Please note this information is for educational purposes only and procedures should not conducted based on this information. OSCEstop and authors take no responsibility for errors or for the use of any content.
Routine indications: AF/atrial flutter after 4 weeks anticoagulation
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) β see ALS
Pre-procedure
Skip this section if it is being performed as an emergency.
Read referral letter
Check potassium >4mmol/L
Check ECG still shows AF/flutter
Consent patient
Risks: 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 weeks
NOAC β check no missed doses
Warfarin β check INRs in last 3 weeks are >2
Check patient is clinically well and fit for anaesthetic
Procedure
Preparation
Anaesthetist must be present to sedate patient
Apply 3-lead cardiac monitoring (clockwise from right arm Ride Your Green Bicycle) and connect lead to external cardiac monitor or defibrillator machine
Red: anterior aspect of right shoulder
Yellow: anterior aspect of right shoulder
Green: left anterior superior iliac spine
Black: not present on defibrillation machine
Apply defibrillator pads (in AP position) after shaving chest if required
βRightβ pad: place longitudinally on left sternal edge
βLeftβ 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 βpadsβ
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 β 200J β 200J (biphasic)
Ask anaesthetist to sedate patient and wait until they are happy to proceed
Ask everybody to move away from the patient and ask for the oxygen to be moved away
Press 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 rhythm
If unsuccessful, repeat at next energy (maximum 3 attempts)
Dealing with complications
Asystole or bradycardia with haemodynamic compromise (SBP<90) β if sustained, proceed to transcutaneous pacing
Bradycardia without haemodynamic compromise β monitor, reduce Ξ²-blockers
Ventricular tachycardia with pulse β repeat synchronised DC shock as above
Pulseless arrhythmia β unsynchronised DC shock if shockable rhythm (VT/VF); if ongoing or not shockable rhythm, start chest compressions and manage as cardiac arrest (see ALS)
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