Republic of Yemen

Sana'a university
Faculty of medicine and
health science
High nursing department
Forth level

Presentation about

DC-Shock

1
Monitor by:

Prepare by : Mouath Mohammed Ahmed Al-salat

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 synchronized no synchronized
electrical electrical
cardio version defibrillation
‫متواقت تحويل كهربائية القلب‬

Definition Is the delivery of energy is a no synchronized

that is synchronized to the delivery of energy during
large R waves or QRS any phase of the cardiac
complex. cycle,

videos
Defibrillation and Cardioversion2.flv Defibrillation and Cardioversion.flv

Indications  Supraventricular  Pulseless ventricular

tachycardia tachycardia (VT)
 Atrial fibrillation  Ventricular
 Atrial flutter‫ارتعاش‬ fibrillation (VF)
 Ventricular  Cardiac arrest due to
tachycardia or resulting in VF
 Any patient with
reentrant tachycardia
with narrow or wide
QRS complex
(ventricular rate
>150) who is
unstable (eg, chest
pain, pulmonary
edema, hypotension)

Contraindicatio  Dysrhythmias due to enhanced automaticity such

as in digitalis toxicity and catecholamine-induced
ns arrhythmia
 Multifocal atrial tachycardia

For dysrhythmias due to enhanced automaticity such as

in digitalis toxicity and catecholamine-induced
arrhythmia, a homogeneous depolarization state already
exists. Therefore, cardioversion is not only ineffective
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 but is also associated with a higher incidence of
postshock ventricular tachycardia/ventricular fibrillation
(VT/VF).

Anesthesia  Is almost always  Is an emergent

performed under maneuver and when
induction or sedation necessary should be
(short-acting agent promptly performed
such as midazolam). in conjunction with or
The only exceptions prior to administration
are if the patient is of induction or
hemodynamically sedative agents.
unstable or if
cardiovascular
collapse is imminent.
For more
information, see
Procedural Sedation.

Equipment Equipment includes the following:

 Defibrillators (automated external defibrillators

[AEDs], semi-automated AED, standard
defibrillators with monitors)
 Paddle or adhesive patch
 Conductive gel or paste
 ECG monitor with recorder
 Oxygen equipment
 Intubation kit
 Emergency pacing equipment

The use of hand-held paddle electrodes may be more

effective than self-adhesive patch electrodes. The
success rates are slightly higher for patients assigned to
paddled electrodes because these hand-held electrodes
improve electrode-to-skin contact and reduce the

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 transthoracic impedance.[1]

Positioning Paddle placement on the chest wall has 2 conventional

positions: anterolateral and anteroposterior.

In the anterolateral position, a single paddle is placed on

the left fourth or fifth intercostal space on the
midaxillary line. The second paddle is placed just to the
right of the sternal edge on the second or third
intercostal space.

In the anteroposterior position, a single paddle is placed

to the right of the sternum, as above, and the other
paddle is placed between the tip of the left scapula and
the spine. An anteroposterior electrode position is more
effective than the anterolateral position for external
cardioversion of persistent atrial fibrillation.[2, 3, 4] The
anteroposterior approach is also preferred in patients
with implantable devices, to avoid shunting current to
the implantable device and damaging its system.
Technique Emergent application,

which may be lifesaving, and elective cardioversion

should be used cautiously, with attention to patient
selection and proper techniques. Repetitive, futile
attempts at direct current cardioversion should be
avoided.

Advanced cardiac life support (ACLS) measures should

be instituted in preparing the patient, such as obtaining
intravenous access and preparing airway management
equipment, sedative drugs, and a monitoring device.

Defibrillation and cardioversion are demonstrated in the

videos below.

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 Monophasic vs. biphasic waveforms

 Defibrillators can deliver energy in various

waveforms that are broadly characterized as
monophasic or biphasic.
 Monophasic defibrillation delivers a charge in only
one direction, while biphasic defibrillation delivers
a charge in one direction for half of the shock and
in the electrically opposite direction for the second
half.
 Biphasic waveforms defibrillate more effectively
and at lower energies than monophasic
waveforms.[5, 6, 7]

Energy selection for defibrillation or cardioversion

 Synchronized electrical cardioversion begins with

25-50 J (or the biphasic equivalent, which is
generally one half of that required with
monophasic waveforms) to treat atrial flutter and
50-100 J (or the biphasic equivalent) to treat atrial
fibrillation for patients in stable condition, as
shown below.

 ECG strip shows a atrial

fibrillation terminated by a synchronized shock
(synchronization marks [arrows] in the apex of the
QRS complex) to normal sinus rhythm.
 Rapid polymorphic ventricular tachycardia (rate
>150 bpm) associated with hemodynamic
instability should be treated with immediate,
direct-current, nonsynchronized defibrillation with
energies of 200-360 J (or biphasic equivalent [100-
200 J]).
 Monomorphic ventricular tachycardia should be
treated with a synchronized discharge of 100-200 J
(or biphasic equivalent [50-100 J]).
 Ventricular fibrillation should be treated with
unsynchronized electrical counter shock with at
least 200-360 J (or biphasic equivalent [100-200
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 J]) administered as rapidly as possible, as shown
below.

 Ventricular fibrillation
terminated by an unsynchronized shock (arrows) to
normal sinus rhythm.

Complications  The most common complications are harmless

arrhythmias, such as atrial, ventricular, and
junction premature beats.

 Serious complications include ventricular

fibrillation (VF) resulting from high amounts of
electrical energy, digitalis toxicity, severe heart
disease, or improper synchronization of the shock
with the R wave.[8, 9]

 Thromboembolization is associated with

cardioversion in 1-3% of patients, especially in
patients with atrial fibrillation who have not been
anticoagulated prior to cardioversion.

 Myocardial necrosis can result from high-energy

shocks. ST segment elevation can be seen
immediately and usually lasts for 1-2 minutes. ST
segment elevation that lasts longer than 2 minutes
usually indicates myocardial injury unrelated to the
shock.

 Pulmonary edema is a rare complication of

cardioversion and is probably due to left
ventricular dysfunction or transient left atrial
standstill.
 Painful skin burns can occur after cardioversion or
defibrillation; they are moderate to severe in 20-
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 25% of patients. They most likely are due to
improper technique and electrode placement.[10]

Nursing 1. Place the client in a flat, firm surface.

2. Apply interface material (gel, paste, saline pads) to
Interventions the paddles.
3. Grasp the paddles only by the insulated handles.
To prevent electrocution.
4. Give command for personnel to STAND CLEAR
of the client and the bed.
5. Apply the chest paddle as follows: one at the right
of the sternum, third ICS, and the other one on the
left mid axillary, fifth ICS.
6. Push the discharge button in both paddles
simultaneously.
7. For defibrillation, release 200 to 360 watts/s.
(Joules); for cardioversion low energy is required.
8. Defibrillation is done before initiating CPR.

Resources http://emedicine.medscape.com/article/80564-
overview#showall

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