Wide Complex Tachycardia Uncertain Origin: Difference between revisions

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==Section 4 - CARDIAC 4.10==
==Section 4 - CARDIAC==
===WIDE COMPLEX TACHYCARDIA – UNCERTAIN ORIGIN (Heart rate >160 beats/minute)===
===4.10 WIDE COMPLEX TACHYCARDIA – UNCERTAIN ORIGIN (Heart rate >150 beats/minute)===


* [[Initial Medical Assessment and Care|INITIAL MEDICAL CARE (2.01)]] - OXYGEN @ 100% via NRB mask or assist with BVM.


* [[Initial Medical Assessment and Care|INITIAL MEDICAL CARE]] (2.01) - OXYGEN @ 100% via NRB mask or assist with BVM.
====STABLE and SVT highly likely:====
 
* Administer [[Antiarrhythmics|ADENOSINE]] 6 mg RAPID IVP, administered at a port closest to the IV site, followed immediately by a rapid 10-20 ml saline flush
==== STABLE and SVT highly likely: ====
* If NO response in 2 minutes, [[Antiarrhythmics|ADENOSINE]] 12 mg RAPID IVP followed immediately by a rapid 10-20 ml saline flush (Maximum dose 18 mg)
* [[Antiarrhythmics|ADENOSINE (Adenocard)]] 6 mg rapid IVP over 1-3 seconds
* If no response in 2 minutes, [[Antiarrhythmics|ADENOSINE]] 12 mg rapid IVP over 1-3 seconds
* If no response in 2 minutes, repeat [[Antiarrhythmics|ADENOSINE]] 12 mg rapid IVP over 1-3 seconds
 


====STABLE and unknown wide complex or ventricular tachycardia likely:====
====STABLE and unknown wide complex or ventricular tachycardia likely:====
* [[Antiarrhythmics|LIDOCAINE]] 1 mg/kg IV over 3-5 minutes If no response, [[Antiarrhythmics|LIDOCAINE]] 0.5-0.75 mg/kg IV over 3-5 minutes (may repeat to a maximum of 3 mg/kg administered. In patients over age 70 or in those with known hepatic disease, administer [[Antiarrhythmics|LIDOCAINE]] boluses at 0.25 mg / kg until maximum of 1.5 mg / kg.
* [[Antiarrhythmics|LIDOCAINE]] 1 mg/kg IV over 3-5 minutes If no response, [[Antiarrhythmics|LIDOCAINE]] 0.5-0.75 mg/kg IV over 3-5 minutes (may repeat to a maximum of 3 mg/kg administered) In patients over age 70 or in those with known hepatic disease, administer [[Antiarrhythmics|LIDOCAINE]] boluses at 0.25 mg / kg (maximum of 1.5 mg / kg)
 


====UNSTABLE WIDE COMPLEX TACHYCARDIA:====
====UNSTABLE WIDE COMPLEX TACHYCARDIA:====
* [[Cardioversion|SYNCHRONIZED CARDIOVERSION]] @ 100 Joules.
**If IV established prior to patient becoming UNSTABLE, may administer [[Sedative Hypnotics|VERSED]] 2-5 mg IVP, IO or IN and repeat 2 mg every 30 seconds to 1 minute if patient is conscious.
* If tachycardia converts refer to STABLE section for administration of [[Antiarrhythmics|LIDOCAINE]].
* If NO response, [[Cardioversion|SYNCHRONIZED CARDIOVERSION]] @ 200 Joules.
* If NO response. [[Cardioversion|SYNCHRONIZED CARDIOVERSION]] @ 300 Joules.
* If NO response, [[Cardioversion|SYNCHRONIZED CARDIOVERSION]] @ 360 Joules.
*Following electrical cardioversion if no antiarrythmic agent was given,
** Administer [[Antiarrhythmics|LIDOCAINE]] 1.0 mg/kg IV bolus.  Use ½ dose if hypotensive. Follow with continuous infusion at 2-4 mg/min Contraindicated if ventricular escape rhythm
* If [[Antiarrhythmics|LIDOCAINE]] was given previously
** Follow with continuous infusion at 2-4 mg/min Contraindicated if ventricular escape rhythm.
* If HYPERKALEMIA suspected in any wide complex Tachycardia, Suspect in patients with any of the following:
**Diagnosis of Renal Failure or any form of Kidney insufficiency
**Widening QRS,
**Increased K+ in diet (excessive consumption of cherries, bananas, melons or citrus) , Acidosis, or Shock.
**'''''Note last dialysis TX.'''''
**CALCIUM CHLORIDE 1 gm IV (Avoid if patient is on digoxin/lanoxin)
**SODIUM BICARBONATE 1 mEq/kg IV
'''''Physician's Orders: If no response, contact Medical Control for consult.'''''


