CARDIOVERSION:

When, how and why?

Dr Luke Lawton FACEM
Staff Specialist, The Townsville Hospital
Consultant Retrieval Physician, CMS Qld
CARDIOVERSION

Cardioversion is a safe, effective, universal remedy for tachyarrythmias.

It is the treatment of choice for any unstable tachyarrythmias.

Issues to consider prior to DC cardioversion include:

- correction of any electrolyte abnormalities, most notably K+ and Mg++
- treatment of any toxicological ingestion with the appropriate antidote
- possible use of adenosine for a known SVT with no evidence of aberrant
conduction, most notably:
o an abnormal axis
o QRS interval >0.12s
- The therapeutic aims for patients in AF (see Dr James Edwards’ talk on
AF for more details)

A Valsalva manoeuvre may be attempted, but is less than 20% likely to succeed in
reversion.

Procedurally for cardioversion:

1) Light sedation is usually required
2) Both leads and defibrillation paddles should be connected to the patient\
a. AP or anterolateral pad position is at the operator’s preference
3) The defibrillator should be synchronised by pressing the “synch” button
4) 200J energy should be selected

Cardioversion without synchronisation carries the significant risk of R on T

phenomenon and consequent polymorphic VT (Torsades de pointes).
 Clinical case
•  45 yo male
– “Palpitations” and “Chest pain”
– PMHx
•  Asthma
•  Peripheral vasc disease
HR 155 BP 95/60
RR 18 Sats 99% (RA)
T 37.1oC
WHAT THE HELL IS
GOING ON ?!?
 Outline
•  WHY?
•  WHY NOT?
•  HOW?
–  Pad position
–  Energy selection
–  Synchronization
 Ask not why?
QUICK

UNIVERSAL

SAFE

EASY

TREATMENT OF CHOICE FOR ANY UNSTABLE

TACHYARRYTHMIA
 Anti-arrythmics
•  Multiple contraindications
–  Rhythm specific
–  Accessory pathway
•  Wide complex
–  Allergies
–  Intercurrent conditions
•  Rate control agents:
–  Band-aid not fix
–  Hypotensive
•  Delayed action
 Why not?
•  Known uncomplicated SVT
•  Adenosine bolus
•  Inability to perform safely
•  Anaesthetic
•  Atrial fibrillation
•  AFFIRM1
•  Reversion rate new AF >50%2
•  >48hrs check INR
•  Toxicology + perfusing arrythmia
 THINGS TO THINK BEFORE
CARDIOVERSION
•  Electrolytes
–  K+
–  Mg++
•  Volume3
–  Bezold-Jarisch reflex (hypotension, bradycardia)
•  Toxicology4
–  Antidotes
•  NaHCO3
•  Digibind
•  Diazepam
 HOW TO…
1.  Conscious sedation
•  Cardiac stable drugs
•  Fentanyl and midazolam
•  Ketamine
2.  Pads
3.  Energy
4.  Synchronize
5.  Shock
 Valsalva Manouvre5

•  Lab induced SVT: 45 – 54%

•  “Real world”: < 20%
 ENERGY
200J
•  BEST-AF Trial6
–  200J (71%) vs 100J (48%)
–  1st shock reversion rate

PAD POSITION
•  Doesn’t matter7
•  Common sense
•  Switch PRN
 SYNCHRONIZATION
•  Essential to shock depolarization
•  All rhythms except VF
•  Steps
1.  Two inputs to defib
–  Leads and pads
 SYNCHRONIZATION
•  Essential to shock depolarization
•  All rhythms except VF
•  Steps
1.  Two inputs to defib
–  Leads and pads
2.  “Leads” button: select II
3.  “Synch” Button: look for arrows
 SYNCHRONIZATION
•  Essential to shock depolarization
•  All rhythms except VF
•  Steps
1.  Two inputs to defib
–  Leads and pads
2.  “Leads” button: select II
3.  “Synch” Button: look for arrows
4.  Shock: expect a pause
 REMEMBER

CARDIOVERSION GETS
YOU OUT OF GAOL

ALWAYS SYNCHRONIZE
 REFERENCES
1.  The AFFIRM investigators. A comparison of Rate Control and Rhythm Control
in Patients with Atrial Fibrillation
2.  Falk RH, Knowlton AA, Bernard SA et al. Digoxin for converting recent-onset
atrial fibrillation to sinus rhythm. A randomized double-blinded trial. Ann intern
med 1987 106(4): 503 – 6
3.  Lim R. Complication after treatment for resistant supraventriuclar tachycadia;
the Bezold-Jarisch reflex. AJEM 31(9) 1425:e3-4
4.  Smith G, Taylor DM, Morgans A, Cameron P. Prehospital Synchronized
Electrical Cardioversion of a Poorly Perfused SVT Patient by Paramedics.
Prehosp Disaster Med. Jun 2013;28(3):301-4.
5.  Smith GD, Dyson K, Taylor D et al. Effectiveness of the Valsalva Manoeuvre.
Cochrane Database Sys Tev 2013 28:3
6.  Glover BM, Wlash SJ, McCann Cj et al. Biphasic energy selection for
transthoracic cardioversion of atrial fibrillation. The BEST AF Trial. Heart 2008
94(7) 884 – 7
7.  Kirkland S, Stiell IG, Al Shawabkeh et al. The efficacy of pad placement
for electrical cardioversion of atrial gibrillation: a systematic review.
CJEM 2013 15(s1)