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Cardioversion(DC Shock)
17 Agustus 2015

1 Oktober 2016
Defibrillation is a procedure used to treat life threatening
conditions that affect the rhythm of the heart such as cardiac
arrhythmia, ventricular fibrillation and pulseless ventricular

- electric shock to the heart --> depolarisation heart muscles

and re-establishes normal conduction of the heart’s
electrical impulse.
- The machine used to deliver this therapeutic shock to the
heart is called a defibrillator.

The different types of defibrillators used include external

defibrillators, transvenous defibrillators and implanted
- Defibrillation was first presented by Prevost and Batelli, two
physiologists from University of Geneva, Switzerland in 1899.
- In animal studies, they observed that small electric shocks
delivered to the heart could trigger ventricular fibrillation,
while the delivery of large electrical charges could reverse
the fibrillation.

- In 1947, the procedure was used for the first time in a

human patient.
- Claude Beck, Professor of surgery, at Case Western
Reserve University treated a 14 year old boy undergoing a
surgical procedure for a chest defect and managed to
restore a normal sinus rhythm in the boy’s heart.
- In the 1950s, an alternative method of delivering an electric
shock to the heart was pioneered by V.Eskin and colleague
A. Klimov from the USSR.
- Rather than the paddle electrodes used in open heart
surgery, the closed-chest device could apply a charge of over
1000 volts through nodes applied to the outside of the chest
- It was in 1959 that Bernard Lown and engineer Barouh
Berkovits developed a way of delivering the charge using
resistance to create a less strong sinusoidal wave that
would last 5 milliseconds using paddle electrodes.

- This technique was termed the Lown-Berkovits waveform

and it became the standard defibrillation treatment to be
used into the late 1980s.
- Thereafter, the biphasic truncated waveform (BTE) was
adopted as an equally effective waveform that required less
charge to achieve defibrillation.
- The unit was also lighter to transport.
Today’s portable defibrillators were introduced in the early
1960s by Prof. Frank Pantridge in Belfast. Today, these tools
form an essential part of the equipment found in an

By Dr Ananya Mandal, MD
A treatment of choice for ventricular fibrillations and pulseless
ventricular tachycardia, must be performed ASAP, even
before intubation or drug administration

Delivers an electric shock to the heart to correct arrhythmias
Basic principles
Transient delivery of electrical current causes a momentary
depolarization of most cardiac cells allowing the sinus node to
resume normal pacemaker activity.

In the presence of reentrant-induced arrhythmia, such as

paroxysmal supraventricular tachycardia (PSVT) and
ventricular tachycardia (VT), electrical cardioversion interrupts
the self-perpetuating circuit and restores a sinus rhythm.

Electrical cardioversion is much less effective in treating

arrhythmia caused by increased automaticity (eg, digitalis-
induced tachycardia, catecholamine-induced arrhythmia) since
the mechanism of the arrhythmia remains after the arrhythmia
is terminated and therefore is likely to recur.
Emergency vs Elective Cardioversion
- hypotension
- respiratory insufficiency
- altered mental status
- ongoing chest pain as a result of the tachycardia.

- The American Heart Association also recommends that for a

heart rate of >150/minute immediate cardioversion be given,
though a brief trial of medications may ensue.

Otherwise cardioversion is considered elective, and often

scheduled to be performed in the Post Anesthesia Care Unit or
other specialty unit.
For elective procedures, prepare as follows:

- Nil per os (NPO) for 8 hours prior to the procedure

- Stop digoxin 48 hours prior to the procedure
- Continue medications on the morning of the procedure
under the direction of the physician
- After the procedure, do not drive, operate machinery, or sign
important documents for 24 hours and/or until sedation has
worn off.

There is no patient preparation for emergency procedures.

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)
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
- 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.
- The anteroposterior approach is also preferred in patients with implantable
devices, to avoid shunting current to the implantable device and damaging its
- The difference between DC shock and defibrillation is only
- If one gives a synchronised shock ( with qrs complex ) it
becomes DC shock .If not , it is defibrillation
- During defibrillation and cardioversion, electrical current
travels from the negative to the positive electrode by
traversing myocardium.

- It causes all of the heart cells to contract simultaneously.

- This interrupts and terminates abnormal electrical rhythm
in turn, allows the sinus node to resume normal pacemaker
Two shock forms are
- Monophasic shocks
- Biphasic shocks

- Monophasic defibrillation delivers a charge in only one

- Biphasic defibrillation delivers a charge in one direction for
half of the shock and in the electrically opposite direction for
the second half.
Differences between monophasic and biphasic systems:

In monophasic systems, the current travels only in one direction -

from one paddle to the other.