'''Discontinue boluses in patients who now manifest tachycardia with hypotension, altered mental status, or widening of the QRS complex. '''
{| class="wikitable"
|-
! Definition of Unstable: Persistent Wide Complex Tachyarrhythmia causing:
|-
|
*Hypotension or signs of decreased tissue perfusion
*Significant dyspnea or significant compromise of the airway
*Acute mental status change
*Signs/symptoms of shock
*Acute heart failure
*Ischemic chest discomfort
|}


This Standing Order is divided between the care and treatment of the stable patient verses the unstable patient. As a matter of definition agreed upon by the Medical Directors, the UNSTABLE patient is one who presents with any of the following: '''''SIGNIFICANT CARDIAC, SUSPECTED CARDIAC, SIGNIFICANT DYSPNEA, ALTERED MENTAL STATUS, OR HYPOTENSION WITH SIGNS OF DECREASED TISSUE PERFUSION, OR SIGNIFICANT COMPROMISE OF AIRWAY, BREATHING, AND/OR CIRCUATION.'''''
* SYNCHRONIZED CARDIOVERSION
** Initial recommended doses:
*** If narrow and regular complexes 50-100 Joules biphasic
*** If narrow and irregular complexes 120-200 Joules biphasic
*** If wide and regular complexes 100 Joules biphasic
*** If wide and irregular complexes – use defibrillation dose (not synchronized)
* If IV established prior to patient becoming UNSTABLE, may administer [[Sedative Hypnotics|VERSED]] 2-5 mg IVP, IO or IN AND REPEAT 2 mg every 30 seconds to one minute if patient is conscious.
* If NO response, SYNCHRONIZED CARDIOVERSION @ 200 Joules.
* If NO response, SYNCHRONIZED CARDIOVERSION @ 360 Joules.


'''''If the patient presents with one or more of the above UNSTABLE criteria, DEFIBRILLATION should be administered to avoid delays associated with synchronization.'''''
{| class="wikitable"
|-
! DEFIBRILLATION should be considered instead of synchronized cardioversion if the patient is deteriorating rapidly to avoid delays associated with synchronization.
|}

Revision as of 18:21, 3 May 2012

Section 4 - CARDIAC

4.10 WIDE COMPLEX TACHYCARDIA – UNCERTAIN ORIGIN (Heart rate >150 beats/minute)

STABLE and SVT highly likely:

  • Administer ADENOSINE 6 mg RAPID IVP, administered at a port closest to the IV site, followed immediately by a rapid 10-20 ml saline flush
  • If NO response in 2 minutes, ADENOSINE 12 mg RAPID IVP followed immediately by a rapid 10-20 ml saline flush (Maximum dose 18 mg)

STABLE and unknown wide complex or ventricular tachycardia likely:

  • LIDOCAINE 1 mg/kg IV over 3-5 minutes If no response, LIDOCAINE 0.5-0.75 mg/kg IV over 3-5 minutes (may repeat to a maximum of 3 mg/kg administered) In patients over age 70 or in those with known hepatic disease, administer LIDOCAINE boluses at 0.25 mg / kg (maximum of 1.5 mg / kg)

UNSTABLE WIDE COMPLEX TACHYCARDIA:

Definition of Unstable: Persistent Wide Complex Tachyarrhythmia causing:
  • Hypotension or signs of decreased tissue perfusion
  • Significant dyspnea or significant compromise of the airway
  • Acute mental status change
  • Signs/symptoms of shock
  • Acute heart failure
  • Ischemic chest discomfort
  • SYNCHRONIZED CARDIOVERSION
    • Initial recommended doses:
      • If narrow and regular complexes 50-100 Joules biphasic
      • If narrow and irregular complexes 120-200 Joules biphasic
      • If wide and regular complexes 100 Joules biphasic
      • If wide and irregular complexes – use defibrillation dose (not synchronized)
  • If IV established prior to patient becoming UNSTABLE, may administer VERSED 2-5 mg IVP, IO or IN AND REPEAT 2 mg every 30 seconds to one minute if patient is conscious.
  • If NO response, SYNCHRONIZED CARDIOVERSION @ 200 Joules.
  • If NO response, SYNCHRONIZED CARDIOVERSION @ 360 Joules.
DEFIBRILLATION should be considered instead of synchronized cardioversion if the patient is deteriorating rapidly to avoid delays associated with synchronization.
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