Electrical Therapy Reference

Indications:

• Hemodynamically unstable atrial fibrillation or flutter
• Unstable SVT not responding to vagal maneuvers or adenosine
• Stable monomorphic ventricular tachycardia with pulse failing pharmacotherapy

Typical Energy Settings (Biphasic):

• Atrial fibrillation: 120–200 J initial
• Atrial flutter / SVT: 50–100 J initial (often terminates at lower energies)
• Monomorphic VT: 100 J initial; escalate if unsuccessful
• Always follow manufacturer and institutional protocol for specific device settings

Key Nursing Considerations:

• Confirm SYNC mode is ON before each shock — many devices revert to unsynchronized mode after delivery
• Ensure IV access and have emergency medications, airway equipment, and resuscitation team available
• Administer procedural sedation per order for conscious patients (midazolam, propofol, etomidate)
• Announce “Clear” and visually confirm all personnel are away before discharge
• Hold discharge button until shock fires — device waits for R wave synchronization (brief delay)
• Anticoagulation: atrial fibrillation of unknown or > 48-hour duration requires anticoagulation or ruling out intracardiac thrombus before elective cardioversion

Indications:

• Pulseless ventricular fibrillation (VF)
• Pulseless ventricular tachycardia (pVT)

Energy Settings (Biphasic — AHA ACLS):

• Initial shock: 120–200 J (device-specific; use manufacturer's recommended dose)
• Subsequent shocks: same or escalating energy per device protocol
• Monophasic devices (older): 360 J for all shocks
• AED: device selects appropriate energy automatically

Key Nursing Considerations:

• Minimize CPR interruptions — < 10-second pause for rhythm check and shock delivery
• Confirm SYNC mode is OFF for defibrillation (asynchronous delivery required)
• Resume CPR immediately after shock — do not wait to check rhythm first
• Reassess rhythm and pulse after 2 minutes of CPR
• Remove supplemental oxygen from immediate area before shocking
• Clear all personnel — call “Clear” and visually confirm before each shock

Indications:

• Symptomatic bradycardia unresponsive to atropine (HR < 60 with hypotension, altered consciousness, chest pain, or signs of shock)
• Third-degree (complete) AV block with hemodynamic compromise
• High-degree Mobitz II block with symptoms
• Bridge therapy while awaiting transvenous pacemaker insertion

Setup and Settings:

• Place anterior pad over the left precordium (V3–V4 position) and posterior pad on the left posterior thorax or right upper back
• Set pacing rate: typically 60–80 bpm for bradycardia; follow provider order
• Set pacing mode: Demand (fires only when patient rate drops below set rate) is preferred in conscious patients
• Increase current (mA) from lowest setting until capture is confirmed — each pacing spike followed by a QRS complex
• Typical capture current: 40–80 mA (varies by patient)

Key Nursing Considerations:

• Confirm capture: Each pacing spike must be followed by a wide QRS complex. Electrical capture on the monitor does not guarantee mechanical capture — always palpate a pulse
• Manage pain and anxiety: TCP is painful — administer analgesia (fentanyl) and sedation (midazolam) per order in conscious patients
• Assess hemodynamic response: blood pressure and mental status should improve with effective pacing
• Document pacing rate, current (mA), capture threshold, and patient response
• TCP is a temporary bridge — prepare patient and family for transvenous pacing or permanent pacemaker