Care During Special Procedure:

Cardioversion and Defibrillator

Presented by:
Sirapa Maharjan
Cardio version

 Cardio version is most often an elective procedure for

dysrhythmias caused by reentry, involves the use of a
synchronized biphasic direct current(DC) electrical
countershock that depolarizes all the myocardial cells
simultaneously, allowing the SA node to resume the
pacemaker role.
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 The electrical discharge is synchronized with or triggered

by client’s QRS complex for avoidance of accidental
discharge during repolarization phase when the ventricle is
vulnerable to development of ventricular fibrillation.
 A QRS complex must be present for successful conversion
of dysrhythmia.
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 Cardio version is used to treat atrial fibrillation, atrial

flutter and supraventricular tachycardia that is resistant to
meditation, and is also used in ventricular tachycardia in
an unstable client(hypotensive or dyspneic, may be
experiencing chest pain, or may have evidence of heart
failure, MI or ischemia.
 Analgesia or sedation may be provided before electrical
shock.
Care Before Cardio version

• Identify the type of dysrhythmias present.

• Client must sign an informed consent.
• The client and family must receive a full explanation of
the cardio version procedure.
• Client should be in fasting state with normal electrolyte
balance.
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• For those client receiving digoxin, a therapeutic drug level

must be present. Digitalis toxicity may predispose the
client to ventricular dysrhythmias during cardioversion.
• An INR should be between 2.0 and 3.0 after 4 to 6 weeks
of receiving anticoagulation therapy( or may be normal if
transesophageal ECG precedes the cardioversion).
• Start an IV line for medication delivery.
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• Client is pre medicated with a rapid, short-acting sedative.

• Oxygen is administered before cardio version, and
discontinued if oxygenation saturation is within normal
limits.
Care During Cardio version

 The physician performs following steps and they are

repeated with each increase in joules:
• Sets the biphasic machine within a range of 50-200J (more
or less, depending on underlying impedances)
• Turn the synchronizer switch to “ON” to deliver the shock
during QRS complex, not on the down-slope of T wave.
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• Calls for all health care personnel to stand back from the
bed.
• While standing back from bed depresses and holds button
on paddle until shock is delivered.
• Reassess cardiac rhythm, rate, BP, pulse oximetry and
client’s airway after every shock delivererd.
Care After Cardio version

• Assess ECG, pulse, BP, respiratory status after procedure.

• Monitor clients ECG rhythm and vital signs continuously
for atleast 2 hours, carefully assess for rhythm changes and
complications.
• Client’s airway is protected until sedation lightens.
• With a good response and no complications, patient may be
discharged later that day when fully awake and able to eat.
 Defibrillation

 The use of defibrillation delivers an electrical biphasic

current of preset voltage to heart through paddles or
special patches placed on chest walls.
 This current causes the entire myocardium to depolarize
completely at the moment of shock, thus producing
transient asystole and allowing heart’s intrinsic pacemaker
to regain control.
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 The amount of energy required to produce this effect is

determined largely by client’s transthoracic impedance or
resistance to current flow.
 If the client has an permanent pacemaker or an internal
cardiac defibrillator, place the paddles or patches atleast 5
inches away from the generator to avoid damaging it.
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 If temporary pacing system is in use, disconnect the

pacing lead from the pulse generator immediately before
defibrillation and reconnect it after the shock.
Care Before Defibrillation

 Immediately before defibrillation, assess the client’s

responsiveness and do the following:
• If the client is not responsive, call for immediate
assistance (or activate the EMS system).
• Call for the defibrillator and crash cart.
• Assess client’s airway, breathing and circulation (ABCs).
Open the airway. Look, listen and feel.
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• If the client is not breathing, give two slow breaths.

• Assess the client’s circulation, if no pulse is present, start
CPR.
• Perform CPR until defibrillation is in place.
• Check the ECG to verify the presence of ventricular
fibrillation or pulseless ventricular tachycardia; confirm in
two leads.
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• Check leads for any loose connections.

• Remove any nitroglycerine patches.
Care During Defibrillation

• To ensure safe defibrillation, people who perform

defibrillation must always announce when they are about
to give shock.
• The phrase “1. I’m clear. 2. You are clear. 3. All clear.” is
recommended. Because electricity is carried along metal
devices and client, all personnel, including clinician
administering the shock, must stand back from bed.
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• Open chest defibrillation occurs when electrical currently

is applied directly to the heart.
Care After Defibrillation

• Clinician immediately assess the ECG and pulse after

defibrillation.
• If first counter shock is unsuccessful, immediate
defibrillation must be performed again at higher energy
joule (300 and 360 joule).
• Monophasic defibrillation may be applied up to 3 times
(200J, 300J, 360J) if needed persistent ventricular
fibrillation or pulseless Ventricular tachycardia.
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• If three defibrillations have not been successful, CPR should

be continued.
• After successful defibrillations, continuous ECG monitoring
is required.
• Client’s vital signs and neurologic status must also be
continuously assessed.
• Continue to monitor for pacemaker or ABCD malfunction
for atleast next 24 hours.
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• Record following points while documenting outcome of

defibrillation:
1. Pre-procedure rhythm.
2. Times and voltage of shock delivered.
3. Post-defibrillation rhythm pattern.
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4. Names, times of administration and doses of administered

medication.
5. Other hemodynamic data available before, during and
after defibrillation.
References: