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Indications
Indications for defibrillation include the following:
Pulseless ventricular tachycardia (VT)
Ventricular fibrillation (VF)
Cardiac arrest due to or resulting in VF
Indications for electrical cardioversion include the following:
Supraventricular tachycardia (atrioventricular nodal reentrant tachycardia [AVNRT] and
atrioventricular reentrant tachycardia [AVRT])
Atrial fibrillation
Atrial flutter (types I and II)
Ventricular tachycardia with pulse
Any patient with reentrant tachycardia with narrow or wide QRS complex (ventricular rate
>150 bpm) who is unstable (eg, ischemic chest pain, acute pulmonary edema, hypotension,
acute altered mental status, signs of shock)
Contraindications
Contraindications include the following:
Dysrhythmias due to enhanced automaticity, such as in digitalis toxicity and catecholamineinduced arrhythmia
Multifocal atrial tachycardia
For dysrhythmias due to enhanced automaticity such as in digitalis toxicity and catecholamineinduced arrhythmia, a homogeneous depolarization state already exists. Therefore, cardioversion is
not only ineffective but is also associated with a higher incidence of postshock ventricular
tachycardia/ventricular fibrillation (VT/VF).
Anesthesia
Defibrillation is an emergent maneuver and, when necessary, should be promptly performed in
conjunction with or prior to administration of induction or sedative agents.
Cardioversion is almost always performed under induction or sedation (short-acting agent such as
midazolam). The only exceptions are if the patient is hemodynamically unstable or if cardiovascular
collapse is imminent. For more information, see Procedural Sedation.
Equipment
Equipment includes the following:
Defibrillators (automated external defibrillators [AEDs], semiautomated AEDs, standard
defibrillators with monitors)
Paddle or adhesive patch
Conductive gel or paste
ECG monitor with recorder
Oxygen equipment
Intubation kit
Emergency pacing equipment
Blood pressure cuff (automatic or manual)
Pulse recorder
Oxygen saturation monitor
Intravenous access
Suction device
Code Cart with ACLS (Advanced Cardiovascular Life Support) medications
The use of hand-held paddle electrodes may be more effective than self-adhesive patch electrodes.
The success rates are slightly higher for patients assigned to paddled electrodes because these handheld electrodes improve electrode-to-skin contact and reduce the transthoracic impedance.[2]
Positioning
Paddle placement on the chest wall has 2 conventional positions: anterolateral and anteroposterior.
In the anterolateral position, a single paddle is placed on the left fourth or fifth intercostal space on
the midaxillary line. The second paddle is placed just to the right of the sternal edge on the second
or third intercostal space.
In the anteroposterior position, a single paddle is placed to the right of the sternum, as above, and
the other paddle is placed between the tip of the left scapula and the spine. An anteroposterior
electrode position is more effective than the anterolateral position for external cardioversion of
persistent atrial fibrillation.[3, 4, 5] The anteroposterior approach is also preferred in patients with
implantable devices, to avoid shunting current to the implantable device and damaging its system.
Technique
Emergent application, which may be life-saving, and elective cardioversion should be used
cautiously, with attention to patient selection and proper techniques. Repetitive, futile attempts at
direct current cardioversion should be avoided.
Advanced cardiovascular life support (ACLS) measures should be instituted in preparing the
patient, such as obtaining intravenous access and preparing airway management equipment,
sedative drugs, and a monitoring device.
For elective procedures, prepare as follows:
Complications
The most common complications are harmless arrhythmias, such as atrial, ventricular, and
junctional premature beats.
Serious complications include ventricular fibrillation (VF) resulting from high amounts of electrical
energy, digitalis toxicity, severe heart disease, or improper synchronization of the shock with the R
wave.[10, 11]
Thromboembolization is associated with cardioversion in 1-3% of patients, especially in patients
with atrial fibrillation who have not been anticoagulated prior to cardioversion. Current American
College of Cardiology (ACC)/American Heart Association (AHA) guidelines recommend to
anticoagulate for 3-4 weeks before and after cardioversion. The presence of an intracardiac
thrombus should be excluded using transesophageal echocardiography prior to cardioversion if
therapeutic anticoagulation has not been achieved.
Myocardial necrosis can result from high-energy shocks. ST segment elevation can be seen
immediately and usually lasts for 1-2 minutes. ST segment elevation that lasts longer than 2 minutes
usually indicates myocardial injury unrelated to the shock.
Myocardial dysfunction is due to an absence of cardiac output and coronary blood flow during
arrest, resulting in ischemia. Myocardial dysfunction due to stunning may reverse within first 24-48
hours. Left ventricle function evaluation should be delayed for 48 hours after arrest.[12]
Pulmonary edema is a rare complication of cardioversion. It is probably due to transient left atrial
standstill and left ventricular systolic dysfunction. It is more common in atrial fibrillation due to
valvular heart disease or left ventricular systolic dysfunction.
Painful skin burns can occur after cardioversion or defibrillation; they are moderate to severe in 2025% of patients. They most likely are due to improper technique and electrode placement. It occurs
less with use of biphasic waveform defibrillators and use of gel-based pads. Prophylactic use of
steroid cream or topical ibuprofen reduces pain and inflammation.[13, 14]
Allergic reaction to sedation medication is a potential complication.
Types of Cardioversion
Chemical cardioversion
Antiarrhythmic medications are used to alter flow of electrical activity through the heart. Based on
the clinical situation, chemical cardioversion can be performed in the hospital in monitored setting
or in an outpatient setting.
Electrical cardioversion
This is also known as direct current (DC) cardioversion. Electrical shock is synchronized (perfectly
timed) to convert an abnormal rhythm to a normal sinus rhythm. DC cardioversion is performed in
the hospital in a monitored setting.
Internal cardioversion
Internal cardioversion is performed less frequently nowadays, owing to the presence of biphasic
waveform defibrillators and intravenous ibutilide. It is performed if external cardioversion fails. It is
performed using preexisting implantable cardioverter defibrillators (ICDs), epicardial wires during
surgery, or internal paddles applied to the epicardium in the presence of sternotomy wires.
Advantages of internal cardioversion are that this technique avoids the risk of a skin irritation from
external shock. Disadvantages are that it may damage ICD systems, it consumes the battery of the
ICD, and it does not always convert atrial arrhythmias.
Special Populations
Cardioversion in patients with digitalis toxicity
Digoxin overdose or toxicity can present with any type of tachyarrhythmias or bradyarrhythmias.
Cardioversion in the setting of digoxin toxicity is a relative contraindication. Digitalis sensitizes the
heart to the electrical stimulus. Prior to cardioversion, electrolytes should be normalized.
Cardioversion may cause additional arrhythmias, especially ventricular fibrillation.