Patient is UNSTABLE if he has any of the following:
- Chest pain
- Shortness of breath
- Altered mental status
- 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
- 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
- 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.