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Defibrillation and Cardioversion
Dr.Venugopalan P P
DA,DNB,MNAMS,MEM-GW
Director ,Emergency Medicine Aster DM healthcare
PG...
Defibrillation
• Defibrillation - is the
treatment for immediately
life-threatening
arrhythmias with which
the patient does ...
Cardioversion
Cardioversion - is any process that
aims to convert an arrhythmia back
to sinus rhythm.
Electrical cardiover...
The aim in both are to deliver electrical energy to the heart to stun the heart momentarily and thus
allow a normal sinus ...
When to defibrillate …
ASAP ……
Defibrillation- A bit of history
• 18th century two
physiologists, Prévost
and Batelli, performed
shock experiments on the
...
Defibrillation-A bit of history
It was first used in humans
by Claude Beck, a cardio-
thoracic surgeon - on a boy
aged 14 ye...
Defibrillation- A bit of history
1959-Bernard Lown
designed the modern day
monophasic defibrillator
This is based on the
cha...
Defibrillation-A bit of history
1980s the biphasic
waveform was
discovered.
This provided a shock at
lower levels of energy...
Mono phasic Vs Biphasic
Monophasic systems, the current travels only in one direction - from one paddle to the
other.
Biph...
Type of Defibrillators
• Automated External Defibrillators [AED]
• Semi- Automated AEDs
• Standard defibrillators with Monito...
AED
Does not require special medical
training to use 

Found in public places - eg, offices,
airports, train stations, shop...
Four steps of AED
operations
• Power on
• Attach paddle
• Analyse Rhythm -Stand clear
• Shock- Stand clear
Semi Automated AEDs
Similar to AEDs but can
be overridden and usually
have an ECG display.
They tend to be used by
paramed...
Standard Defibrillators
• Monophasic
• Biphasic - Different
waveforms
• Biphasic Truncated Exponential
(BTE) waveform
• Rec...
Implantable Cardiac
Defibrillators -ICD
• Trans-venous
• Implanted
Paddles versus Patches
Paddles were originally used but their
use is being superseded by adhesive
patches.

Adhesive patch...
Paddles versus Patches
Paddles require a significant level of
force, which is not needed with
adhesive electrodes.

Adhesiv...
Energy Level
Cardiac Arrest
Monophasic - Single
shocks started at and
repeated at 360 J.

Biphasic -Single and
repeated sh...
COACHED
Continue Chest Compressions
Oxygen Away

All Else Clear

Charging
Hands Off

Evaluate the Rhythm -
Shockable vs No...
Cardioversion
Indications
• Unstable tachycardia
• Decompensated rapid AF with a rapid ventricular
response - eg, a hypotensive patient,...
Cardioversion the shock has to be properly timed, so that it does not occur during
the vulnerable period, ie during the T ...
Signs of Unstable
Tachycardia
• AMS
• Cold and clammy extremities
• Chest pain
• Dyspnea
• Diaphoresis
• Hypotension
• Rap...
Atrial Fibrillation-Special
considerations
Cardioversion is used for rhythm
control.

Not all cardioversion is successful
...
Atrial Fibrillation-Special
considerations
Transoesophageal
echocardiogram-TEE- during the
procedure, in order to look for...
How to Cardiovert ?
Cardioversions are performed under general anaesthesia or sedation.
Sedation decisions need to be made...
How to Cardiovert ?
Get Crash cart ready
Turn on the machine and attach adhesive electrodes (efficacy may be better with an...
Synchronisation mark in Monitor
How to Cardiovert ?
Ensure all is clear around the bed including Oxygen

Discharge or shock - there may be a 1- to 2-secon...
Consider Nine C’s of
Cardioversion
• Consent
• Consult as needed
• Consider sedation
• Crash Cart
• Confirm Synchronization...
Paediatric cardioversion/
Defibrillation
Supraventricular tachycardias synchronised
DC shocks are usually given at 1 J/kg.
...
Thanks a lot for Patient listening
drvenugopalpp@gmail.com
www.drvenu.blogspot.com
91 9847054747
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Defibrillation and cardioversion

