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Paddle position in emergency cardioversion of atrial fibrillation
  1. Katherine Potier de la Morandiere, Specialist Registrar,
  2. Henry Morriss, Specialist Registrar
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK;


    A short cut review was carried out to establish whether the antero-lateral or antero-posterior paddle position is best at reverting acute atrial fibrillation to sinus rhythm. Altogether 954 papers were found using the reported search, of which five presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

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    Report by Katherine Potier de la Morandiere,Specialist RegistrarChecked by Henry Morriss, Specialist Registrar

    Clinical scenario

    A 60 year old man presents to the emergency department with a history of sudden onset palpitations. This is associated with some mild chest discomfort and breathlessness. On examination he is in atrial fibrillation at a rate of 180, and has a blood pressure of 95/60. He looks pale and sweaty. You feel he needs urgent electrical cardioversion and wonder whether the paddle position used will affect your success rate.

    Three part question

    In [a patient with new onset AF who needs urgent electrical cardioversion] is [antero-posterior better than antero-lateral paddle position] at [reverting the patient to sinus rhythm]?

    Search strategy

    Medline 1966–09/04 using the OVID interface and Cochrane database 2004 Issue 3, using NeLH link. Medline: ([exp atrial fibrillation OR] AND [exp electric countershock OR electrode OR electrical OR DC]) LIMIT to human, English language AND adults. Cochrane: [Paddle] next [Position].

    Search outcome

    Altogether 954 papers were found in Medline of which five were relevant to the question (see table 2). No additional papers were found in the Cochrane library.

    Table 2


    AF is a common problem encountered in the emergency department. These papers shows that some good quality research has been done on cardioversion but not in the emergency setting. The five best papers show conflicting results regarding the positioning of paddles in elective cardioversion, the most recent showing no difference between the two positions. In our clinical scenario the AP position may be difficult to achieve in such an unwell, shocked patient.


    There is little evidence to suggest that paddle position significantly influences the success of cardioversion emergency department patients with AF.

    Report by Katherine Potier de la Morandiere,Specialist RegistrarChecked by Henry Morriss, Specialist Registrar