Cardioversion in ICU


  • cardioversion is the delivery of electrical energy that is synchronised with the QRS complex in an attempt to revert an abnormal rhythm
  • defibrillation is the non-synchronised delivery of electrical energy and is used in unstable rhythms (pulseless VT or VF)
  • benefits and risks need to weighed
  • may be monophasic or biphasic
  • low to high energy (150-200J biphasic) can be used


  • high success rates in SVT and atrial flutter
  • less successful in AF, especially with: large atria, long duration, precipitating cause still present


  • quick, easy, available and familiar
  • repeatable
  • correction of underlying rhythm
  • high success rates in SVT and atrial flutter
  • improved LVEF, cardiac output and haemodynamics
  • improved exercise tolerance
  • decreased hospitalisation
  • improved quality of life
  • avoid side effects of anti-arrhythmic drugs


  • failure (less successful on AF, with large atria, if chronic or precipitant still present)
  • requirement for sedation and analgesia (potential for awareness)
  • hypotension
  • myocardial damage (ST changes and myocardial stunning short term)
  • arrhythmia (SVT, non-sustained VT)
  • conduction abnormalities (bradycardia, heart block); may require temporary pacing
  • embolisation (AF > 48 hrs without anticoagulation; can exclude by performing TOE)
  • damage to permanent pacemaker if present
  • skin burns
  • pulmonary oedema
  • spark/fire risk
  • electrocution of staff risk
CCC 700 6

Critical Care


Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

One comment

  1. An anteroposterior paddle placement may help achieve success with cardioversion in some difficult situations.

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