Tachycardia With a Pulse Algorithm

Question 1

Treatment of tachycardia is is typically considered appropriate over what rate?

Answer 1

Typically >= 150 bpm

Question 2

First consideration in treating tachycardia

Answer 2

Identify and treat underlying causes

1. Airway and breathing adequate
2. O2 if hypoxic O2 sat%
3. BP (fluid bolus?)
4. 12 Lead rhythm
5. IV

Question 3

What is considered unstable tachycardia?

Answer 3

Rate greater than 150 associated with one of the following:

1. Hypotension
2. Acute AMS
3. Shock
4. CPx
5. Acute Heart Failure

Question 4

Treatment for unstable tachycardia?

Answer 4

Synchronized Cardioversion

1. Consider sedation
2. If narrow complex, consider adenosine

Question 5

Treatment for stable tachycardia with wide QRS?

Answer 5

1. IV
2. 12 lead
3. Consider adenosine only if monomorphic and regular
4. Consider antiarrhythmic infusion

Question 6

Treatment for stable tachycardia with narrow QRS?

Answer 6

1. IV
2. 12 lead
3. Vagal maneuvers
4. Adenosine (if regular)
5. Beta blocker or calcium channel blocker

Question 7

Adenosine dosage for tachycardia

Answer 7

Print strip during drug administration
1st dose - 6mg rapid IV push followed immediately with 20cc NS flush
2nd dose - 12mg rapid IV push followed immediately by 20cc NS flush
(give in larger bore left AC)

Question 8

Antiarrhythmic infusions for tachycardia

Answer 8

Amiodarone:
1st dose - 150mg/10 min, repeat if needed and VT reoccurs
follow with maintenance infusion of 1mg/min for 6hrs
Procainamide:
20-50mg/min until arrhythmia is suppressed, hypotension ensues, QRS duration increases by 50%, or max dose of 17mg/kg is achieved
Follow with maintenance infusion of 1-4 mg/min. (Avoid if prolonged QT or CHF)

Question 9

Synchronized Cardioversion Indications

Answer 9

1. Unstable tachycardia >150

a. Consider a brief trial of medications for specific arrhythmias

Question 10

Synchronized Cardioversion Precautions/Contraindications

Answer 10

1. If critical go immediately to unsynchronized shocks
2. Usually not needed if HR<150
3. Avoid O2 flowing across chest. (consider discontinuing momentarily during shock
4. Reactivate sync required for each attempt
5. Prepare to defibrillate if sync causes VF
6. May need to make sure pt is also connected to 4 lead in order to achieve sync

Question 11

Synchronized Cardioversion Technique

Answer 11

1. Pre-medicate if able
2. Engage sync prior to each attempt
3. Look for sync markers on monitor
4. “Clear” before each shock press charge and hold shock until it delivered.
5. For reg. narrow QRS 50-100j and increase if needed
6. For irregular narrow QRS 120-200j and increase if needed
7. For reg. wide QRS 100j increase if needed
8. Irregular wide QRS consistent with unstable polymorphic VT Defibrillate w/ 360j (unsynchronized shock)