unstable tachycardia hany el-zahaby, md, anesthesiologist
TRANSCRIPT
Objectives
By the end of this talk we should be able to describe or demonstrate:
1- 1ry and 2ry ABCD surveys 2- Identify unstable from stable
tachycardia3- Identify the rhythm of tachycardia4- Determine if tachycardia is producing
hemodynamic instability or the instability is producing tachycardia
Objectives (cont.)
5- Follow the algorithms for tachycardia and cardioversion
6- Operation of a defibrillator/monitor to perform both defibrillation and synchronized cardioversion
7- Provide post-cardioversion care
Case Scenario
52-year-old man presented to ED complaining of shortness of breath, palpitations, dizziness and severe chest pain. He is pale and sweaty. His Pulse rate is 178 and blood pressure is 81/50
Action
Check responsiveness and apply primary and secondary ABCD surveys
If not in cardiac arrest or VF and tachycardia is observed, order oxygen-IV-monitor-fluids
Identify the rhythm
Prepare for synchronized cardioversion
Prepare oxygen saturation monitor, suction device, IV line, intubation equipment, call the code team and explain to the patient if awake
Premedicate Sedatives and anesthetics: Midazolam (0.01-0.05mg/kg), Diazepam (0.05-0.1mg/kg), Ketamine(1-2 mg/kg), Etomidate (0.2-0.5 mg/kg), Thiopentone (3-5 mg/kg), Propofol (1-2 mg/kg)
Steps for synchronized cardioversion Turn on defibrillator Attach monitor leads to the patient Ensure proper display of the
patient’s rhythm (lead II) Press ‘sync’ control button Look for markers on R waves If no markers, adjust monitor gain
until markers on each R
Select appropriate energy level for type of arrhythmia
Apply gel to paddles and position it on patient (sternum and apex)
Announce to team-members “Charging defibrillators-stand clear”
Press charge button on apex paddle (right hand)
When the defibrillator is charged state firmly: “I am going to shock on three. One, I am clear. Two, you are clear. Three, everybody is clear”
Apply 25 Ib pressure on both paddles Press the “discharge” buttons
simultaneously
Check the monitor, if tachycardia persists, increase the joules according to the algorithm
Reset to “sync” mode after each synchronized cardioversion
If VF occurs, switch to “defibrillation” mode and follow the VF/Pulseless VT algorithm
Energy levels: Standard sequence is 100 J→ 200 J
→ 300 J → 360 J Exceptions:
Atrial flutter 50 J→ 100 J→ 200 J→ 300 J→ 360 J
Polymorphic VT 200 J→ 300 J → 360 J
Post-conversion care: Closely monitor vital signs Continue oxygen-IV-monitor-fluids Search for a cause for this
tachycardia and treat it If VF occurs, recognize need to
defibrillate Documentation
Conclusion
Always start with ABCD Unstable means either patient or
tachycardia Unstable tachycardia is treated
with synchronized cardioversion Steps for cardioversion should be
strictly followed