B.External defibrillation with the ICD/pacemaker in situ

•If the ICD is currently delivering shock (as evidenced by external muscle contraction similar to external defibrillation), allow 30–60 s for the ICD to complete the treatment cycle.

•Place the pads at least 8 cm away from the ICD/pacemaker, but placing the paddle should not be delayed in defibrillation.

•It is not desirable to place the pads or paddles directly over the device.

C.Pregnancy

Cardioversion and defibrillation have been performed in all trimesters of pregnancy. It has been found to have no obvious adverse fetal effects or premature labor. Fetal heart rhythm monitoring is recommended.

D.Pediatric age group

•The lowest energy dose for effective defibrillation is not known. The lower and upper limits to safe defibrillation are not known for infants and children.

•Biphasic shocks appear to be at least as effective as monophasic shocks and are less harmful than monophasic shocks.

•It is recommended to use an initial dose of 2–4 J/kg, and for refractory VF, increase the dose to 4 J/kg. Subsequent energy levels should be at least 4 J/ kg, and higher energy levels may be considered, but not to exceed 10 J/kg or the adult maximum dose.

•For infants (<1 year of age), a manual defibrillator is preferred. If a manual defibrillator is not available, an AED with pediatric attenuation is desirable. If neither is available, an AED without a dose attenuator may be used.

E.Drowning

•Removal of the patient from water and thorough wiping of the chest and the patient is prerequisite before attempting electrical therapy.

Suggested Reading

1.Link MS, Atkins DL, Passman RS, Halperin HR, Samson RA, White RD, Cudnik MT, Berg MD, Kudenchuk PJ, Kerber RE. Electrical therapies. Automated external defibrillators, defibrillation, cardioversion, and pacing. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(Suppl 3):S706–19.

A recent recommendation and comprehensive review of AHA.

2.Irwin RS, Rippe JM. Irwin and Rippe’s intensive care medicine. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 73–9.

Detailed procedure and indication with pictorial depiction for electrode placement.

3.Field JM, Gonzales L, Hazinski, Rupie J, Talley R, Elling B, et al. Advanced cardiac life support. Dallas: American Heart Association; 2006. p. 34–8.

AHA guidelines for management of tachyarrhythmias.

4.Field JM, Gonzales L, Hazinski, Rupie J, Talley R, Elling B, et al. Advanced cardiac life support. Dallas: American Heart Association; 2006. p. 90–5.

AHA guidelines for management of tachyarrhythmias.

5.Fink MP, Abraham E, Vincent JL, Kochanek PM. Textbook of critical care. 5th ed. Philadelphia: Elsevier Sauders; 2005.

This gives a comprehensive description of cardioversion.