Types of shocking

1. Defibrillation (also known as asynchronized cardioversion)

a. Delivery of electrical energy to terminate lethal arrythmia
b. Indication is lethal arrythmia
i. Ventricular fibrillation
ii. Ventricular tachycardia (pulseless)
c. Joules set at maximum 200 J for biphasic, maximum 360 J for monophasic
d. Biphasic deliver electricity in two directions, using lower energy to prevent burns
and injury to myocardium.
e. Recommended energy steps for initial and successive shocks for adult
i. Start at 120J  150J  200J  then maintained at 200J

2. Synchronized cardioversion
a. It is delivery of electrical energy to terminate tachyarrhythmias.
b. It synchronizes with patient rhythm (R-wave). Delivering shock on R wave; while
defibrillation is delivery of shock at any point.
c. Different from defibrillation in steps of doing it: Hold the shock button (shock is not
immediately delivered as delivery of the shock have to wait to be sync with patient’s
R wave)
d. Energy delivery is 50-100 J for adults.
e. If possible give analgesia/sedation prior as cardioversion is painful and patient in this
case usually is awake. (Not necessary if it’s very emergency condition)
f. Not always a medical emergency
g. Indication (tachyarrhythmia with unstable sign)
i. Atrial fibrillation
ii. Atrial flutter
iii. Atrial tachycardia/supraventricular tachycardia
iv. Ventricular tachycardia (with pulse)
h. Patient with tachyarrhythmia but is stable, they are treated with medication.

3. Transcutaneous pacing
a. Consistently delivering electrical energy (in mA) to cause cardiac contraction.
b. Analgesia/sedation should be used.
c. It is only a temporary measure until a permanent solution is put in place. Permanent
solution means pacemaker implanted or transvenous pacemaker.
d. Need a separate 3 leads cable to monitor patient’s rhythm as the original electrodes
are used to consistently delivering pacing shocks.
e. Indication (bradyarrhythmia and symptomatic)
i. All the heart block (1st degree, 2nd degree, 3rd degree)
f. Steps in using transcutaneous pacing:
i. Attach pads with 3 lead
ii. Turn on into pacer mode
iii. Set the rate of pacing
iv. Increase output (mA) until capture is seen. Capture means:
1. Spike (deep negative wave) followed by a wide QRS complex
v. Increase each time by 5mA until reaches maximum at 140mA
 vi. Once capture is seen, slowly decrease output (mA) until a minimum level
for capture (known as mA threshold)
vii. Then increase the mA by 10% more of the mA threshold
viii. Set the mode into asynchronous or demand
1. Asynchronous mode deliver pacing shock at specific rate we set,
regardless of patient’s rhythm
2. Demand mode deliver pacing shock when patient’s heart rate is
below set rate on the machine

Delivery of shock
1. How to put the pad?
a. Anterior posterior
i. One put at anterior of low chest, in front of heart
ii. Another put behind the heart, between the scapula
b. Anterior apex
i. One put at the right upper chest, below clavicle
ii. Another put at left side below pectoral muscle/breast