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Introduction ⬇

Synchronized cardioversion delivers an electrical charge to the myocardium that’s timed with the QRS complex. This charge causes immediate depolarization, interrupting reentry circuits and allowing the sinoatrial node to resume control.1 Synchronizing the electrical charge with the QRS complex prevents delivery during the relative refractory period of the cardiac cycle, when a shock could lead to ventricular fibrillation.2

Synchronized cardioversion is the treatment of choice for such arrhythmias as unstable supraventricular tachycardia, unstable atrial flutter, unstable atrial fibrillation, or unstable monomorphic ventricular tachycardia with a pulse that doesn’t respond to vagal maneuvers (Valsalva maneuver or carotid sinus massage) or drug therapy. The procedure can be elective or urgent depending on the patient’s tolerance of the arrhythmia.1 For example, if the patient is hemodynamically stable, the procedure is often elective, allowing for time to assess the patient’s cardiac and metabolic status to determine whether a reversible cause exists that would resolve with treatment. If the patient is unstable (for example, has altered mental status, hypotension, or chest pain or is in shock), immediate cardioversion is necessary.1

Contraindications to synchronized cardioversion include tachycardia related to digoxin toxicity, sinus tachycardia, and multifocal atrial tachycardia. Atrial fibrillation increases the risk of stroke; therefore, cardioversion is contraindicated in patients with atrial fibrillation who aren’t receiving anticoagulation, unless transesophageal imaging rules out thrombus formation.2,3 Anticoagulant therapy is recommended for at least 3 weeks before cardioversion and for 4 weeks after cardioversion to normal sinus rhythm in patients with atrial fibrillation for 48 hours or longer or when the duration of atrial fibrillation is unknown.4

Practitioners using synchronized cardioversion should adhere to the American Heart Association guidelines.1

Equipment ⬆ ⬇

Equipment

Cardioverter-defibrillator ▪ self-adhesive cardioversion-defibrillation pads or anterior, posterior, or transverse paddles and conductive gel pads ▪ cardiac monitor with recording system ▪ disposable pregelled electrodes ▪ 12-lead electrocardiogram (ECG) machine ▪ oxygen administration equipment ▪ suction equipment ▪ emergency equipment (code cart with artificial airway and intubation supplies, handheld resuscitation bag and mask, emergency cardiac medications, and emergency pacing equipment) ▪ automatic blood pressure device ▪ pulse oximeter and probe ▪ stethoscope ▪ disinfectant pad ▪ facility-approved disinfectant ▪ Optional: prescribed sedation or analgesia, IV catheter insertion equipment, disposable-head clippers, prescribed cardiac medications, gloves, gown, mask with face shield, mask, goggles.

Preparation of Equipment ⬆ ⬇

Preparation of equipment

Make sure that the cardioverter-defibrillator pads or paddles are connected to the cardioverter-defibrillator, and that the cardioverter-defibrillator battery is adequately charged or plugged into a wall outlet. Have emergency equipment and suction and intubation equipment readily available at the patient’s bedside and make sure that it’s functioning properly.

Inspect all equipment and supplies. If a product is expired, is defective, or has compromised integrity, remove it from patient use, label it as expired or defective, and report the expiration or defect as directed by your facility.

