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Defibrillation and cardioversion are used for rapid termination of a tachyarrhythmia (a fast abnormal rhythm originating either in the atrium or ventricle) that is unresponsive to baseline treatment or is causing the patient to have cardiovascular compromise (inadequate systemic perfusion). Baseline treatment consists of correction of a metabolic problem, use of vagal maneuvers (bag of ice water over the eyes and face of the infant without obstructing the airway, putting pressure on closed eyelids), use of medications (adenosine, digoxin, propranolol, verapamil, amiodarone, procainamide, lidocaine, or magnesium sulfate), or transesophageal pacing. It is best to try these maneuvers or medical therapy if intravenous access is available. Neonatal arrhythmias are rare, and the majority of them can be treated with these initial measures.


Current defibrillators are capable of delivering two modes of shock: synchronized and unsynchronized. Synchronized shocks are lower dose and used for cardioversion. Unsynchronized shocks are higher dose and used for defibrillation. Pediatric cardiology consultation is recommended for all infants with a tachyarrhythmia.


  1. Indications

      1. Cardioversion. Synchronized cardioversion is used for:

          1. Unstable patients with tachyarrhythmias who have a perfusing rhythm but evidence of poor perfusion, heart failure, or hypotension (signs of cardiovascular compromise). Examples of tachyarrhythmias are:

              1. Tachycardia (supraventricular tachycardia [SVT] or ventricular tachycardia [VT]) with a pulse and poor perfusion.

              1. Supraventricular tachycardia with shock and no vascular access.

              1. Atrial flutter with shock.

              1. Atrial fibrillation with shock (very rare in infants).

          1. Elective cardioversion in infants with stable SVT, VT, or atrial flutter (good tissue perfusion and pulses) unresponsive to other treatments. This is always done under the close supervision of a pediatric cardiologist. Sedation and a 12-lead electrocardiogram are recommended prior to cardioversion.

      1. Defibrillation (asynchronized) is used in pulseless arrest with a shockable rhythm (VT and ventricular fibrillation). It is used in between cardiopulmonary resuscitation (CPR) and not used in asystole or pulseless electrical activity. The most common cause of a ventricular arrhythmia in a neonate is electrolyte imbalance. Defibrillation will not stop the arrhythmia in these patients. Defibrillation is the most effective treatment for:

          1. Ventricular fibrillation.

          1. Pulseless ventricular tachycardia.

  2. Equipment

      1. External standard defibrillator (manual or semiautomated) and two paddles of the correct sizes with conductive pads. For infants, use the smallest size. It is important to be familiar with the institution's equipment because there are many different types and models of machines. Pediatric-capable automatic external defibrillators have been approved by the U.S. Food and Drug Administration but are not readily available yet.

      1. Other equipment includes a heart rate monitor, airway equipment, resuscitation medications, antiarrhythmic medications, and equipment used in basic and advanced life support.

  3. Procedure

      1. Adequate sedation (may not be possible in emergency situations) and preoxygenation are essential. Emergency airway equipment should be readily available. Continuous heart monitoring should be done during the procedure.

      1. Wipe any cream or soap off the chest.

      1. Place the paddles firmly on the chest wall. To prevent skin burns, be sure the conductive pad totally covers the paddle and that the skin is not ...

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