Synchronized cardioversion | ACLS-Algorithms.com

Comments

  1. Zach says

    If you sync cardioversion Pulsing V-Tach and the patient is still in pulsing V-Tach, what is the next action you do after you deliver your second sync cardioversion dose and the patient is still in pulsing V-tach? Do you skip the first does of epi and go straight to Amioderone?

    • ACLS says

      You would be using the tachycardia with a pulse algorithm. Epinephrine is not given in this algorithm. Amiodarone would be the next option.

      Kind regards,
      Jeff

  2. Noor Makadma says

    Thanks for the very informative review.
    Can you please explain briefly what is the difference between monophasic and biphasic synchronisation ?
    Thanks in advance.

    • ACLS says

      Monophasic uses direct current which passes in one direction from one paddle to the next. Biphasic defibrillation, alternates the direction of the pulses and requires less energy for the same effect.
      Most biphasic defibrillators have a first shock success rate that is significantly higher than monophasic defibrillators. Roughly 20% higher success with biphasic. Here is a study
      Biphasic defibrillation significantly decreases the energy level necessary for successful defibrillation, decreasing the risk of burns and myocardial damage.

      Kind regards,
      Jeff

  3. Kathleen Braico MD says

    I am not sure I would be able to tell atrial flutter with hi capture rate (with ventricular response >180) from SVT on an EKG, can you help me tell the difference? Thanks

    • ACLS says

      Differentiating between atrial flutter with a rapid ventricular response and SVT can be challenging. The easiest and safest method for differentiating when the patient is stable would be to perform vagal maneuvers or administer adenosine per the AHA ACLS protocol.

      When you slow the rate with vagaries maneuvers or adenosine, you will see the flutter waves if you are dealing with atrial flutter.

      Without slowing and simply looking at the ekg, differentiation may often be impossible.

      Kind regards, Jeff

  4. mike says

    Hey there Jeff, in regards to syncing v tach. In the midst of a cardiac arrest setting, should a pulse check be completed on seeing VT on the monitor? What are the odds of achieving ROSC with VT? Is there evidence that pulsing VT in the midst of a code is a life sustaining, perfusing rhythm, that can achieve ROSC? There has been some debate here on performing a pulse check upon seeing VT to sync the monitor if it does happen to be pulsing in the middle of a code, or rather continue with a pulseless arrest algorithm, thus limiting pulse checks to any other organized rhythms that are NOT in fact shockable. Hope this is clear enough to provide an answer.

    Thanks!

    • ACLS says

      There is ongoing debate about this issue. Typically, ventricular tachycardia will not produce an effective perfusing rhythm and so it is the opinion of most that a pulse check is not necessary if a rhythm change from a non-perfusing rhythm is ventricular tachycardia.

      The debate really comes down to the determination of whether to provide an unsynchronized shock or a synchronized shock.

      As a rule, Ventricular tachycardia does not produce an effective perfusing rhythm and unsynchronized cardioversion is the method of choice for treating pulseless ventricular tachycardia. In my professional opinion, it would therefore be prudent to provide a rapid unsynchronized shock. If an AED were being used, the AED would instruct to provide a shock and therefore it seems logical that this would be the preferred method of choice and the pulse check would not be necessary. Kind regards, Jeff

  5. Nikita says

    In monomorphic and polymorphic vt which one should be treated with synchronised cardioversion? And why?

    • ACLS says

      Monomorphic ventricular tachycardia is treated with synchronized cardioversion. Synchronization avoids the delivery of a LOW ENERGY shock during cardiac repolarization (t-wave). If the shock occurs on the t-wave (during repolarization), there is a high likelihood that the shock can precipitate VF (Ventricular Fibrillation).

      Kind regards,
      Jeff

  6. Ray says

    Dear Jeff,

    Repeating my original question as I didn’t get an answer. I will be more explicit – I contend that the only reason we still treat VT with a pulse & pulseless VT differently is that we have not changed our practice to fit in with modern defibrillators. The old defib machines (particularly the monophasic ones) used to take so long to charge up and then sync that there was too much of a delay in treating pulseless VT. That is not the case anymore.

