Defibrillation

and
Cardioversion

Dr. Asim Biswas

MD Final Part Student
NHFH&RI
Cardioversion

• Chemical cardioversion
• External Electrical cardioversion
• Internal Electrical cardioversion
• Defibrillation is nonsynchronized random
administration of shock during a cardiac cycle.
In 1956, alternating current (AC) defibrillation was first introduced
to treat ventricular fibrillation in humans. Later in 1962, direct
current (DC) defibrillation was introduced.

• Cardioversion is a synchronized administration

of shock during the R waves or QRS complex of a
cardiac cycle.
• 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. This, in turn, allows the sinus node to
resume normal pacemaker activity.
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 catecholamine-induced
arrhythmia
• Multifocal atrial tachycardia

For dysrhythmias due to enhanced automaticity such as in digitalis

toxicity and catecholamine-induced 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).
Equipment
• 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
Technique

Patient preparation:
There is no patient preparation for emergency procedures.

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
Anesthesia
elective cardioversion should be performed under
general anesthesia; conscious sedation is often
inadequate.
Synchronization

It is essential to synchronize the electrical discharge on the R

wave of the QRS complex;
if the shock falls in the vulnerable period of the cardiac cycle
(on T wave), VF may be induced.
This is the most frequent serious complication of elective
cardioversion of atrial arrhythmias and usually results from
the operator’s failure to enable properly the synchronizing
device or to verify that the R wave of the ECG lead chosen is
sufficiently tall to be recognized by the synchronizer.
Synchronization
If the patient is hemodynamically unstable owing to rapid
ventricular tachycardia, unsynchronized shocks may be
delivered; if VF results from the first shock, an immediate
second shock is administered to terminate the VF.
The operator must be prepared, in such circumstances, to
quickly disable the synchronizing setting; if this is not done
the defibrillator will not identify an R wave (which is not
present in VF) and will not deliver a shock.
• ECG strip shows a atrial fibrillation terminated by a
synchronized shock (synchronization marks
[arrows] in the apex of the QRS complex) to normal
sinus rhythm.
• Ventricular fibrillation terminated by an
unsynchronized shock (arrows) to normal sinus
rhythm.
Positioning of Paddle
Paddle placement on the chest wall has 3 positions:
• Apex-anterior / anterolateral
• Apex-posterior
• Anteroposterior
In the anterolateral position, one 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.
• The anteroposterior approach is also preferred in
patients with implantable devices, to avoid shunting
current to the implantable device and damaging its
system.
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 hand-held
electrodes improve electrode-to-skin contact and
reduce the transthoracic impedance.
Monophasic versus biphasic waveforms

• Defibrillators can deliver energy in various waveforms

that are broadly characterized as monophasic or biphasic.
• Monophasic defibrillation delivers a charge in only one
direction. Biphasic defibrillation delivers a charge in one
direction for half of the shock and in the electrically
opposite direction for the second half.
• Newer defibrillators deliver energy in biphasic
waveforms. Biphasic waveform defibrillators deliver a
more consistent magnitude of current. They tend to
successfully terminate arrhythmias at lower energies than
monophasic waveform defibrillators.
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
• 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 monophasic devices
• 120-200 Joules for biphasic devices
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.
Complications
• 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.
Complications
• 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
Complications
• Pulmonary edema is a rare complication of
cardioversion. It is probably due to transient left
atrial standstill and left ventricular systolic
dysfunction.
Complications
• 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
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.
Cardioversion in patients with permanent pacemakers/ICDs

Improper technique may damage the device, lead system,

or myocardial tissue, resulting in device malfunction.
The electrode paddle or patch should be at least 12 cm
from the pulse generator and in anteroposterior position.
The lowest amount of energy should be used during
cardioversion, based on the patient’s clinical condition.
After cardioversion, the pacemaker/ICD should be
interrogated to ensure normal function of the device.
Special Populations
Cardioversion during pregnancy
Cardioversion can be performed safely in pregnant
women. The fetal heart rate should be monitored
during the procedure using fetal monitoring
techniques.
Thank
You