wall and not over breast tissue.

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  • Continue to monitor blood pressure, heart rate, rhythm, and oxygen saturation.
  • Monitor the airway and level of anesthesia/sedation.
  • Obtain a 12-lead ECG.
  • Continue anticoagulation therapy in patients who have required it for at least 4 weeks after the procedure unless otherwise contraindicated.
  • Thromboembolic events including stroke
  • Benign arrhythmias including premature ventricular beats, premature atrial beats, bradycardia, and short periods of sinus arrest
  • Ventricular tachycardia or ventricular fibrillation: Proceed with cardioversion or defibrillation as needed.
  • Marked sinus bradycardia or prolonged sinus arrest
  • Airway compromise/respiratory failure
  • Skin erythema/burns
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