Table of Contents Pre-procedureProcedurePreparationCardioversionDealing with complicationsPost-procedure Before you start Routine indications: AF/atrial flutter after 4 weeks anticoagulation Emergency indications: tachyarrhythmia with adverse signs (shock, syncope, myocardial ischaemia, heart failure) Synchronised DC cardioversion is used for patients with a pulse (shock synchronises with R wave to avoid inducing VF) Unsynchronised DC cardioversion (defibrillation) is used for patients without a pulse (cardiac arrest) – see ALS Pre-procedure Skip this section if it is being performed as an emergency. Read referral letterCheck potassium >4mmol/LCheck ECG still shows AF/flutterConsent patientRisks: stroke (<1%), pain or burns from pads, failure (1/3), ventricular arrhythmias (may require further shocks/CPR), bradycardia or asystole (may require external pacing)Check anticoagulation has been taken for >4 weeksNOAC – check no missed dosesWarfarin – check INRs in last 3 weeks are >2Check patient is clinically well and fit for anaesthetic Procedure Preparation Anaesthetist must be present to sedate patientApply 3-lead cardiac monitoring (clockwise from right arm Ride Your Green Bicycle) and connect lead to external cardiac monitor or defibrillator machineRed: anterior aspect of right shoulderYellow: anterior aspect of right shoulderGreen: left anterior superior iliac spineBlack: not present on defibrillation machineApply defibrillator pads (in AP position) after shaving chest if required‘Right’ pad: place longitudinally on left sternal edge‘Left’ pad: place longitudinally on left paraspinal muscles (in line with anterior pad)Connect pads lead to defibrillator machine Cardioversion Set defibrillator machine monitoring trace to ‘pads’Set defibrillator to synchronised mode (synchronises shock with R wave to avoid inducing VF)Set energy level (increase as shown if unsuccessful)Broad-complex tachycardia or AF: 150J → 200J → 200J (biphasic)Narrow complex tachycardia or atrial flutter: 70J → 120J → 200J (biphasic)Ask anaesthetist to sedate patient and wait until they are happy to proceedAsk everybody to move away from the patient and ask for the oxygen to be moved awayPress charge (then move hand away from button)Re-check everybody and oxygen is away from the patient, announce you are about to shock and press and hold the shock button until shock is delivered (it will wait for the R wave)Re-assess the rhythmIf unsuccessful, repeat at next energy (maximum 3 attempts) Dealing with complications Asystole or bradycardia with haemodynamic compromise (SBP<90) → if sustained, proceed to transcutaneous pacingBradycardia without haemodynamic compromise → monitor, reduce β-blockersVentricular tachycardia with pulse → repeat synchronised DC shock as abovePulseless arrhythmia → unsynchronised DC shock if shockable rhythm (VT/VF); if ongoing or not shockable rhythm, start chest compressions and manage as cardiac arrest (see ALS) Post-procedure Document procedureComplete discharge letterContinue all medications (except digoxin if taking and successfully cardioverted)Continue anticoagulation until patient has been reviewed at least 4 weeks post-cardioversionBook for clinic follow upRe-check ECG and observationsAdvise patient not to drive for 24 hours and stay with someone overnight DC cardioversion set up