  1. 1. Defibrillation and Cardioversion Dr.Venugopalan P P DA,DNB,MNAMS,MEM-GW Director ,Emergency Medicine Aster DM healthcare PG Teacher -EM NBE Deputy Director -MIMS Academy
  2. 2. Defibrillation • Defibrillation - is the treatment for immediately life-threatening arrhythmias with which the patient does not have a pulse • Ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT)
  3. 3. Cardioversion Cardioversion - is any process that aims to convert an arrhythmia back to sinus rhythm. Electrical cardioversion is used when the patient has a pulse but is either unstable, or chemical cardioversion has failed or is unlikely to be successful Scenarios may be associated with chest pain, pulmonary oedema, syncope or hypotension. Used in less urgent cases - eg, atrial fibrillation (AF) - to try to revert the rhythm back to sinus
  4. 4. The aim in both are to deliver electrical energy to the heart to stun the heart momentarily and thus allow a normal sinus rhythm to kick in via the heart's normal pacemaker, ie the sinoatrial node. Defibrillation and Cardioversion
  5. 5. When to defibrillate … ASAP ……
  6. 6. Defibrillation- A bit of history • 18th century two physiologists, Prévost and Batelli, performed shock experiments on the hearts of dogs. • Applied electrical shocks and discovered that small shocks put the dogs' hearts into VF and this was successfully reversed with a larger shock
  7. 7. Defibrillation-A bit of history It was first used in humans by Claude Beck, a cardio- thoracic surgeon - on a boy aged 14 years who was undergoing cardio-thoracic surgery for congenital heart disease.
  8. 8. Defibrillation- A bit of history 1959-Bernard Lown designed the modern day monophasic defibrillator This is based on the charging of capacitors and then delivering of a shock by paddles over a few milliseconds.
  9. 9. Defibrillation-A bit of history 1980s the biphasic waveform was discovered. This provided a shock at lower levels of energy which were just as efficacious as monophasic shocks.
  10. 10. Mono phasic Vs Biphasic Monophasic systems, the current travels only in one direction - from one paddle to the other. 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 and they are associated with fewer burns and less myocardial damage Mono phasic 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 mono phasic defibrillators has not been consistently reported
  11. 11. Type of Defibrillators • Automated External Defibrillators [AED] • Semi- Automated AEDs • Standard defibrillators with Monitor • Trans-venous or Implanted defibrillators
  12. 12. AED Does not require special medical training to use 
 Found in public places - eg, offices, airports, train stations, shopping centres. Analyse the heart rhythm and then charge and deliver a shock if appropriate. It cannot be overridden manually and can take 10-20 seconds to determine arrhythmias. Unsurprisingly ease of use and speed of use are important factors for success
  13. 13. Four steps of AED operations • Power on • Attach paddle • Analyse Rhythm -Stand clear • Shock- Stand clear
  14. 14. Semi Automated AEDs Similar to AEDs but can be overridden and usually have an ECG display. They tend to be used by paramedics. They also have the ability to pace.
  15. 15. Standard Defibrillators • Monophasic • Biphasic - Different waveforms • Biphasic Truncated Exponential (BTE) waveform • Rectilinear Biphasic Waveform (RBW)
  16. 16. Implantable Cardiac Defibrillators -ICD • Trans-venous • Implanted
  17. 17. Paddles versus Patches Paddles were originally used but their use is being superseded by adhesive patches.
 Adhesive patches are placed most commonly antero-apically - the anterior patch goes under the right clavicle and the apical patch is placed at the apex.
 Adhesive electrodes are better, as they stick to the chest wall, so there is no mess with gels.

