Synchronized Cardioversion (Ambulatory) - CE
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Do not perform cardioversion as the first-line treatment for stable atrial fibrillation and atrial flutter because there is a risk of a mural thrombus breaking loose and creating emboli.undefined#ref1">1
The goal of synchronized cardioversion is to deliver an electrical shock with a goal of converting tachyarrhythmia to a normal stable rhythm.5,7 Cardioversion is performed using a defibrillator; some defibrillators deliver monophasic waveforms, whereas others deliver biphasic waveforms. Knowing which type of waveform the defibrillator delivers is important because the recommended joules (J) for cardioversion are different for monophasic and biphasic waveforms.
The AHA recommends emergent synchronized cardioversion for these conditions:6
An unstable patient has an acute altered mental status, ischemic chest discomfort, hypotension, or other signs of shock that are likely to be secondary to the arrhythmia.
If the patient is stable, a 12-lead electrocardiogram (ECG), consultation with a cardiac specialist, and pharmacologic therapy should be considered before synchronized cardioversion. For patients with atrial fibrillation lasting longer than 48 hours, treatment options include rate control with medication or delayed cardioversion after anticoagulation therapy.9
If the patient’s heart rate is less than 150 beats per minute with a regular rhythm,6 the patient probably has an underlying noncardiac condition, such as sepsis or fever, which is unlikely to respond to synchronized cardioversion. Treatment should instead focus on correcting the causative condition.
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Rationale: If the patient is stable, transportation to a facility with cardiology specialty evaluation is recommended before synchronized cardioversion.
Prevent burns and inappropriate transmission of current by keeping the patient away from metallic objects, which are excellent conductors of electrical current.
Rationale: The ointment or patches may result in an alternate path for the electrical current and may cause skin burns.
Rationale: A lack of privacy may increase the patient’s anxiety level.
Rationale: Removing skin oils and lotion with soap and water, and then drying the skin completely, improves electrode adherence and maximizes delivery of pacing energy through the chest wall.
Rationale: The use of clippers or scissors rather than shaving prevents microscopic skin tears that may lead to infection.
Rationale: Cardioversion may be painful and cause anxiety for patients.
Rationale: Sudden deterioration of the patient’s condition may warrant rapid synchronized cardioversion or an asynchronous shock if the patient becomes pulseless and converts to ventricular fibrillation or ventricular tachycardia.6
Rationale: Using frayed, broken, or discolored cables or lead wires could cause harm to the patient or health care team member delivering the shock to the patient.
Rationale: The recommendation is to use multifunction electrodes rather than paddles. They are safer for the patient and health care team members and provide better skin contact and conduction.
For atrial arrhythmias, the clinical team leader may prefer alternate pad locations; place multifunction electrode pads as directed.
Do not place the multifunction electrode pads over wires, drains, dressings, ECG electrodes, or medication patches.
If a patient has either an internal cardiac defibrillator (ICD) or an implanted pacemaker, ensure that the multifunction electrodes are placed a minimum of 10 cm (4 inches) from the implanted device.7
Observe for whether the defibrillator reverts to synchronization mode after each attempt or whether it needs to be reset each time to deliver a subsequent synchronized shock.
Rationale: Ensuring that synchronization markers occur on each QRS complex avoids a delay or failure to deliver the shock in synchronization mode and prevents delivery of the shock during the relative refractory period.
Rationale: Burns may occur if there is insufficient or excessive conductive medium.
Rationale: A path of gel or incomplete paddle contact may cause an energy arc to occur.
Rationale: Maximal contact between the chest wall and the paddle decreases transthoracic impedance. Proper pressure applied to the paddles and proper positioning decrease the risk of burns.
Rationale: Bystanders in contact with the patient during cardioversion may receive a mild shock or burns.
Look at the patient when depressing the discharge button(s) to ensure that no one is touching the patient.
Check that synchronization mode is active after each attempt.
*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.
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