CARDIOVERSION

INTRODUCTION: Synchronised Cardioversion:

INDICATIONS:
- Atrial fibrillation
- Atrial flutter
- Atrial tachycardia
- Supraventricular tachycardias

Unsynchronised Cardioversion/Defibrillation:
INDICATIONS:
- Ventricular tachycardia - compromising
- Ventricular fibrillation

Both compromising causing loss of consciousness.

STANDARDS:
* Management and care of cardioversion procedure is to be undertaken by:
- Medical officers of either ICU or CCU.
- Registered nurses who have been accredited for the emergency care protocol or FLEC
(First Line Emergency Care) accredited by the Richmond Health Service.
* In emergency situations registered nurses only who are FLEC accredited may
defibrillate in a cardiac arrest.
* Procedure should be carried out by authorised medical personnel.
* Should be done under close monitoring continuous ECG and recording facilities.

* Cardioversion requires an anaesthetist and anaesthetic agents, laerdel bag and

oxygen equipment to maintain airway with induced unconsciousness.
* The defibrillator should be checked prior to use and the emergency trolley should also
be checked and placed in patients room.
* Ensure patient has been on NBM for 4-6 hours prior to elective cardioversion.
* Ensure patient has an IV cannula.
* Ensure a recent 12 lead ECG is available and recording of a baseline observation.
* Patient should have procedure explained to them by medical officer and a consent
form signed.
* All cardioversion being elective are to be attended in ICU or CCU.

OUTCOMES: The procedure will be terminated either by a successful reversion to sinus

rhythm or when the medical officer determines that cardioversion will not revert the
rhythm.

SPECIAL
CONSIDERATIONS:
In elective cardioversion the delivery of a synchronised external electrical impulse via the
chest wall in order to revert an arrhythmia to sinus rhythm. The current is delivered at a
pre-determined point in the cardiac cycle (the peak of the R wave) so as to avoid
discharging during the relative refractory stage of the cycle (the end of the T wave), as
this may result in the development of ventricular fibrillation.

EQUIPMENT: Defibrillator with a synchronising button

Emergency trolley with emergency drugs; lignocaine atropine and adrenaline
Intubation equipment
Oxygen mask, laerdel bag - Guedels airway
Hudson mask
Monitor and continuous recording facilities

PRE PROCEDURE:
PATIENT PREPARATION:
* Baseline observations - BP pulse and ECG for post procedure comparison.
* Be aware of the patients serum K+ level or whether the patient has been digitalised.
Notify medical officer.
NB: Digitalis is usually discontinued 24-36 hours prior cardioversion; its presence may
result in an increased risk of cardioversion induced arrhythmias.
* Ensure patient IV access.
* The patient is connected to the monitoring function of the defibrillator baseline rhythm
recorded, Lead selected for recording, Lead II.

PROCEDURE:
* The anaesthetic agents are chosen by the Anaesthetist; short acting general
anaesthetics. The patient will require recovery nursing care.
* Once the patient is anaesthetised get gel pad interface or defibrillator pads are applied
to the chest. The correct positions are to the right of the upper sternum for the sternal
pad and paddle and between the left midclavicular line and the left mid axillary line for
the apical pad and paddle.
* Place defibrillator paddles over the gel or defibrillator pads apply 10-12kg of weight;
charge machine to the joule level selected by the medical officer. Commencement at 50-
150j increasing to 300-360j.
* Ensure bed is clear; no one is in contact.
* Press the discharge buttons and maintain pressure on the paddles for one second
following electrical discharge.

POST PROCEDURE:
* The procedure will be terminated either by a successful reversion to sinus rhythm or
when the medical officer determines that cardioversion will not revert the rhythm.
* Ensure the patients airway is patent.
* Patient nursed in the left lateral position until fully conscious. Oxygen administration c/-
hudson mask.
* BP record immediately post procedure at 5 minute intervals for 15 minutes then 15
minute intervals for 2 hours.
* A 12 lead ECG is recorded within _ an hour of the procedure.

