NURSING PATIENT CARE POLICY & PROCEDURE
October 27, 2017
Nursing Manual (Red)
Policy #: 1.38AP
Title: Elective Direct Current (DC)
Cardioversion (Adult & Pediatric)
To provide guidance for performing external electrical conversion of tachydysrhythmias.
A. Elective cardioversion should only be performed in an appropriately monitored
environment. This can include General Care and Intermediate Care units with
telemetry capability, Intensive Care units, Catheterization Lab area or
Echocardiography Lab with the appropriate medical, nursing and respiratory therapy
(if needed) support.
B. A credentialed provider in moderate sedation must be present during the entire
procedure in the patient’s room during the cardioversion procedure and for any
procedural sedation according to UW Health Clinical Policies 2.3.29, Adult
Procedural Sedation and 2.3.30, Pediatric Procedural Sedation.
C. The administration of the shock during this procedure should be performed by a
registered nurse (RN) certified in Advanced Cardiac Life Support (ACLS) or
Pediatric Advanced Life Support (PALS) or a provider.
A. Defibrillator with self-adhesive hands-free pads and cable or paddles
B. Resuscitation bag with mask
C. Oxygen delivery supplies
D. Oxygen flowmeter
E. Yankauer suction and tubing
F. Suction canister and suction regulator
G. Code Blue Cart available with Advanced Cardiac Life Support/Pediatric Advanced
Life Support (ACLS/PALS) medications and emergency pacing equipment
H. Pulse oximetry
I. Non-invasive blood pressure cuff or arterial line
J. Appropriate documentation forms based on patient’s location for procedure
K. Intravenous sedative and analgesic agents as ordered
L. Normal saline flushes
M. Follow UW Health Clinical Policies 2.3.29, Adult Procedural Sedation and 2.3.30,
Pediatric Procedural Sedation regarding reversal agents for this procedure.
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1. Ascertain that provider has obtained consent and ordered the procedure. Refer
to UW Health Clinical Policy 2.3.32, Operative, Invasive & Other Procedures.
2. Provider will determine if anesthesia is needed for cardioversion. Attending
provider credentialed in moderate sedation is required as outlined in UW
Health Clinical Policies 2.3.29 and 2.3.30, Adult Procedural Sedation and
Pediatric Procedural Sedation.
3. The Registered Nurse (RN) should notify pharmacist and respiratory therapist
of planned time of cardioversion as needed for the procedure.
4. Inform the patient and/or caregiver of the plan for the procedure. Complete
and document procedural teaching prior to sedation.
5. Refer to UW Health Clinical Policy 2.3.29, Adult Procedural Sedation
Appendix B and 2.3.30, Pediatric Procedural Sedation Appendix E for
information about NPO status.
6. Complete pre-procedure patient assessment including: cardiac rhythm with
interval measurements, patency of intravenous line, vital signs, respiratory
function and neurologic status and document according to UW Health Clinical
Policies 2.3.29, Adult Procedural Sedation and 2.3.30 Pediatric Procedural
Sedation. Verify with physician the placement of hands-free pads (sternum
and apex vs. anterior and posterior). Anterior-posterior pad placement is
a. Anterior and posterior: parasternal and left infrascapular. NOTE: The
hands-free pads for the Zoll E Series® defibrillators contain three (3)
ECG electrodes within them. Transcutaneous pacing can be done with
these defibrillators without attaching additional ECG electrodes and
the ECG monitoring cable from the defibrillator.
b. Sternum and apex: sternal pad should be placed just to the right of the
upper sternal border below the clavicle and apical patch to the left of
the nipple with center of patch on the midaxillary line (place under
breast tissue). NOTE: The hands-free adhesive pads for the Zoll E
Series® defibrillators contain three (3) electrodes for cardiac rhythm
monitoring. When you place both pads on the anterior chest, you must
also attach additional ECG electrodes and the ECG cable from the
defibrillator in order for the machine to display the ECG waveform
during transcutaneous pacing.
7. Clip chest hair if needed. Apply pads to a clean and dry chest. Ensure pads are
in full contact with the skin. Do not place the pads directly over a permanent
pacemaker or implanted cardiac defibrillator. Do not place pads over
medication patches (see also #11 below regarding medication patches).
