# can anyone tell me what the joules setting are for cardioversion



## emtssave (Nov 10, 2015)

we use a biphasic lifepak 15 monitor and we are starting to learn about sync pacing and defib .I wanted to know what joules to sync vtach with a pulse ,afib ,a flutter,and svt ?I tried to search online and found that svt you start and 50 joules and go up to 300? and vtach is 120 ? im sorry for the noob questions but I really would like to be ahead of the class =)  any input would be greatly appreciated thanks


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## chaz90 (Nov 10, 2015)

Completely depends on local protocols, provider preference, and manufacturer recommendations in some cases.

We use 100 J, 200, 300, and 360 J for all rhythms if we get to the point of cardioversion.


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## emtssave (Nov 10, 2015)

For school purpose is what I mean or standard .for example what would you start for a vtach with a pulse and unstable ?afib what would you start and aflutter ?I know for svt we start at 50 and if it does not change we go to 100 and 200


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## chaz90 (Nov 10, 2015)

Right. I don't know what your preferred school settings are. There is no defined "standard."

As mentioned, if I were presented with an unstable wide complex tachycardia with a pulse right now, I would use escalating joule settings, starting at 100 J. 

If I were presented with unstable atrial fibrillation or atrial flutter, I would also start at 100 J and work my way up.


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## emtssave (Nov 10, 2015)

How far can you go if you don't cause a change in rhythm? My only issues are knowing what to start at and if I don't change the rhythm how much higher can I go .let's say I sync vtach at 100 than 200 than 300 and still no change will you resort to amio?150mg even if pt is unstable ?we're being taught if pt is stable to use drugs. Vs unstable you sync


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## emtssave (Nov 10, 2015)

And sorry for the noob questions but just want to know


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## onrope (Nov 10, 2015)

emtssave said:


> How far can you go if you don't cause a change in rhythm? My only issues are knowing what to start at and if I don't change the rhythm how much higher can I go .let's say I sync vtach at 100 than 200 than 300 and still no change will you resort to amio?150mg even if pt is unstable ?we're being taught if pt is stable to use drugs. Vs unstable you sync



Sounds like you're on the right track with stable being the medication route and unstable being cardioversion. You would not bolus an anti dysrhythmic if cardioversion failed unless your protocols are that way but most protocols follow ACLS. I use zolls at work which are biphasic and local protocol for cardioversion is (70j, 120j, 150j, 200j) stacked. If the patient does not convert with the max dose contact BH for further orders.


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## emtssave (Nov 11, 2015)

ok so let me get this out of the way lol if I get an unstable pt with afib ,we use cash for determing if pt is unstable ,chest pain,altered mental,shortness of breath,and hypotensive !if I sync 120 ,200,300,360 and still no change would you use Cardizem at .25mg/kg and second dose .35mg/kg? or is this wrong ?


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## SandpitMedic (Nov 11, 2015)

Dude... Are you like looking for some specific test answer or something? What do you not understand about* local protocols* differing among each other?

Stop trying to "get ahead of the class." You're not good at it. Just follow along in your class and learn with everyone else.


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## emtssave (Nov 11, 2015)

who died and made you god cool guy ? how would any of my question be asking for a test answer or question ? its called a forum for a reason ! no one said I was good its called asking to learn ! and to answer you protocols I am just asking to see if my thinking is on the right path and has anyone ever taught you that if you have nothing good to say don't say it at all , you must be one of those medics who thinks they know it all


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## chaz90 (Nov 11, 2015)

@SandpitMedic is completely right here @emtssave. Be civil, or this thread will be closed. You seem to be looking for some kind of specific answer that we cannot give you.

I'll try one last time to make this as clear as possible. There is no single "right" answer, which is often the case in medicine. 

Instability is defined by your local protocols and a complete clinical picture, so if the patient is unstable by whatever methods you use, carry on with cardioversion. My idea of unstable might vary a little bit from yours, but they'll both probably include pretty much the same patients. 