* Documentation should include:

- pre and post procedure ECG
- pre and post procedure rhythm strip
- pre and post procedure observations
- the number of shocks and joules used
- the condition of the skin following cardioversion
There are two ways to convert your heart to a normal rhythm. They are:

• Electrical cardioversion. An external defibrillator is used in electrical

cardioversion. After you are given a sedative, a doctor places metal paddles or
patches on your chest wall. The paddles send an electric current to your heart.
The electric current resets your heart rhythm and your heart usually starts in a
normal rhythm.
• Chemical cardioversion. Antiarrhythmic medications—such as flecainide,
propafenone, or ibutilide—convert your heart to a normal rhythm by reducing
atrial excitability and stabilizing the heart muscle tissue. Chemical cardioversion
may be used when electrical cardioversion or sedation is considered unsafe or
inappropriate. It is less physically traumatic than electrical cardioversion, but it is
also less effective. Antiarrhythmic medications also have many potentially serious
side effects.

How effective is cardioversion?

Electrical cardioversion successfully restores a normal sinus rhythm in about 85% of

people who have recent-onset atrial fibrillation.1 Staying in a normal rhythm is more likely
when the underlying cause is not heart disease. However, in many cases, atrial
fibrillation is caused by underlying heart disease and is highly likely to recur.

The longer you have had atrial fibrillation, the lower your chance is of staying in a normal
rhythm after cardioversion.

What are the risks of cardioversion?

Having a stroke is the most serious risk of cardioversion. Cardioversion may dislodge a
blood clot in your heart, causing a stroke. However, this risk can be significantly reduced
by taking the following precautions:

• If your atrial fibrillation has lasted for more than 48 hours, your doctor will
probably prescribe anticoagulants for several weeks before attempting
cardioversion to reduce the risk of stroke.
• Your doctor may use a test called transesophageal echocardiography to assess
whether you have a clot in your heart that could cause a stroke. If the heart is
clear of clots, cardioversion can be attempted.
• Anticoagulant medication is taken for 4 weeks after cardioversion.

Other risks of cardioversion include the following:

• You can get a small area of burn on your skin where the paddles are placed.
 • Antiarrhythmic medications used before and after cardioversion or even the
cardioversion itself may cause a life-threatening irregular heartbeat.
• You can have a reaction to the sedative given to you before the procedure.
Harmful reactions are rare.
• The procedure may not work. Additional cardioversion or other treatment may be
needed.

What are the risks of not having cardioversion?

If you choose not to try cardioversion, you still will be at risk for problems from atrial
fibrillation.

You may have heart palpitations, chest pain, or shortness of breath, especially during
physical activity or emotional stress. You may also tire easily or have problems with
weakness, confusion, dizziness, or fainting.

If you are not bothered by symptoms of atrial fibrillation, your doctor may prescribe
medications to slow your heart rate but allow the atrial fibrillation to persist.

You will still probably need to take anticoagulant medications to decrease your risk of
stroke. However, these medications increase your risk of developing a serious problem
with bleeding. You will need to have your blood tested frequently while you are taking an
anticoagulant. With these blood tests, your doctor can tell whether your anticoagulant
medication is at an effective and safe level.

For more information, see the topic Atrial Fibrillation.

Your choices are:

• Try cardioversion in an attempt to convert to a normal rhythm.

• Do not have cardioversion. Instead, take medications to control your heart rate,
and take anticoagulants.

The decision about whether to try cardioversion takes into account your personal
feelings and the medical facts.
 Deciding about cardioversion

Reasons to try cardioversion Reasons not to try cardioversion

• Your atrial fibrillation is not related
to underlying heart disease.
• You have had only one episode of
atrial fibrillation.
• You have symptoms of atrial
fibrillation that are bothersome,
such as palpitations, or that affect
the quality of your life, such as
shortness of breath with exertion.
• If cardioversion was successful the
first time but you reverted to atrial
fibrillation after some time, you may Are there other reasons you might not want
want to try it again.
• You have had several atrial
fibrillation episodes and have
underlying heart disease.
• You do not have any symptoms of
atrial fibrillation.
• You have tried cardioversion once or
twice and atrial fibrillation recurred.
• You have been in atrial fibrillation for
a long time, and cardioversion is
unlikely to be successful.
to try cardioversion?

