[Music] thank you in synchronized cardioversion the defibrillator is synchronized with the QRS complex so that a shock cannot be given during cardiac repolarization which can trigger a ventricular fibrillation the procedure can be done urgently or electively [Music] if time permits clean and dry the patient's skin shave or clip any hair to ensure good contact between the defibrillation pads or paddles and the skin you can do synchronized cardioversion using adhesive electrode pads or paddles you may use anterior placement for both pads and paddles place the anterior pad just to the right of the sternum below the clavicle at the second or third intercostal Space Place the lateral pad below the left nipple just medial to the anterior axillary line of the fifth or sixth intercostal space in patients with a large chest cavity or overlying breast tissue the anterior posterior placement may be more useful only adhesive pads should be used not paddles place the anterior pad just to the left of the sternum in the third or fourth intercostal space the posterior pad to the left of the spine and the back below the left scapula in this position the heart is sandwiched between the anterior and the posterior pad attach the defibrillation cables from the pads to the defibrillator if using paddles you must Place conducting material between the paddles in the chest to avoid skin burns use either a conducting gel sheet or liquid gel that you place on the paddles because the procedure is frightening and painful give IV analgesia and sedation if time and patient condition permit turn the machine on ensure the monitor is displaying a clear Rhythm so that it may synchronize if the rhythm is unclear switch to a different lead on the monitor press the sync button this activates synchronization which prevents a shock from being delivered during cardiac repolarization phase which can trigger ventricular fibrillation look at the monitor to confirm synchronization which is usually indicated by a brightening of the peak of each QRS complex select the desired energy level recommendations vary but usually for a biphasic machine start at about 100 to 120 joules for atrial fibrillation 50 joules for other supraventricular tachycardia and 100 joules from anamorphic ventricular tachycardia for monophasic machine select 200 joules for atrial fibrillation and 100 joules per other supraventricular tachycardia or for monomorphic ventricular tachycardia press the charge button when the machine is charged loudly State all clear and look to ensure that no Personnel are touching the patient or the patient's bed if using pads deliver the shock by pressing the button on the machine if using paddles press down firmly on the chest wall and push buttons on both paddles at the same time check the monitor to determine whether the patient is converted to sinus rhythm if not an additional shock may be given for additional shocks increase the energy delivered to 200 joules for a biphasic machine and 360 joules for a monophasic machine foreign