What is your approach during DCCV if you have an obese patient with atrial fibrillation refractory to up to 3, 360 J shocks?   

The main question is are we sure there is a cardioversion and not just a quick recurrence. If it is a recurrence, would use AAD like amio. If not capturing myocardium, would use another vector or use 2 synced shocks (and 360 biphasic if you have that).

To some degree it depends on what happened with the first three shocks, (I would have applied pressure to shorten the AP diameter for the second and/or third).   If the patient converted but it didn't stick, I would consider AAD loading followed by a repeat procedure. If the patient did not a...

Agree with the above comments. I also would consider the addition of ibutilide with mag. The "dueling defibrillator" technique works, but the more important question is if sinus rhythm in such obese patients will be maintained long term. How about rate control, and weight loss (by whatever means -GL...

I had better luck with biphasic.

Try anterolateral pad position.

I open with AP placement of the pads, so if the patient doesn't cardiovert with 360J x 2: If the patient converts but it doesn't stick, consider AED and revisiting a cardioversion. If they don't convert then I will place a second set of pads in the sternoapical position to shock with 720 Joules ...

No point in doing repeated cardioversions. These patients simply do not hold NSR. Choose a different strategy.

We’re fortunate to have a 360 biphasic device which generally works for obese patients. If not working the first time, I apply pressure on the second attempt. If there is conversion and reversion, I would stop at 3 and add AED for a couple of weeks then try DCCV again.  If no conversion ...