Implementation ⬆ ⬇

Implementation
  • Verify the practitioner’s orders. Check to see whether cardiac medications have been prescribed for administration before the procedure.
  • Check the patient’s medical record for recent serum potassium and magnesium levels and arterial blood gas results. Also check the patients most recent digoxin level, as ordered. Electrolyte imbalances, acid-base disturbances, and digoxin toxicity increase the risk of arrhythmias.5 Notify the practitioner of critical test results within your facility’s established time frame so that the patient can be treated promptly.6
  • If required by your facility, confirm that informed consent has been obtained and that the signed consent form is in the patient’s medical record.5,7,8,9,10
  • Gather and prepare the necessary equipment and supplies.
  • Conduct a preprocedural verification to make sure that all relevant documentation, related information, and equipment are available and correctly identified to the patients identifiers.11
  • Perform hand hygiene.12,13,14,15,16,17
  • Confirm the patient’s identity using at least two patient identifiers.18
  • Provide privacy.19,20,21,22
  • Explain the procedure to the patient and family (if appropriate) according to their communication and learning needs to increase their understanding, allay their fears, and enhance cooperation.23
  • If the patient’s condition allows, have the patient maintain nothing-by-mouth status before the procedure; if nonemergent, minimum fasting recommendations include 2 hours for clear liquids, 6 hours or more for a light meal, and 8 hours or more for fried or fatty foods or meat.24
  • Raise the patient’s bed to waist level before providing care to prevent caregiver back strain.25
  • Perform hand hygiene.12,13,14,15,16,17
  • Ensure that the patient is attached to a cardiac monitor, pulse oximeter, and automatic blood pressure device. Make sure that the alarm limits on each medical device are set appropriately for the patient’s current condition, and that the alarms are turned on, functioning properly, and audible to staff.26,27,28,29
  • Obtain the patient’s vital signs and oxygen saturation level using pulse oximetry, and assess neurologic, cardiovascular, and respiratory status to determine whether immediate cardioversion is necessary.5
  • If the patient has inadequate oxygenation or shows signs of labored breathing, notify the practitioner and administer supplemental oxygen, as prescribed.1
  • Perform hand hygiene.12,13,14,15,16,17
  • Put on gloves and other personal protective equipment, as needed, to comply with standard precautions.30,31,32
  • Make sure that the patient has patent IV access. Insert an IV catheter as needed. (See the “IV catheter insertion and removal” procedure.)
  • Obtain a 12-lead ECG to better define the patients heart rhythm and to serve as a baseline for comparison. Don’t delay immediate cardioversion to obtain the ECG if the patient is unstable.1,5
  • Administer cardiac medications, if prescribed, following safe medication administration practices.33,34,35,36
  • Remove all metal objects from the patient, because metal conducts electricity and could cause burns during cardioversion.5
  • If the patient has dentures, a partial plate, or another oral prosthesis, determine whether the device supports airway patency or has the potential to obstruct it. Remove the device if it increases the risk of airway obstruction.5
  • Make sure that the patient is in a dry environment and that the patient’s chest is dry, because if the rescuer or patient comes in contact with water, a conductor of electricity, the rescuer can receive a shock and the patient can receive a skin burn.5
  • Position the patient supine to provide access to the patients chest during the procedure.5
  • If necessary, clip hair from the patient’s chest to make sure that the electrodes adhere properly.5
  • Remove transdermal medication patches from the patient’s chest, if present, or make sure that the cardioversion-defibrillation pads or paddles don’t touch the patches during the procedure to prevent a chest burn during cardioversion.5
  • If the patient isn’t already receiving supplemental oxygen, consider preoxygenation before cardioversion to promote myocardial oxygenation and to reduce the risk of cerebral and cardiac complications.5
  • A specially trained health care provider will administer moderate sedation or anesthesia if time allows and the patient’s condition permits.1
  • Monitor the patient’s heart rate, blood pressure, and respiratory rate to promptly detect changes in the patients condition and, subsequently, prevent treatment delays.
  • Conduct a time-out before starting the procedure, if the patient’s condition allows, to perform a final assessment ensuring that the correct patient, site, positioning, and procedure are identified and, as applicable, that all relevant information and necessary equipment are available.37
  • Turn on the cardioverter-defibrillator.5
  • Apply the electrodes to the appropriate locations on the patient’s chest (if not already present) and attach the monitoring lead wires on the cardioverter-defibrillator, because the device must be able to sense the R wave to provide synchronized cardioversion.5 Ensure that there is an adequate cardiac rhythm tracing.5
  • Apply the self-adhesive cardioversion-defibrillation pads according to the manufacturer’s directions. If you’re using anterolateral placement, place one pad at the heart’s apex just left of the nipple at the midaxillary line and the other pad just below the right clavicle to the right of the sternum. Alternatively, remove the paddles from the machine. Place the paddles and the conductive gel pads using anterolateral placement.5 Alternative pad positions, including anteroposterior, anterior–left infrascapular, and anterior–right infrascapular, can also be used depending on the patient’s individual characteristics.
  • To decrease transthoracic resistance, avoid placing the self-adhesive cardioversion-defibrillation pads or paddles over a female patient’s breast.5
  • Turn on the ECG recording device to obtain a continuous printout to document the patients response to cardioversion.5
  • Push the SYNC button to synchronize the machine with the patients QRS complex. Assess the cardioverter-defibrillator waveform and make sure that a synchronized marker appears with the QRS complex and that its location is consistent from beat to beat. Also, make sure that the SYNC button flashes with each of the patient’s QRS complexes; listen for audible beeps. If necessary, adjust the R wave gain until synchronization occurs. Synchronization with the patients QRS complex prevents the random discharge of electrical charges, which may cause ventricular fibrillation.5
  • Set the energy level to the prescribed dose. Advanced cardiac life support protocols call for an initial shock of 50 to 100 joules for a patient with unstable supraventricular tachycardia, 120 to 200 joules for a patient with atrial fibrillation, 50 to 100 joules for a patient with atrial flutter, and 100 joules for a patient with monomorphic ventricular tachycardia with a pulse.1
  • Make sure that everyone stands clear from contact with the patient and the bed to prevent conduction of electrical current to health care workers.5
  • Charge the cardioverter-defibrillator.
  • Disconnect the oxygen source before cardioversion to decrease the risk of combustion in the presence of electrical current.5
  • Confirm that all personnel are clear of the patient and the bed.
  • If you’re using cardioversion-defibrillation pads, push and hold the discharge button until the energy is delivered. Alternatively, if you’re using paddles, apply firm pressure (approximately 25 to 30 lb [11.3 to 13.6 kg])38 to each paddle against the patient’s chest wall, and push and hold the discharge button until the energy is discharged. Keep in mind that the machine has to synchronize the discharge with the QRS complex.

