DEFIBRILLATION

AND
CARDIOVERSION

MRS. CHINJU CYRIL

TRAINEE CLINICAL INSTRUCTOR

Objectives
At the end of this session, the attendees will be able to:
1. Define cardioversion and defibrillation
2. State the goals
3. Enumerate the indications and contraindications
4. Explain the mechanism
5. List down the types of defibrillators
6. Describe the procedure
7. Enlist the complications

DEFINITION
The therapeutic use of controlled electric
current over a brief period of time.

Contd

DEFINITION
Defibrillation is the non-synchronized
delivery of energy during any phase of the
cardiac cycle.
Cardioversion is the delivery of energy that
is synchronized to the large R waves or QRS
complex.

ANATOMY AND
PHYSIOLOGY

ELECTRICAL ACTIVITY
OF HEART AND ECG

Why Synchronization?
Synchronization avoids the delivery of a low
energy shock during cardiac repolarization (t-wave).
If the shock occurs during repolarization, there is a
high likelihood that the shock can precipitate VF.

HISTORY
Prevost and Bateli (18th century) performed shock
experiments on the hearts of dogs.
Claude Beck first used this technique in humans.

Bernard Lown (1959) designed modern day

monophasic defibrillator.

GOALS OF CARDIOVERSION &

DEFIBRILLATION

To restore
a normal
heart beat.

To disrupt the
abnormal
electrical circuits
in the heart.

CARDIOVERSION

INDICATIONS
Supra
ventricular
tachycardia

Atrial
fibrillation

Atrial
flutter

Ventricular
tachycardia

CONTRAINDICATIONS
Dysrhythmias due to enhanced automaticity
(digitalis toxicity and catecholamine-induced
arrhythmia)
Multifocal atrial tachycardia

DEFIBRILLATION

INDICATIONS

Pulseless ventricular tachycardia (VT)

Ventricular fibrillation (VF)

CONTRAINDICATIONS
Awake, responsive patients

Any arrhythmias with a pulse

MECHANISM
The delivered shock causes electric current to go from the
negative to the positive electrode of the defibrillator,
passing the heart on its way.
It causes all the heart cells to contract simultaneously,
thereby interrupting and terminating the abnormal
electrical rhythm and thus allowing the sinus node to
resume normal pacemaker activity.

TYPES OF
DEFIBRILLATORS

Current-based
Impedance- defibrillators
based
defibrillators
Energybased
defibrillators

Energy-based defibrillators
The device charges a capacitor to a selected
voltage and then delivers a pre-specified
amount of energy in joules.

Impedance-based defibrillators
Allow selection of the current applied based
upon the transthoracic impedance (TTI).

Transthoracic Impedance
Resistance to the current flow
If transthoracic impedance is high, a low
energy shock may fail to pass enough current
through the heart to achieve defibrillation.

Impedance-based defibrillators
TTI is assessed initially with a test pulse and
subsequently the capacitor charges to the
appropriate voltage.

Current-based defibrillators
A fixed dose of current is delivered, results
in defibrillation thresholds that are independent
of transthoracic impedance and are invariant
for the individual.

TYPES OF
DEFIBRILLATORS
Manual external defibrillator
Manual internal defibrillator
Semi- automated external defibrillators
Automated external defibrillators
Implantable cardioverter-defibrillator
Wearable cardiac defibrillator

Automated external
defibrillators (AED)

Manual external
defibrillator
Classes of discharge waveform
Monophasic pulse or waveform
Biphasic pulse or waveform

Why biphasic is preferred?

A monophasic type, give a high-energy shock, up to
360 to 400 joules due to which increased cardiac injury
and in burns the chest around the shock pad sites.
A biphasic type, give two sequential lower energy
shocks of 120 - 200 joules, with each shock moving in
an opposite polarity between the pads.

TYPES OF DEFIBRILLATOR
ELECTRODES
Spoon shaped
Paddle type
Pad type

SIZE OF PADDLES
Adult size (10-13cm diameter)
Pediatric size ( 4.5 cm diameter) for
patient weight < 10 kg.
Children > 10 kg 8 cm.
Contd

SIZE OF PADDLES
Small paddles concentrate current, burns heart.
Large paddles reduces current density.
In pediatric patient ensure 3 cm distance between
pads.

PADDLE PLACEMENT
ANTEROLATERAL

ANTEROPOSTERIOR

PROCEDURE

EQUIPMENTS
Defibrillators with paddle or adhesive patch
Conductive gel
Crash Cart with emergency drugs
Sedatives
Intubation set
Suction apparatus & catheters

PREREQUISITES FOR
CARDIOVERSION
Explain the procedure
Obtain Informed consent
Maintain NPO for 4-6 hours prior to elective
cardioversion
Digitalis is usually discontinued 24-36 hours prior
cardioversion
Contd

PREREQUISITES FOR
CARDIOVERSION
Check defibrillator prior to use
Crash cart should be ready
Obtain 12 lead ECG
Check serum K+ level
Remove dentures/ jewelleries

Contd

PREREQUISITES FOR
CARDIOVERSION
Empty bladder
Ensure a patent IV cannula
Anaesthetic agents and oxygen to maintain airway
with induced unconsciousness.
TEE is usually done to rule out absence of emboli in
heart.

PROCEDURE

Shock energy Defibrillation

Biphasic : 120 200 J initially. Second and
subsequent doses should be equivalent or higher
dose may be considered.
Monophasic : 360 J

Shock energy - Cardioversion

Narrow regular :

50 100 J

Narrow irregular :

120 200 J biphasic

200 J monophasic
Wide regular :

100 J

POST PROCEDURE
CARE
Monitor the patient closely
Ensure patent airway.
Check and record vitals
Obtain 12 lead ECG
Record joules administered, number of shocks,
result of defibrillation/cardioversion
Record any pre-medications given
Contd

POST PROCEDURE
CARE
Record condition of skin
Provide continuous O2
Administer antiarrhythmics as per order
Oral fluids can be started after 2 hrs
Care of defibrillator

COMPLICATIONS

Arrhythmias (premature beats)

Ventricular Fibrillation
Thromboembolization
Myocardial necrosis
Pulmonary edema
Skin burns

Quiz
1. Patient X in ICU was found unresponsive with
monitor showing flat line ECG. Which of the
following would you consider in his management:
a) Prepare for Cardioversion
b) Immediately Defibrillate
c) Do not attempt Cardioversion or Defibrillation

Quiz
2. A patient was experiencing palpitations with BP 122/76 mm of
Hg and heart rate of 180/min. ECG showed Monomorphic VT.
Few minutes later BP dropped to 70/40 mm of Hg associated with
chest pain. Which treatment is likely to be given?
a) Synchronized shock
b) Non-Synchronized shock

Quiz
3. Which of the following cardiac rhythms are
indicated for defibrillation?
a) Ventricular fibrillation
b) Pulseless electrical activity
c) Pulseless VT