In biphasic systems, the current travels towards the positive paddle

and then reverses and goes back; this occurs several times.
Biphasic shocks deliver one cycle every 10 milliseconds.
They are associated with fewer burns and less myocardial damage.

With monophasic shocks, the rate of first shock success in cardiac

arrests due to a shockable rhythm is only 60%, whereas with
biphasic shocks, this increases to 90%.

However, this efficacy of biphasic defibrillators over monophasic

defibrillators has not been consistently reported.
What is the fundamental difference between the two ?

In biphasic shocks , the current traverses the myocardium

twice .
So, it has a second chance to interrupt the critical tachycardia
circuit , if the first one fails.
In other words, biphasic shocks are technically equivalent to
“two sequential low energy shocks” delivered in opposite
polarity . This change in direction happens in micro seconds .
The shape of biphasic DC current wave form can be a
truncated sine wave or square wave .The maximum energy
of DC shock in biphasic mode is 200 joules (In Monophasic it
is 360joules) . All AEDs, ICDs, now use biphasic shocks to
conserve energy .
A biphasic shock waveform has a proven advantage .
It has greater efficacy ( because it traverses the heart twice ) ,
requires fewer shocks with low delivered energy and hence
less myocardial and dermal injury.

Even though there is general acceptance of superiority of bi

phasic shocks , it is still considered by some , that there is no
great difference in the overall outcome .
The success of defibrillation depends on many factors .

The following are most important:

- The critical myocardial mass must be depolarized by the
current delivered.
- The direction and the angle of current entry with reference to
advancing end of abnormal waveform is also important.
- Distance between the paddles.(Antero posterior paddles
more effective than Apex /Sternal pads )
- Energy level (seems to be less important ! )
Energy selection for defibrillation or cardioversion
In 2010, the American Heart Association issued guidelines for initial energy
requirements for monophasic and biphasic waveforms.

Atrial fibrillation energy requirements are as follows:

- 200 Joules for monophasic devices
- 120-200 Joules for biphasic devices

Atrial flutter energy requirements are as follows:

- 100 Joules for monophasic devices SVT
- 50-100 Joules for biphasic devices

Ventricular tachycardia with pulse energy requirements are as follows:

- 200 Joules for monophasic devices
- 100 Joules for biphasic devices.

Ventricular fibrillation or pulseless ventricular tachycardia energy

requirements are as follows:
- 360 Joules for monomorphic devices
- 120-200 Joules for biphasic devices
The most common complications are harmless arrhythmias, such as atrial, ventricular, and junctional premature

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.

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.

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 20-25% 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.

Allergic reaction to sedation medication is a potential complication.

Based on a study by Joglar and colleagues, it has been
recommended that a 100 J monophasic shock should not be
used as the initial energy level for cardioversion of atrial
fibrillation because of the relatively low success rate.

Current recommendations suggest using higher initial energy

levels because the success rate only becomes satisfactory at
an energy level of 200 J or more (for monophasic waveforms),
with a consequent decrease in cumulative delivered energy.

According to the results of former studies with biphasic

cardioversions, we hypothesised that a biphasic shock of 120
J may be as effective as a monophasic shock of 200 J.

Heart. 2003 Sep; 89(9): 1032–1034.

M Scholten, T Szili-Torok, P Klootwijk, and L Jordaens
Defibrillation / Cardioversion – Special Considerations
- For every 1 minute that defibrillation is delayed, a patient’s
chance of surviving VF drop by 7 – 10%.
- VF that lasts for more than a few minutes causes irreversible
brain damage.
- VF causes cardiac output to drop to zero that leads to
- Convert to pediatric size for children or internal if the patient
has an open chest.
- If the ECG or monitor shows VF and you suspect cardiac
arrest always check for the level of consciousness of the
patient. If patient remains REPONSIVE and AWAKE
immediately check vital signs and recheck tracing for electrical
- Never defibrillate a patient who is alert, if you do, you will
trigger lethal arrhythmias which will lead to CARDIAC
Defibrillation / Cardioversion - Contraindications
- Myocardial Infarction within 1 month prior to entry
- Undergone revascularization procedures within 3 months
- Less than 8 years old or under 55 pounds
- Obviously dead criteria
- Honoring pre-hospital DNR (Do not resuscitate) orders
- Dysrhythmias due to enhanced automaticity, such as in
digitalis toxicity and catecholamine-induced arrhythmia
- Multifocal atrial tachycardia
Thank Q