UNSTABLE TACHYCARDIA

Patient is UNSTABLE if he has any of the following:

• Chest pain
• Shortness of breath
• Hypotension
• Altered mental status
• Shock
• Pulmonary edema

NOW MEMORIZE THIS PART: WE CARDIOVERT UNSTABLE TACHYCARDIA.

While getting ready to perform cardioversion, have your team perform the following steps:

• Oxygen by simple face mask
• Connect a 3 lead EKG
• Start an iv line
• Hook up a NIBP
• Connect a pulse oximeter
• Remember to listen to the heart and lungs
• DONT LET ANY OF THIS DELAY SYNCHRONIZED CARDIOVERSION

Synchronized cardioversion:

• Press LEAD BUTTON, Select Lead II ;use the lead that gives the tallest complexes.
• Press the SYNC BUTTON. The sense markers will appear, these are little triangles that will appear over the QRS complexes.
• Increase the EKG size if needed so that the sense markers will pick out the QRS complexes
• Now press ENERGY SELECT. Start with an energy setting of 100 joules
• Press CHARGE BUTTON. You will hear the sound of the machine charging up.
• Press the SHOCK button. Remember, there is a delay as the machine waits for the next R wave, so dont take your finger off the button too fast. Remember, the machine delivers the shock just after the peak of R
• After each shock , do a pulse check.
• WATCH OUT FOR ANY RHYTHM CHANGES OR FOR PEA. Remember, if he is tachycardic and has no pulse he is in PEA!
• Conscious sedation with Valium 5mg or Versed can be given, but be watchful for respiratory depression.
• If 100 Joules did not work, escalate to 200 joules, and then to 300 joules.

There is one type of unstable tachycardia you will not cardiovert: TORSADES DE POINTES

Management:

• Defibrillate, just like you would do for Vfib (cannot cardiovert since there are no complexes that the machine can clearly target)
• Magnesium 1 to 2 grams IV or IO. The magnesium is given as 2 to 4 ml. of a 50% solution, diluted in 10 ml of D5W or normal saline given over 1-2 minutes.