Page 54 - 2023 SMOG Digital

Cardiac

TACHYCARDIA w/PULSE

Signs and Symptoms: Differential Diagnosis (Wide Complex Differential Diagnosis (Narrow QRS):
• Ventricular Tachycardia on EKG QRS >.12sec): • Wolf–Parkinson––White Syndrome
–
(rate typically >150/min) • Artifact/Device Failure • Valvular Heart Disease
• Conscious, Rapid Pulse • Cardiac • Sick Sinus Syndrome
• Chest Pain/Shortness of Breath • Endocrine/Metabolic • Myocardial Infarction
• Palpitations • Hyperkalemia • Electrolyte Imbalance
• Dizziness • Drugs • Sinus Tachycardia/Atrial Flutter
• Anxiety • Pulmonary • Hypoxia
• Drug Overdose/Toxin
• Hyperthyroidism
Universal Patient Care Guideline METOPROLOL DILTIAZEM ADENOSINE
O2 (if Hypoxemic) 5mg IV q5min X 3 20mg (0.25mg/kg) IV over • 1 st Dose: 6mg rapid IV
IV/IO Guideline Hold if SBP <100, P <60 2min. If no hypotension, push: followed by NS
Monitor and 12– –lead ECG (ASAP) after 15min repeat at Flush
25mg (0.35mg/kg) • 2 nd Dose: 12mg
Chest Pain / SOB / “Sinus Tach” YES STABLE NO
Dizziness? UNSTABLE: Signs / Symptoms of:
YES NO • BP Low (hypotension) *Synchronized
• Altered mental status
Cardioversion:
Chest Pain QRS Width? • Signs/symptoms of shock • Narrow Irregular, A-Fib
NO Guideline No unstable signs / • Ischemic chest pain • Narrow Regular, SVT,
symptoms, No • Congestive heart failure (acute) Atrial Flutter
Observe “Sinus Tach” • Wide Regular, Stable
Reassess q5min Monomorphic VT
Consider Sedation:
• Vagal Maneuvers: Regular Narrow QRS? Wide QRS? Regular Midazolam 2–5mg IV/IO
Blow through 18ga IV <0.12 Second >0.12 Second
catheter, carotid massage, Consider:
bear down. Irregular • AMIODARONE
• ADENOSINE: use for Consider: AMIODARONE
Regular Rhythm ONLY! • DILTIAZEM • **Torsades Stable Wide-QRS Tachy
• DILTIAZEM • METOPROLOL • A-Fib with/or Wolff- • 1 st Dose: 150mg IV
• METOPROLOL Parkinson-White (look If refractory or over 10min
for a delta wave) becomes unstable • Repeat prn if VT recurs
at any time!
*Synchronized • Procainamide 20- • Maintenance infusion:
1mg/min for 1 st 6hr
Cardioversion: 50mg/min until
• Narrow Irregular, A-Fib arrhythmia
• Narrow Regular, SVT, suppression, All Pathways End with Continuous Monitoring
Atrial Flutter hypotension, QRS
widens by >50%, or
Consider Sedation: total dose 17mg/kg
Midazolam 2–5mg IV/IO reached *Synchronized Cardioversion
(Increase Js per manufacture’s recommendation)
Pearls: Narrow Irregular, Atrial Fibrillation:
• **Torsades de Pointes may benefit from early use of • 120–200 J biphasic
Magnesium: 1–2 grams IV over 60 min (mix in 50ml Narrow Regular, Other SVT, Atrial Flutter:
D5W) Start drip of 0.5–1g/hr and titrate to effect. • 50–100 J, increase in stepwise fashion
• If hyperkalemia suspected (end-stage renal disease, Wide Regular, Stable Monomorphic VT:
100 J, increase in stepwise fashion
•
dialysis)–administer Ca Chloride through central Wide Irregular:
access or Ca Gluconate through peripheral IV. • Defibrillate (NOT Synchronized)
• All patients should be warned of discomfort/feeling of • Go to: Cardiac Arrest Guideline
heart stopping prior to adenosine administration.
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