Tachycardia; Wide Complex (Unstable w/ pulse)

Determine Patient Stability

Patient is considered unstable if there is hypotension, poor skin signs, shortness of breath, chest pain, evidence of CHF, or decreased mentation [or any other symptom felt to be caused by the bradycardia].

This protocol is for Wide QRS >0.08 sec

1. Evaluate ABC's
   • Stabilize Airway/Breathing
   • Apply oxygen
   • Place cardioversion/defibrillation pads
   • Establish IV
   • Monitors (Rhythm, Oximetry, BP)
   • Obtain 12 lead EKG
   • Code cart
2. Obtain history and perform physical examination and consider causes:
   • Differential diagnosis includes:
   • Ventricular tachycardia (Monomorphic)
   • Ventricular tachycardia (Polymorphic)
   • Supraventricular tachycardia (SVT) w/ aberrancy
   • Consider Causes
   • Hypovolemia/Hypoxia/Hypothermia
   • Sepsis/Infections
   • Drugs: Cocaine, Amphetamines, Decongestants, Ephedra, Ginseng
   • Metabolic: Thyroid disease, hyper/hypokalemia, hypercalcemia, acidosis
   • Hypoglycemia
   • Pneumothorax or Tamponade
   • Acute myocardial infarction, pulmonary embolus
   • Cardiomyopathy/Valvular heart disease
3. Treatment for unstable wide complex tachycardia:
   • Immediate cardioversion; Sedate if possible, but don't delay cardioversion.
   • May attempt adenosine 0.1 mg/kg IVP (Max 6 mg) with 5-20 mL flush if dose not delay electrical conversion
   • Synchronized cardioversion:
   • 0.5-1 J/kg, may repeat at 2 J/kg
   • Sedation if possible (agents such as Etomidate, Fentanyl or Midazolam are common choices)
   • Pads on patient (or paddles)
   • Press sync button (make sure to have 3 lead monitor leads attached to the defibrillator/cardiovertor)
   • Confirm Joule setting appropriate
   • Monitor for response to therapy; if needed, increase joules for subsequent shocks and make sure to press the sync button prior to each shock.
4. Antiarrhythmic Agents should be utilized as soon as possible concomitant with or after cardioversion. Use EITHER (not both) Amiodarone OR Procainamide
   1. *Amiodarone 5 mg/kg IV (Max 300 mg) over 20-60 minutes [Preferred] OR
   2. Procainamide 15 mg/kg IV over 30-60 minutes.
   
   * Amiodarone infusion can be repeated to a maximum of 15 mg/kg total cumulative dose if needed.
5. Standard laboratory evaluation (if indicated):
   • CBC, Electrolytes, TSH, Cardiac enzymes and toxicology testing
   • CXR
   • EKG pre and post conversion (if conversion occurs)
6. Consultation and admission to hospital if indicated.

Source: Circulation 2005;112. 2005 AHA Guidelines for CPR and ECC.