Hrev_master [Emergency Care Journal 2016; 12:5685] [page 23] Electrical cardioversion performed by emergency physicians in the emergency department Andrea Bellone, Massimiliano Etteri, Kirsten Sielert Emergency Department, Sant’Anna Hospital, San Fermo della Battaglia, Italy Dear Editor, We would like to discuss about electrical car- dioversion in emergency department (ED) patients with acute atrial fibrillation (AF). AF is the most common type of arrhythmia in adults, accounting for about one third of hospitalizations for arrhythmia.1 The incidence of new onset of atrial fibrillation increases with age and is about 5% in people over 65 years old and it rises to around 10% in the population over 80 years old.2 Diagnosis and appropriate management of this increasingly prevalent heart arrhythmia are criti- cal because complications due to heart failure and stroke may result in high levels of functional debility or death.3 For those patients who do not have a clear indication for hospitalization (such as hemodynamic instability or significant heart failure), ED or observational unit cardioversion of new onset AF (less than 48 h duration) are effec- tive and safe. Direct current (DC) cardioversion is a commonly performed procedure with a high success rate and a low complication rate when performed by experienced clinicians.4-6 Currently, in Italy, the electrical cardioversion (EC) is per- formed in the majority of EDs by the cardiologists along with the anesthetists without any clear rationale. On the opposite, we suggest that emer- gency physicians should always manage autonomously electrical cardioversion for at least four reasons: i) sedoanalgesia; ii) safety; iii) waste of time; iv) the role of emergency physi- cians. As for sedoanalgesia, it is important that the patient is not fully conscious during the pro- cedure, as it can be painful and distressing. The drug used to make patients unaware of the proce- dure should rapidly achieve the desired level of sedation, should wear off quickly and should not cause cardiovascular or respiratory side effects. Anesthesiologists use different drugs (propofol, midazolam, fentanyl) with a single bolus dose normally used for the sedoanalgesia in the oper- ating room, usually causing rapid deep sedoanal- gesia with side effects such as low blood pressure or respiratory depression.7 Instead, we used a lower dosage of sedative and opioids medica- ments in order to avoid side-effects like respirato- ry center depression and/or arterial hypotension: patients were submitted to a oxygen therapy in order to obtain SpO2 about 100% for 2 min before starting with bolus of Fentanyl 1 mcg/kg. Then, patients were sedated with midazolam 0.05 mg/kg, then boluses 2 mg every 2 min (max 15 mg) until patient was non-responsive (level 6 of Ramsay sedation score levels).8 Regarding safety, synchronized electrical car- dioversion performed in patients with acute onset of AF was safe and effective as shown by previous randomized studies. The technique performed by the cardiologist is the same that emergency physicians perform: the plates are placed on the chest in the anteroposterior and perform a DC- shock of 100 joules (if not effectively repeat up to a maximum of 3 times at increasing energy). The arrhythmic risk post procedure does not exist, the embolic risk is the same as cardioversion per- formed pharmacologically.9,10 The third reason mentioned above is waste of time. First, it makes no sense to keep the patient in for more than four hours’ to perform the same procedure. Second, cardiologists and anesthesiologists are often busy so they tend to delay the procedure. Hence, the mean total time patients spent in the ED before treatment was lower in patients treated by emer- gency physicians compared with patients treated by cardiologists plus anesthetists. This meant improving patients’ turn-over by reducing the time spent in ED waiting for the procedure acti- vation. In our study there was a difference of 240 min between the two groups.10 The fourth reason for emergency physicians to autonomously man- age electrical cardioversion is their role. Indeed, while many cardiologists are trained in the administration of moderate sedation, they are not used to manage complications. Conversely, seda- tion may also be administered by an anesthesiol- ogist who can immediately assist in the manage- ment of respiratory complications. However, this is rare and transitory with no need to intubation easily manageable by a trained emergency doctor. The tradeoff for such involvement is often added costs and scheduling complexity. In our experi- ence, we are used to perform in autonomy the procedure of EC since 2003. We did not meet any adverse event such as death or need of endotra- cheal intubation during all this time. After the first two years, cardiologists and anesthesiolo- gists were fully satisfied of our strategy. Moreover, the first step of patients’ clinical evaluation is in ED, where our aim is to do well and quick with few adverse events. References 1. Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study. J Am Med Assoc 2001;285:2370-5. 2. Sudlow M, Thompson B, Thwaites B, et al. Prevalence of atrial fibrillation and eligi- bility for anticoagulants in the community. Lancet 1998;352:1167-71. 3. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the manage- ment 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 2014; 64:2246-80. 4. Dell’Orfano JT, Kramer RK, Naccarelli GV. Cost-effective strategies in the acute man- agement of atrial fibrillation. Curr Opin Cardiol 2000;15:23. 5. Kim MH, Conlon B, Ebinger M, et al. Clinical outcomes and costs associated with a first episode of uncomplicated atrial fibrillation presenting to the emergency room. Am J Cardiol 2001;88:7-74. 6. Michael JA, Stiell IG, Agarwal S, Mandavia DP. Cardioversion of paroxysmal atrial fib- rillation in the emergency department. Ann Emerg Med 1999;33:379. 7. Lewis SR, Nicholson A, Reed SS, et al. Anaesthetic and sedative agents used for electrical cardioversion. Cochrane Database Syst Rev 2015;3:CD010824. 8. Chernik DA, Gillings D, Laine H, et al. Validity and reliability of the observers assessment of alertness sedation scale- study with intravenous midazolam. J Clin Psychopharmacol 1990;10:244-51. 9. Kerber RE. Indications and techniques of electrical defibrillation and cardioversion. In: Fuster V, Walsh RA, Harrington RA, eds. Hurst’s the heart. 13th ed. New York, NY: McGraw-Hill; 2011. pp 1088-93. 10. Bellone A, Etteri M, Vettorello M, et al. Electrical cardioversion in patients with acute atrial fibrillation in Emergency Departments: a prospective randomized trial. Emerg Med J 2012;29:188-91. Emergency Care Journal 2016; volume 12:5685 Correspondence: Andrea Bellone, Emergency Department, Sant’Anna Hospital, via Ravona 1, 22020 San Fermo della Battaglia, Italy. Tel. +39.02.48703668 - Fax: +39.031.5855853. E-mail: andreabellone@libero.it Key words: Electrical cardioversion; Emergency physicians; Emergency department. Received for publication: 14 December 2015. Revision received: 8 February 2016. Accepted for publication: 9 February 2016. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright A. Bellone et al., 2016 Licensee PAGEPress, Italy Emergency Care Journal 2016; 12:5685 doi:10.4081/ecj.2016.5685 Non co mmerc ial us e o nly