    It is well established that delivering a shock on the T-wave rather than the R-wave can cause VF. This is the basis of synchronised shocks.

    Why should our ability to detect a pulse have an impact on the electrical treatment of VT?

    Modern defib machines are quick to charge, have sync buttons and we can monitor the ecg through the pads. Why not use synchronisation for all patients with VT, regardless of whether a pulse can be detected?

    All the best

    Ray

    • ACLS says

      I agree that our ability to detect a pulse should not impact the electrical treatment of VT. That being said, both synchronize cardioversion and defibrillation have a fairly high success rate for conversion of VT. I have not seen a good rationale for continuing with no synchronization for pulseless VT.

      In these situations, a physician does have the discretion to attempt synchronization. Healthcare providers are allowed to tailor their actions using their discretion for the best outcome.

      Kind regards,
      Jeff

  7. Ignacy says

    Once you deliver unsynch shock to VT is there a chance for conversion to VF? If so why should we create a risk of VF not trying to synchronize the shock in any VT? Pulse has nothing to do, I presume, as you may feel the pulse while I can not… Is the patient pulseless?

    • Jeff with admin. says

      The research and clinical data from the past 70 years indicates that the most effective intervention for pulseless ventricular tachycardia is and unsynchronized shock. This is what should be performed if no pulse is felt and a patient is unresponsive. After the unsynchronized shock, chest compressions should begin immediately. If VF is present when a rhythm check is performed after 2 min. of chest compressions you would perform an unsynchronized shocker the treatment of the VF.

      Healthcare providers may tailor the interventions to best suit the scenario that is before them, and if a physician thought that synchronized cardioversion should be attempted in a pulseless state he would need to provide justification his reason. Let the weight of research and clinical data guide your interventions.

      Kind regards,
      Jeff

  8. Pumlani says

    When heart rate is 230 PT is unstable pulseless on peripheral, central you cannot feel properly, must I deffibrilate with unsychronised or achy?

    • Jeff with admin. says

      If the patient is unresponsive and pulseless with a narrow complex tachycardia you would use the right branch of the cardiac arrest algorithm. Neither defibrillation North synchronize cardioversion would be indicated. (it would be very important to determine the cause in this situation.)

      If the patient is unresponsive and pulseless with a wide complex tachycardia you would use the left branch of the cardiac arrest algorithm. Defibrillation would be indicated.

      If the patient is not unresponsive, but unstable with a narrow complex tachycardia you would perform synchronized cardioversion.

      Kind regards,
      Jeff

    • Jeff with admin. says

      There are a couple of reasons for this.

      First, pulseless ventricular tachycardia degenerates fairly rapidly into ventricular fibrillation and there is a high likelihood that synchronization will not be possible with pulseless ventricular tachycardia. In light of this, defibrillation is recommended over attempting synchronized cardioversion when the ventricular tachycardia is pulseless.

      Second, the body of literature that is available indicates that defibrillation is quite effective for pulseless ventricular tachycardia, and therefore, defibrillation is recommended for pulseless ventricular tachycardia.

      Kind regards,
      Jeff

      • Ray says

        Dear Jeff,

        It is well established that delivering a shock on the T-wave rather than the R-wave can cause VF. This is the basis of synchronised shocks.

        Why should our ability to detect a pulse have an impact on the electrical treatment of VT?

        Modern defib machines are quick to charge, have sync buttons and we can monitor the ecg through the pads. Why not use synchronisation for all patients with VT, regardless of whether a pulse can be detected?

        All the best

        Ray

  9. emergency_training_center says

    Thankyou for a very informative and well written , easy to read site. I have been doing this fo rover 20 years and its great to see a different way of looking at rythms, and am glad I have still learnt a few things. Keep up the great work

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