Intensive Care Nursing – Skills Checklist

Synchronized Cardioversion

Purpose:
Cardioversion is the application of electricity to attempt to terminate a still perfusing
rhythm to allow a normal sinus rhythm to restart. The electrical current is delivered in a
synchronized manner to be discharged in the peak of R wave and not to hit T wave in the cardiac
cycle, because an electric discharge during this phase may cause ventricular fibrillation.

Indications:
 Atrial fibrillation
 Atrial flutter
 Supraventricular tachycardia
 Ventricular tachycardia with a pulse

Equipment:
 Cardioverter-defibrillator (biphasic preferred over monophasic)
 ECG Machine
 Interface material (disposable conducive gel pads, electrode gels and pastes)
 Resuscitative Equipment including cardiac medications

Implementation of the Procedure/Steps with Rationale

Steps/Procedure Rationale
1. If the procedure is elective, it is During sedation or the procedure, the patient
advisable to have the patient nothing may vomit and aspirate if the stomach is full.
by mouth 12 hours before Anticoagulant is used to prevent
cardioversion and treated with thromboembolism
anticoagulant. To minimize anxiety and fear; to practice
a. Reassure the patient and make sure patient safety.
that informed consent has been
obtained.
Low potassium level may precipitate post-
b. Make sure the patient has not been
shock dysrhythmias.
taking digoxin and that the serum
potassium level is normal
2. Make sure an IV line is secure. An I.V. line is necessary for the
administration of emergency medications and
sedation.
3. Obtain a 12 lead ECG before and after An ECG is taken to ensure that the patient has
cardioversion with the ECG machine. not had a recent myocardial infarction or
The ECG machine wires are best left converted back to sinus rhythm prior to the
on the patient, because the ECG cardioversion.
printout is of much better quality than
that of a monitor. The fact is
especially important when trying to
dissect complicated dysrhythmias.
4. Allow the patient to receive oxygen Patients should be fully preoxygenated for at
before and after cardioversion. least 3 min prior to cardioversion. This buys
valuable time if unanticipated airway
difficulty or apnea occurs. It is also needed if
arrhythmias occur after cardioversion.
Remove oxygen from the immediate A spark from the paddles can ignite the
area during the delivery of shock. oxygen and can cause an explosion.
5. Place the paddles in one of two
positions:
a. Anterolateral Position: Apply one Anterolateral placement of the pads when
electrode just to the right of the upper conducting the initial shock appears to be
sternum below the clavicle and the more effective when utilizing biphasic
other electrode just to the left of the defibrillators.
cardiac apex or left nipple.
b. Anteroposterior position: The anterior
A single paddle is placed to the right of the
paddle is held with pressure on the
sternum, as above, and the other paddle is
middle of the sternum while the
placed between the tip of the left scapula and
patient lies on the posterior paddle
the spine. Conductive gel or pre-gelled pads
under the left infrascapular region.
are commonly used to ensure good contact,
because the skin can conduct away a
significant portion of the current. Even under
ideal circumstances, only 10-30% of the total
current reaches the heart.
6. Determine if the machine’s To ensure the equipment is working and to
synchronization mechanism is have a smooth and quick flow procedure.
working before applying the paddles.
If the electrical discharge hits the T wave,
a. The discharge should hit near the peak ventricular fibrillation may occur.
of the R wave. -Synchronization in the early part of the QRS
b. The R wave must usually be of complex avoids energy delivery near the apex
substantial height; if it is not, adjust of the T wave in the surface
the gain (sensitivity) or change the electrocardiogram (ECG), which coincides
 lead. On many other machines, the R with a vulnerable period for induction of
wave must be upright before there is ventricular fibrillation. The peak of the T
synchronization. You should see a wave represents the terminal portion of the
spike or dot highlighted on the R refractory state when adjacent heart fibers are
waves. in differing states of repolarization.
-Synchronization to an R or S wave prevents
the delivery of a shock during the vulnerable
period of cardiac repolarization when
ventricular fibrillation can be induced.
7. If using paste, apply it to the entire To avoid arcing and skin burns.
paddle surface, but make sure there is
no excess around the edges of the
paddles.
To avoid arcing and skin burns.
a. The paste should be rubbed into the
skin thoroughly
b. Make sure paddles are clean because Surface material will interfere with electricity
surface material will interfere with flow.
flow of electricity
c. Apply firm pressure to the paddle. To avoid arcing and skin burns.
8. If using gel pads, place pads where the Excessive energy may cause unnecessary
paddles are to be positioned. discomfort to the patient and create
unnecessary electrical hazard.
9. Set the dial for desired electrical The recommended energy levels used to
energy expected to convert the perform synchronized cardioversion vary
dysrhythmia. It may range between 50 from 50 to 200 joules. The safest and easiest
to 200 joules. recommendation is to start at the lowest
energy level (50 joules), and if the shock is
unsuccessful, double the amount of energy
used. In a refractory case, you will be at 200
joules after just three shocks.
10. A short acting sedative, and possibly This helps produce amnesia concerning the
an analgesic, may be given by the cardioversion.
anesthesiologist or to be ordered by
the doctor.
11. After the patient is in a light sleep, and To avoid touching patient and receiving
no one is touching the bed, the shock.
healthcare provider will discharge the
cardioverter. Charge the paddles.
Once paddles are charged, give the
command for personnel to stand clear
of the patient and bed. “Shockin’ on 3
 & oxygen out; 1 I’m clear, 2 you’re
clear, 3 everyone is clear!”
12. Monitor the ECG after cardioversion The patient may revert to previous
occurs. BP should be monitored and dysrhythmias after conversion
recorded every 15 minutes until the
preshock blood pressure is reached.
13. Document the procedure and your To promote patient safety, ensure continuity
reassessment findings after the of care, foster communication amongst
cardioversion. rotating providers, and safeguard providers
from malpractice.
Score:

References:
 Hudak, et al. Critical Care Nursing: A Holistic Approach
 Schumacher & Chernecky. Critical Care and Emergency Nursing
 Lippincott. Manual of Nursing Practice
 Emergency Nurses Association of the Philippines. BLS & ACLS Handbook