1. History and examination.
2. Check for features of digoxin toxicity eg nausea, visual disturbance, confusion.
3. Ensure digoxin omitted on the day of cardioversion.
4. Ensure patient fasted for at least 4 hours.
5. Ensure patient has been successfully anti-coagulated for a minimum of three weeks, either by checking recent INR results or confirming with patient that they have been compliant with their NOAC.

1. 12 lead ECG. Ensure patient still in rhythm requiring cardioversion.
   
   
2. Take blood for electrolytes and INR if on warfarin. Ensure INR = 2.0 or greater than 2.0, K = 3.8 or greater than 3.8 and less than or equal to 5.0.
   
   
3. Obtain IV access.
   
   
4. Consent patient.
   
   
5. Remove nitrate patch.
   
   
6. Discuss with the patient’s consultant on the day of cardioversion before cancelling procedure.
   
   
7. On call anaesthetist – bleep 23933 to arrange a suitable time.

1. Ensure good cardiac monitoring equipment is working with a technically good display of rhythm and good R wave for sensing.
   
   
2. Check resuscitation and pacing equipment.
   
   
3. Set BIPHASIC defibrillator to SYNCHRONISED setting.
   
   
4. Place defibrillator contact pads.
   
   
5. Anaesthetise patient.
   
   
6. Defibrillate shock series:

           atrial flutter 30, 50,100,150 AP joules ENSURING STICKY PADS WELL APPLIED

           atrial fibrillation 100,150,150,150 AP ENSURING STICKY PADS WELL APPLIED

      After series of above shocks if unsuccessful consider AP shock 150 Joules

      If VF develops set defibrillator to DESYNCHRONISED, defibrillate as per ALS guidelines.

1. Post-cardioversion 12 lead ECG (whatever the final rhythm)
   
   
2. Monitor recovery for as long as is necessary (at discretion of the anaesthetist)
   
   
3. If well at 4 hours – fit for discharge home.
   
   
4. In most patients if cardioversion successful stop digoxin, but continue any beta-blocker and amiodarone unless patient is very bradycardic once in sinus rhythm - always continue anticoagulation.
   
   
5. Follow up in one month for review of medication.