TACHYCARDIA WITH PULSE – UNSTABLE

Inclusion Criteria:  Adult patients with heart rate greater than 150 bpm with sustained or non-sustained wide complex tachycardia, and pediatric patients with a heart rate greater than normal for their age, and both of the following two criteria are met: 

1. Sinus tachycardia is NOT suspected, and
2. There are signs or symptoms of hypoperfusion (hypotension, acutely altered mental status, signs of shock, ischemic chest discomfort or acute heart failure).

Basic Level

1. Assess and support ABCs.
2. Place the patient in a position of comfort.  If there is evidence of shock, place the patient supine with the feet elevated, if tolerated.
3. Administer oxygen, as needed, to maintain a SpO2 of at least 94%.
4. If chest pain/discomfort is present or develops, treat the pain according to the CHEST PAIN Guidelines while continuing these guidelines.
5. Once advanced level care arrives on scene, give report and transfer care.

Advanced Level

6. Continuously monitor ECG.  Continuously monitor ETCO2 if the patient is hypotensive. 
7. Obtain a 12-Lead ECG and consult with BioTel, as needed.  (12-lead acquisition MUST NOT delay care of the unstable patient.)
8. Establish IV/IO access at TKO rate or use saline lock.  (Vascular access MUST NOT delay care of unstable patient.)
9. UNSTABLE PATIENT WITH NARROW-COMPLEX TACHYCARDIA (probable SVT):
   
   If signs or symptoms of hypoperfusion are present or develop:
   

Adult

• Immediate synchronized cardioversion at 50 J, 70 J, 100 J, 150 J, 200 J, or per manufacturer recommendations.
• If the patient is conscious, sedate prior to cardioversion attempt:
• Diazepam, 2.5 mg – 5 mg slow IVP/IO/IN/IM (may repeat once); OR
• Midazolam, 2.5 mg – 5 mg slow IVP/IO/IN/IM (may repeat once).
• If the patient is conscious, sedate prior to cardioversion attempt:
• If the QRS complex is regular and the rhythm is regular, consider adenosine 12 mg RAPID IVP followed immediately by 20 mL Normal Saline RAPID IVP.

Pediatric

•    Prepare to administer adenosine:
• 0.1mg/kg RAPID IVP (maximum 6 mg)
• Flush with 5 – 10 mL Normal Saline.
• May repeat once at 0.2 mg/kg RAPID IVP (maximum 12 mg).
• Flush with 5 – 10 mL Normal Saline.
• AND Contact BioTel for authorization.
• ECG monitor must run continuously before and during adenosine administration and response.
• If IV/IO access is unavailable, or if adenosine is unavailable or ineffective, prepare for immediate synchronized cardioversion:
• Dose: 0.5 – 1.0 J/kg.
• May repeat once at 2 J/kg.
• BioTel may authorize sedation with midazolam or diazepam.

NOTE: Individual agencies may carry only one sedative - they are not required to carry both.

9. UNSTABLE PATIENT WITH WIDE-COMPLEX TACHYCARDIA (possible Ventricular Tachycardia)
   
   If signs or symptoms of hypoperfusion are present or develop:

Adult

•  Immediate synchronized cardioversion at 100 J or 150 J; (repeat 200 J, 300 J or 360 J), or per manufacturer recommendations.
• If the patient is conscious, sedate prior to cardioversion attempt
• Diazepam, 2.5 mg – 5 mg slow IV/IO/IN/IM (may repeat once); OR
• Midazolam, 2.5 mg – 5 mg slow IV/IO/IN/IM (may repeat once).
• Following cardioversion, consider amiodarone infusion for frequent PVCs – Contact BioTel.
• If wide complex tachycardia could be torsades de pointes, add 2 grams Magnesium Sulfate to 250 mL Normal Saline bag and infuse IV piggyback over 20 minutes.
• BioTel authorization required if dialysis patient

Pediatric

• Prepare to perform immediate synchronized cardioversion:
• Dose: 0.5 – 1.0 J/kg.
• May repeat once at 2 J/kg.
• AND Contact BioTel for authorization.
• ECG monitor must run continuously before and during treatment and response.
• Establish precautionary IV/IO access:
• Vascular access should not delay treatment of the unstable patient.
• BioTel may authorize antiarrhythmic administration (adenosine and/or amiodarone) or sedation (diazepam or midazolam).

NOTE: Individual agencies may carry only one sedative - they are not required to carry both.

10. Initiate transport and monitor closely.
11. For additional patient care considerations not covered under standing orders, consult BioTel.