Ver el código de «Synchronized cardioversion»

''See [[critical care quick reference]] for doses by weight.''
==Background==
*Low energy shock synchronized with peak of QRS complex
*Machine leads synchronized with patient's EKG rhythm

{{Defibrillation and cardioversion indications}}

==Contraindications==
*None

==Equipment Needed==
*Defibrillator
*Consider sedation medication in conscious patient (e.g. etomidate, ketamine), but do not delay procedure in unstable patient
**Give [[fentanyl]] 1 μg/kg before sedation, and consider slow 0.5 mg/kg [[lidocaine]] IV 1 min before sedative
**[[Etomidate]] superior to [[propofol]] in terms of recovery and hemodynamic stability<ref>Desai PM, Kane D, Sarkar MS. Cardioversion: What to choose? Etomidate or propofol. Ann Card Anaesth. 2015;18(3):306–311. doi:10.4103/0971-9784.159798.</ref>
***Etomidate 0.1 mg/kg, followed by etomidate second dose of 0.05 mg/kg just prior to shock
***VS propofol 1 mg/kg, followed by propofol second dose of 0.5 mg/kg just prior to shock

==Procedure==
===Cardioversion===
*Apply pads
**Anterior-Posterior placement is preferred <ref>Kirchhof P et al. Anterior-posterior versus anterior-lateral electrode positions for external cardioversion of atrial fibrillation: A randomised trial. Lancet 2002 Oct 26; 360:1275-9</ref> but may not be as important as previously thought and most studies are for atrial fibrillation or flutter <ref>Kirkland S et al. The efficacy of pad placement for electrical cardioversion of atrial fibrillation/flutter: A systematic review. Acad Emerg Med. 2014 Jul;21(7):717-26</ref>
***Avoid placing in close proximity to implanted devices if possible <ref>Manegold J. External cardioversion of atrial fibrillation in patients with implanted pacemaker or cardioverter-defibrillator systems: A randomized comparison of monophasic and biphasic shock energy application. European Heart Journal, 28(14);1731–1738</ref>
*Select appropriate energy (Joules)
*Ensure machine is "synced" before each discharge
**Most machines show an indicator (arrow or dot) above each beat if appropriately synchronized
*Ensure R or S wave is bigger than T wave
**Machine may read T wave as depolarization and shock during an actual repolarization phase
**May induce shock on T and subsequent VT/VF
**Move leads to avoid this
*Give sedation, if indicated
**All awake and hemodynamically stable patients
*Ensure safety of environment prior to cardioversion
**Nobody touching patient
**Nobody touching equipment that is touching patient
**Consider removing supplemental oxygen
*Cardiovert
**Hold 'Shock' button until shock discharged
***Shock delayed until peak of QRS complex in synchronized cardioversion (keep holding button down)
*Repeat PRN
**May require escalating energy

===Doses===
Initial recommendations:
*Tachycardia with pulse
**Narrow regular (SVT): 50-100 J
**Narrow irregular (A fib, A flutter)
***Biphasic: 120-200 J (may start as low as 50 - 100 J for A flutter)
***Monophasic: 200 J
**Wide regular (VT with pulse): 100 J
**Wide irregular: [[defibrilate]] (NOT synchronized)

==Complications==
 
==See Also==
*[[ACLS (Main)]]
*[[PALS (Main)]]
*[[Defibrillation]]
*[[In-Training Exam Review]]

==External Links==
*[https://www.merckmanuals.com/professional/cardiovascular-disorders/arrhythmias-and-conduction-disorders/direct-current-dc-cardioversion-defibrillation?query=synchronized%20cardioversion Merk Manual - Direct-Current Cardioversion-Defibrillation]

===Videos===
*Larry Mellick-live demonstration (https://www.youtube.com/watch?v=uCETUw0Bssw)
{{#widget:YouTube|id=T7Zv9vLdWtE}}

==References==
*AHA 2010 ACLS Recommendations
<references/>

[[Category:Critical Care]]
[[Category:Cardiology]]
[[Category:Procedures]]