Case8_Unstable

Assess primary ABCDs

1. Pt responsive

2. Pt breathing

3. Pt has a pulse present - Rapid

4. Do not defibrillate a rhythm if there is a pulse. See cardioversion below.

Assess secondary ABCDs

1. Secure airway if needed

2. "O2, IV, Monitor"- place on O2, place an IV, and place on a heart

monitor

3. Check Vital Signs

If the patient has poor perfusion because of the rate, low BP, decreased LOC, ongoing chest pain, then 4-6 may be delayed until the patient is stable.

4. Review history and physical exam

5. Get a 12 lead ECG

6. Get a portable Chest X-Ray

Assess Rapid Heart Rate

Ask, "Does the patient have adequate perfusion related to the fast rate?"

Ventricular rate > 150 bpm

Chest pain, shortness of breath, decreased level of consciousness

(L.O.C.), decreased BP, shock, pulmonary congestion, CHF, Acute

If yes, then the patient is considered unstable. It doesn't matter whether it is wide or narrow complex tachycardia, prepare for immediate cardioversion (hit the sync button on the defibrillator). This will allow the defibrillator to synchronize with the pt's QRS complex so as not to shock during the vulnerable repolarization phase (on the T-wave). This is known as synchronized cardioversion.

1. Monitor O2 saturations

2. Prepare suction device

3. Make sure intubation equipment is available

4. Make sure IV line is patent

5. Premedicate whenever possible: Midazolam or Diazepam for sedation

with or without analgesia such as Morphine or Demerol

Synchronized Cardioversion Procedure

Note: I'm calling the machine that does this procedure a defibrillator. The difference between cardioversion and defibrillation is that the sync button is on for cardioversion and off for defibrillation. The machine will still be called a defibrillator, but defibrillation and cardioversion are different procedures as described.

V. Tach

PSVT

A. Fib

A. Flutter

Turn on defibrillator

Attach monitor leads to pt (White to right shoulder, Red to left ribs, what's

Left Over goes over to the left shoulder)

Hit SYNC button

Look for markers on the R waves on the defibrillator's monitor indicating

sync mode (increase the gain if necessary so each R wave has a marker)

Select energy level, start at 100J, then increase in above increments with

each shock

Place pads on pt as marked (Sternum-Apex)

or paddles with gel

Announce charging defibrillator- "Stand Clear!"

Press the charge button on the defibrillator or on the apex paddle

State: I'm clear! - make sure you are clear

You're clear! - make sure your helpers are clear

Everybody's clear! - make sure everyone is clear of the patient

If using paddles, apply at least 25lbs of pressure on the chest. Also if using paddles, you need a water soluble lubricant placed on the paddles.

Press the discharge button on the defibrillator or discharge buttons simultaneously on each paddle.

Check the monitor for the rhythm

Each time shocking, you must reset the sync button to continue to shock using cardioversion.