Assess breathing and integrate with chest compressions at ratio. Immediate defibrillation when indicated Maximize hemodynamics by effective chest compression, pharmacological and antidysrhythmic treatment. Differential diagnosis. Medication profile may be helpful. Rule out correctable causes of cardiac arrest. Lab studies are seldom useful during initial phase of resuscitation. Stable monomorphic VT : See wide-complex tachycardia above. Stable polymorphic VT. If no change in condition: repeat primary survey.
Identify inciting events. Heart rate is EKG shows atrial fibrillation… What are you going to do??? Wonderful, except it didn't change a thing.
Now what? If the patient is chronically in atrial fib, the shock rarely works. Your patient is unstable, so you decide to give it a shot. You might as well give yourself the best chance of success, so go right for J on monophasic, or equivalently high on your biphasic. This will not cause more injury than lower joules Heart , and Resuscitation ; PA is probably better than AA if you have pads.
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- ACLS Stable and Unstable Tachycardia Guide.
Make sure the synch is on. You need to give your patient something to disguise the fact that you are electrocuting them. Yet you don't want to drop their pressure. Ketamine is ok in disassociative dosing, but then your patient is loopy and you lose your mental status exam. Consider mg of etomidate along with a pain dose of ketamine, mg.
Treatment Guidelines of Atrial Fibrillation (AFib or AF)
If you have a. This is WPW and these patients just love to ruin your day by going into v. Shock early, shock often, light them up. So you made sure it's not WPW and the cardioversion has failed, as it so often does in chronic a. Now you need to raise the BP before anything else. Use push-dose phenylephrine.
Use diltiazem, but not as a push. Drip it in at 2. Resuscitation , See here for more. Podcast: Play in new window Download Duration: — 8.
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Scott Weingart. EMCrit Blog. Published on February 12, Accessed on November 11th Unless otherwise noted at the top of the post, the speaker s and related parties have no relevant financial disclosures.
ACLS Tachycardia Algorithm for Managing Stable Tachycardia
Sign Up Today! If you enjoyed this post, you will almost certainly enjoy our others. Subscribe to our email list to keep informed on all of the Resuscitation and Critical Care goodness. We never spam; we hate spammers! Spammers probably work for the Joint Commission. Hi Scott. Doing so has got to minimize the hypotensive effect. Clearly there is a balance one is seeking — which is to slow the rate of AFib so as to increase diastolic filling time and improve hemodynamics while not giving IV Dilt at too fast a rate such that BP is further lowered ….
We have been having the same conversation about Dig on our tachy septic patients. What dose are you giving? Absolutely agree. And of course, no hypotension…. I agree with the use of digoxin in these situations. I presume it is inexpensive, and it does seem to kick in within fifteen minutes or so. I start with 0. Most chronic Afib pts come in on metoprolol, sometimes in addition to another agent e.
I have the most experience with diltiazem for treating rapid afib, but would it make sense to start with metoprolol for this patient, as we may avoid combining agents to increase the chance of causing complete heart block? It seems like the ED usually prefers dilt, while cardiology often prefers metoprolol.
Now on to the Podcast…
What about procainamide for unstable Afib with WPW? I think the way to go is to avoid giving two classes of meds IV. But if they are not shocking out, you can consider it. Great talk about a scary topic. In Australia, instead of phenylephrine, Metaraminol Aramine is a more popular drug, It is a fast acting peripheral vasocontrictor, loved by most anesthetist.
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In common practice, most doctors would mix one ampoule 2 mg with Normal Saline to make up 20 ml and give one to two ml at a time. The bolus dose of Amiodaro0ne recommended is 3oomg followed by an infusion. Fortunately, the emergent cardioversion worked and he improved on NIV. Thanks for the info and the comment. It sounds like metaraminol is very similar to phenylephrine. So you folks start with the higher dose of amio right off the bat? Do you see a lot of hypotension from it?
I ve read about the use of calcium as a pre treatment agent prior the use of calcium channel blockers ie ditialzem. They advocated us to give cc of calcium gluconate as to offset the hypotensive effect of the drug. What do you think? Calcium showed good effect as a pretreatment for verapamil. The data have not supported Ca pretreatment for dilt J Emerg Med. However, calcium is an excellent inopressor in any patient, so I heartily agree that it would be a great thing to give in the patient above. Thanks for the comment. Thanks for this podcast. Can you do one on all remaining tachyarrythmias!
Regarding shock is it defibrillation or cardioversion in atrial fib with lo BP!. I believe its cardioversion; the machine should still be able to sync on the R wave. Phenyl will not make the heart rate higher and may actually lower it through vagal tone. Hi Dr. Weingart, In light of your push dose pressers update- are you still using push dose phenylephrine for these patients, or are you now using push dose epi?