8. Remove any metal (piercings, rings, watches, necklaces, etc.) and medication
patches from the patient as these can cause burns.
9. Secure patient belongings according to UW Health Clinical Policy 2.1.22
Patient Belongings and Valuables.
10. Administer oxygen as ordered by provider.
1. Immediately prior to procedure, perform the Universal Protocol (Time-out) to
verify correct patient, procedure, equipment, and position according to UW
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Health Clinical Policy 2.3.32, Operative, Invasive and Other Procedures.
Document the completion of the Universal Protocol.
2. Administer sedation and analgesia as ordered by provider.
3. Document vital signs and level of sedation according to sedation policies
during the procedure.
4. Turn Zoll defibrillator to “Defib” mode.
5. Activate "sync" function and verify synchronization.
a. Look for white * over the QRS to verify in “sync” mode.
6. The physician or designee will:
a. Select the energy and make sure synchronization is active on the
b. Assess and monitor cardiac rhythm on the defibrillator. Select a lead
with large R waves on the QRS complex.
c. Verify the resuscitation bag with mask and all staff members have
been moved away from patient just prior to pushing “shock” button.
d. Perform cardioversion according to ACLS/PALS guidelines.
e. After each shock, reselect sync if continuing with cardioversion and
f. If the defibrillator is charged, but the shock is not required, discharge
the defibrillator according to the manufacturer’s recommendation.
1. Follow procedures for completing recovery for moderate sedation as outlined
in UW Health Clinical Policies 2.3.29, Adult Procedural Sedation and 2.3.30
Pediatric Procedural Sedation..
2. Complete and document post-procedure patient teaching after patient
completes Phase II recovery.
3. Obtain 12 lead ECG as ordered.
4. Remove pads as appropriate and assess for skin burns. Discontinue ECG and
pulse oximetry unless ordered to continue.
5. Clean the defibrillator and cables with hospital disinfectant and return to
location on unit.
V. UW HEALTH CROSS REFERENCES
A. UW Health Clinical Policy 2.1.22 Patient Belongings and Valuables
B. UW Health Clinical Policy 2.3.29 Adult Procedural Sedation
C. UW Health Clinical Policy 2.3.30 Pediatric Procedural Sedation
D. UW Health Clinical Policy 2.3.32, Operative, Invasive & Other Procedures
E. Provider Privilege Lists (found on U-Connect)
A. Zoll E Series® Operator’s Guide, June 2014. Available online at:
B. American Heart Association and American Academy of Pediatrics, Pediatric
Advanced Life Support Provider Manual (2011).
C. American Heart Association (2015). American Heart Association guidelines update
for cardiopulmonary resuscitation and emergency cardiovascular care.
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D. Page, R.L., Joglar, J.A., Caldwell, M.A., Calkins, H., et al. (2015). 2015
ACC/AHA/HRS guideline for the management of adult patients with supraventricular
E. Hambach, C. (2011). Cardioversion. In D. Lynn-McHale Wiegand (Ed.), AACN
Procedure Manual for Critical Care (319-328). St. Louis, MO: Elsevier Saunders.
F. Sucu, M., Vedat, D., & Ozer, O. (2009). Electrical cardioversion. Annals of Saudi
Medicine, 29(3), 201-206.
G. Gibson, T. (2008). A practical guide to external direct current cardioversion. Nursing
Standard, 22(37), 45-50.
H. January, C. T., et al (2014). 2014 AHA/ACC/HRS guideline for the management of
patients with atrial fibrillation: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines and the
Heart Rhythm Society. Circulation, 129.
VII. REVIEWED BY
Clinical Nurse Specialist, Cardiac Surgery and Cardiopulmonary Transplant
Clinical Nurse Specialist, Cardiology
Clinical Nurse Specialist, Critical Care
Clinical Nurse Specialist, Emergency Department
Clinical Nurse Specialist, Neonatal Intensive Care Unit
Clinical Nurse Specialist, Pediatric Universal Care Unit
Clinical Nurse Specialist, Thoracic Surgery
Nursing Patient Care Policy and Procedure Committee, October 2017
Beth Houlahan, DNP, RN, CENP
Senior Vice President, Chief Nurse Executive