Your energy settings are completely determined by your protocols. You mentioned 120-200-300-360, which is fine. The next step, be it continued cardioversion attempts or medication, is also determined by your local protocols. Personally, I have never seen a rhythm fail to convert one way or the other after 4x cardioversion attempts. I'm sure it happens occasionally, but unstable patients in a potentially lethal arrhythmia are either going to get worse and become pulseless, or convert to something more conducive to life. By definition, "unstable" rhythms aren't going to last forever. 

Is that somewhat clear? We can't give you the absolutes you seem to want.


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## emtssave (Nov 11, 2015)

makes sense and thank you,however, Stop trying to "get ahead of the class." You're not good at it. that's not civil at all !


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## jwk (Nov 11, 2015)

Lighten up Francis.

Local is local.  End of story.  Cardiologists each have their own way of doing things as well, depending on the exact rhythm, history, etc.  I give sedation for cardioversions all the time.  Most of our guys use 100-120 joules for STABLE A-Fib, but some are as low as 50, and others go right to 200.  For unstable rhythms, personally I would hit em hard right up front.


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## Doczilla (Nov 12, 2015)

I rearranged "CASH" to "CRAP" because it's a) funny and b) more retainable for the young students 

C- chest pain 
R- respiratory distress 
A - altered mentail status 
P - piss poor perfusion 

If they look like crap...


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## Underoath87 (Nov 14, 2015)

ACLS recommendations for first shock:
Narrow regular 50-100 j 
Narrow irregular 120-200 j
wide regular 100 j
Wide irregular gets defibrillated.

Each subsequent shock should be equal to or greater in joules than the previous.


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## Gurby (Nov 15, 2015)

Doczilla said:


> I rearranged "CASH" to "CRAP" because it's a) funny and b) *more retainable for the young students *
> 
> C- chest pain
> R- respiratory distress
> ...



And those of us young at mind... Definitely going to use this!


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## jlw (Jan 2, 2016)

Doczilla said:


> I rearranged "CASH" to "CRAP" because it's a) funny and b) more retainable for the young students
> 
> C- chest pain
> R- respiratory distress
> ...



I'm also going to steal this, excellent pneumonic.

I'll echo whats being said, if they look like CRAP and you need to juice 'em, you really can't go wrong with 100J as your first one IMHO.


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## hogwiley (Jan 5, 2016)

Doesn't your class have a text book and an ACLS book? The recommended joules you'd use for each type of tachycardia are right there in the ACLS al gore rhythm
 under tachycardias.

Amazing concept I know, reading the book before something is covered in class.


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## Underoath87 (Jan 5, 2016)

hogwiley said:


> Doesn't your class have a text book and an ACLS book? The recommended joules you'd use for each type of tachycardia are right there in the ACLS *al gore rhythm*
> under tachycardias.
> 
> Amazing concept I know, reading the book before something is covered in class.



Now that would make for a funny/awkward music video...


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## hogwiley (Jan 5, 2016)

Underoath87 said:


> Now that would make for a funny/awkward music video...


Would make a good name for some emo vegan alternative indie band.


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## Summit (Jan 5, 2016)

It depends on the manufacturer recommendations, your protocol, and/or the cardiologist.

If you can't remember, 100J is good for almost anything as a start.


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## Akulahawk (Jan 6, 2016)

I would suggest the following setting...









In case anyone wonders, I'm actually kidding... If biphasic, IIRC it's 100J, 200J, then 300J for defib.


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## RocketMedic (Jan 6, 2016)

1-2 joules per kilogram isn't a bad place to start either, fwiw.


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## patzyboi (Jan 6, 2016)

What we are learning are:

Narrow, regular: 50J-100J
Narrow, irregular: 120J-200J
Wide, regular: 100J
Wide, irregular: Unsynchronized cardioversion

But alot of people's  been talking about the 100,200,300 rule


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