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 [[Adenosine|ADENOSINE]] 12 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|ADENOSINE]] 12 mg RAPID IVP followed immediately by a rapid 10-20 ml saline flush (Maximum dose 24 mg)


==== STABLE and SVT highly likely: ====
====STABLE and unknown wide complex or ventricular tachycardia likely:====
* [[Antiarrhythmics|ADENOSINE (Adenocard)]] 6 mg rapid IVP over 1-3 seconds
* [[Lidocaine|LIDOCAINE]] 1 to 1.5 mg/kg IV over 3-5 minutes
* If no response in 2 minutes, [[Antiarrhythmics|ADENOSINE]] 12 mg rapid IVP over 1-3 seconds
**If no response, [[Lidocaine|LIDOCAINE]] 0.5-0.75 mg/kg IV over 3-5 minutes (may repeat to a maximum of 3 mg/kg administered)
* If no response in 2 minutes, repeat [[Antiarrhythmics|ADENOSINE]] 12 mg rapid IVP over 1-3 seconds
**In patients over age 70 or in those with known hepatic disease limit the use of [[Lidocaine|LIDOCAINE]] to a maximum of 1.5 mg/kg)
 
====UNSTABLE WIDE COMPLEX TACHYCARDIA:====


{| 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
|}


====STABLE and unknown wide complex or ventricular tachycardia likely:====
* SYNCHRONIZED CARDIOVERSION
* [[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.
** 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|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.


{| class="wikitable"
|-
! DEFIBRILLATION should be considered instead of synchronized cardioversion if the patient is deteriorating rapidly to avoid delays associated with synchronization.
|}


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


'''''Physician's Orders: If no response, contact Medical Control for consult.'''''


{| class="wikitable"
|-
! Discontinue boluses in patients who now manifest tachycardia with hypotension, altered mental status, or widening of the QRS complex.
|}


'''''Physician's Orders: If no response, contact Medical Control for consult.'''''
[[Category:Cardiac|0410]]
 
'''Discontinue boluses in patients who now manifest tachycardia with hypotension, altered mental status, or widening of the QRS complex. '''
 
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.'''''
 
'''''If the patient presents with one or more of the above UNSTABLE criteria, DEFIBRILLATION should be administered to avoid delays associated with synchronization.'''''

Latest revision as of 14:01, 24 April 2020

Section 4 - CARDIAC

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

STABLE and SVT highly likely:

  • Administer ADENOSINE 12 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 24 mg)

STABLE and unknown wide complex or ventricular tachycardia likely:

  • LIDOCAINE 1 to 1.5 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 limit the use of LIDOCAINE to a 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.

Following electrical cardioversion if no antiarrythmic agent was given:

  • Administer LIDOCAINE 1.0 mg/kg IV bolus.
    • Use ½ above dose if hypotensive.
    • Follow with continuous infusion at 2-4 mg/min
    • Contraindicated if ventricular escape rhythm
  • If 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.
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