Are there other reasons you might want to

try cardioversion?
 DEFIBRILLATION

Definition

Defibrillation is a process in which an electronic device sends an electric shock to the

heart to stop an extremely rapid, irregular heartbeat, and restore the normal heart
rhythm.

Purpose

Defibrillation is performed to correct life-threatening fibrillations of the heart, which could

result in cardiac arrest. It should be performed immediately after identifying that the
patient is experiencing a cardiac emergency, has no pulse, and is unresponsive.

Precautions

Defibrillation should not be performed on a patient who has a pulse or is alert, as this
could cause a lethal heart rhythm disturbance or cardiac arrest. The paddles used in the
procedure should not be placed on a woman's breasts or over a pacemaker.

Description

Fibrillations cause the heart to stop pumping blood, leading to brain damage and/or
cardiac arrest. About 10% of the ability to restart the heart is lost with every minute that
the heart stays in fibrillation. Death can occur in minutes unless the normal heart rhythm
is restored through defibrillation. Because immediate defibrillation is crucial to the
patient's survival, the American Heart Association has called for the integration of
defibrillation into an effective emergency cardiac care system. The system should
include early access, early cardiopulmonary resuscitation, early defibrillation, and early
advanced cardiac care.

Defibrillators deliver a brief electric shock to the heart, which enables the heart's natural
pacemaker to regain control and establish a normal heart rhythm. The defibrillator is an
electronic device with electrocardiogram leads and paddles. During defibrillation, the
paddles are placed on the patient's chest, caregivers stand back, and the electric shock
is delivered. The patient's pulse and heart rhythm are continually monitored. Medications
to treat possible causes of the abnormal heart rhythm may be administered. Defibrillation
continues until the patient's condition stabilizes or the procedure is ordered to be
discontinued.

Early defibrillators, about the size and weight of a car battery, were used primarily in
ambulances and hospitals. The American Heart Association now advocates public
access defibrillation; this calls for placing automated external defibrillators (AEDS) in
police vehicles, airplanes, and at public events, etc. The AEDS are smaller, lighter, less
expensive, and easier to use than the early defibrillators. They are computerized to
provide simple, verbal instructions to the operator and to make it impossible to deliver a
shock to a patient whose heart is not fibrillating. The placement of AEDs is likely to
expand to many public locations.

Preparation

After help is called for, cardiopulmonary resuscitation (CPR) is begun and continued until
the caregivers arrive and set up the defibrillator. Electrocardiogram leads are attached to
the patient's chest. Gel or paste is applied to the defibrillator paddles, or two gel pads
are placed on the patient's chest. The caregivers verify lack of a pulse, and select a
charge.

Aftercare

After defibrillation, the patient's cardiac status, breathing, and vital signs are monitored
until he or she is stable. Typically, this monitoring takes place after the patient has been
removed to an intensive care or cardiac care unit in a hospital. An electrocardiogram and
chest x ray are taken. The patient's skin is cleansed to remove gel or paste, and, if
necessary, ointment is applied to burns. An intravenous line provides additional
medication, as needed.

Risks

Skin burns from the defibrillator paddles are the most common complication of
defibrillation. Other risks include injury to the heart muscle, abnormal heart rhythms, and
blood clots.

Key Terms

Cardiac arrest
A condition in which the heart stops functioning. Fibrillation can lead to cardiac
arrest if not corrected quickly.
Fibrillation
Very rapid contractions or twitching of small muscle fibers in the heart.
Pacemaker
A surgically implanted electronic device that sends out ele