  18. 18. Paddles versus Patches Paddles require a significant level of force, which is not needed with adhesive electrodes.
 Adhesive electrodes also allow good ECG trace without interference.
 Adhesive electrodes are also safer, as no operator is required Before discharging a shock, it is important to ensure everyone is clear of the patient.
  19. 19. Energy Level Cardiac Arrest Monophasic - Single shocks started at and repeated at 360 J.
 Biphasic -Single and repeated shock 200 J Use maximum energy available in your machine
  20. 20. COACHED Continue Chest Compressions Oxygen Away
 All Else Clear
 Charging Hands Off
 Evaluate the Rhythm - Shockable vs Non-shockable Defibrillate or Disarm
  21. 21. Cardioversion
  22. 22. Indications • Unstable tachycardia • Decompensated rapid AF with a rapid ventricular response - eg, a hypotensive patient, not responding to medical therapy • VT with a pulse • Supraventricular tachycardias including AF without decompensation; not acutely urgent
  23. 23. Cardioversion the shock has to be properly timed, so that it does not occur during the vulnerable period, ie during the T wave. If this occurs then VT can be triggered. Synchronisation
  24. 24. Signs of Unstable Tachycardia • AMS • Cold and clammy extremities • Chest pain • Dyspnea • Diaphoresis • Hypotension • Rapid thready pulse • Syncope
  25. 25. Atrial Fibrillation-Special considerations Cardioversion is used for rhythm control.
 Not all cardioversion is successful and, at one year, 50% redevelop AF 
 Medical treatments and cardioversion are of similar efficacy (unless permanent AF). Cardioversion of AF is associated with increased risk of thromboembolic disease (TED) Anticoagulation is required for at least three weeks before and at least four weeks afterwards
  26. 26. Atrial Fibrillation-Special considerations Transoesophageal echocardiogram-TEE- during the procedure, in order to look for thrombus POC Echo to rule out Thrombus Sotalol or amiodarone can be given for at least four weeks prior to cardioversion in patients who have had a previous failure to cardiovert or early recurrence of AF .
 Others advocate the use of medications such as sotalol and amiodarone to maintain sinus rhythm after cardioversion
  27. 27. How to Cardiovert ? Cardioversions are performed under general anaesthesia or sedation. Sedation decisions need to be made carefully Get consent Usually done in theatres or Cardiac ICU or Resuscitation bay with the support of an anaesthetist , Cardiologist or Emergency physician or Intensivist The majority of cardioversions are elective procedures; however, some are performed when patients are acutely unwell with tachycardia - eg, chest pain, breathlessness. Decisions regarding sedation will need to be made and in practice this involves the anaesthetist.
  28. 28. How to Cardiovert ? Get Crash cart ready Turn on the machine and attach adhesive electrodes (efficacy may be better with anterior- posterior electrodes)
 Choose the energy level. IV-O2 -Monitor - Get a clearly visible trace on the monitor - eg, using lead II.
 Hit the 'sync' button - usually a blip or dot appears on the monitor, marking each QRS complex. Higher starting energy is associated with better success and fewer shocks 
 Broad complex tachycardia and AF: monophasic - begin with 200 J, or biphasic - 120-150 J.
 Atrial flutter and narrow complex tachycardia: monophasic - 100 J, or biphasic - 70-120 J.
 Charge.

  29. 29. Synchronisation mark in Monitor
  30. 30. How to Cardiovert ? Ensure all is clear around the bed including Oxygen
 Discharge or shock - there may be a 1- to 2-second delay as the machine ensures synchronisation Check rhythm after the shock - if sinus rhythm, then stop; if not, then you may need to deliver another shock at higher energy levels.
 Look for burns afterwards and obtain a 12-lead ECG.
 Sync may not be successful in tachycardias where the QRS complex has a variable morphology.
  31. 31. Consider Nine C’s of Cardioversion • Consent • Consult as needed • Consider sedation • Crash Cart • Confirm Synchronization • Confirm shock delivery • Continuous monitoring • Consider POC Echo and TEE • Consider Anticoagulant in AF
  32. 32. Paediatric cardioversion/ Defibrillation Supraventricular tachycardias synchronised DC shocks are usually given at 1 J/kg. Cardiac arrest situation with a shockable rhythm, note the following: Manual defibrillator should be used for children <1 year of age. Manual defibrillator energy levels are 4 J/kg.
 AED: Child aged 1-8 years - either use paediatric pads which reduce the energy delivered or AED device with paediatric program to reduce the energy delivered. Child aged >8 years - same energy levels as adult Advanced Life Support (ALS) guidelines. AED can be used in Infants also using infant Pads
  33. 33. Thanks a lot for Patient listening drvenugopalpp@gmail.com www.drvenu.blogspot.com 91 9847054747
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