NURSING ALERT Don’t touch the bed, the patient, or any equipment attached to the patient while cardioversion is being administered to prevent transfer of the electrical current to caregivers.

  • Assess the patient’s cardiac rhythm on the monitor.
  • If the arrhythmia fails to convert after the initial shock, repeat the procedure. Increase the energy dose in a stepwise fashion or as instructed by the practitioner.1 Check that the synchronization mode is active after each cardioversion attempt, because many defibrillators automatically default to the unsynchronized mode.
  • When the patient’s rhythm converts, monitor vital signs, oxygen saturation level, and cardiovascular, neurologic, and respiratory status to evaluate patient response to the procedure.5 Reconnect the patient to the oxygen source, if appropriate.
  • Turn off the continuous ECG recording device.
  • Obtain a follow-up 12-lead ECG, as ordered.
  • Inspect the patient’s chest for electrical burns. Treat burns as needed and prescribed.5
  • Screen and assess for the patient’s pain using facility-defined criteria that are consistent with the patient’s age, condition, and ability to understand.39
  • Treat the patient’s pain, as needed and ordered, using nonpharmacologic, pharmacologic, or a combination of approaches. Base the treatment plan on evidence-based practices and the patient’s clinical condition, past medical history, and pain management goals.39
  • Return the bed to the lowest position to prevent falls and maintain patient safety.40
  • Discard used supplies in the appropriate receptacles.30
  • Remove and discard your gloves or other personal protective equipment, if worn.30
  • Perform hand hygiene.12,13,14,15,16,17
  • Reassess and respond to the patient’s pain by evaluating the response to treatment and progress toward pain management goals. Assess for adverse reactions and risk factors for adverse events that may result from treatment.39
  • Clean and disinfect your stethoscope using a disinfectant pad.41,42
  • Perform hand hygiene.12,13,14,15,16,17
  • Put on gloves, if needed.
  • Clean and disinfect the cardioverter-defibrillator according to the manufacturer’s instructions to prevent the spread of infection and to make sure that its ready for its next use.5,41,42
  • Perform hand hygiene.12,13,14,15,16,17
  • Document the procedure.43,44,45,46

Special Considerations ⬆ ⬇

Special considerations
  • Synchronization to the R wave prevents the discharge of electrical energy randomly on the T wave, which can lead to ventricular tachycardia or ventricular fibrillation. If ventricular fibrillation does occur, turn off the synchronization and defibrillate according to the defibrillation procedure.5
  • If the patient has a permanent pacemaker or an implantable cardioverter-defibrillator, don’t place the pads or paddles over the device, because doing so can impair current flow to the patients heart and damage the device or cause it to malfunction.5
  • The Joint Commission issued a sentinel event alert concerning medical device alarm safety, because alarm-related events are associated with permanent loss of function or death. Among the contributing factors are improper alarm settings, alarm settings turned off inappropriately, and alarm signals not audible to staff. Make sure that alarm limits are set appropriately and that alarms are turned on, functioning properly, and audible to staff. Follow facility guidelines for preventing alarm fatigue.26

Complications ⬆ ⬇

Complications

Common complications following synchronized cardioversion are altered level of consciousness, cerebral emboli, skin burns, respiratory depression, and arrhythmias.5

Documentation ⬆ ⬇

Documentation

Document the date and time that the procedure was performed, including the voltage delivered with each attempt, the patient’s heart rhythm (preprocedure and postprocedure ECG rhythm strips), medications you administered, and the patient’s tolerance of the procedure. Note any emergency interventions that the patient required and the patient’s response to those interventions. Record the patient’s vital signs and your other assessment findings. Document teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up teaching.

References ⬆

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    Application to healthy patients undergoing elective procedures

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    Standardizing use of physiological monitors and decreasing nuisance alarms

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    Accreditation requirements for acute care hospitals

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    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
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    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
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    Accreditation requirements for acute care hospitals

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  46. DNV GL-Healthcare USA, Inc. (2020). MR.2.SR.1. NIAHO accreditation requirements, interpretive guidelines and surveyor guidancerevision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)