Bystanders performed CPR on the scene. Patient arrives in the emergency department with initial vitals demonstrating T: 35, P: thread, BP: 60/30, O2: 95%.
What are initial steps in management?
Adenosine
Consult cardiology
Cardiovert
ABC’s
The patient is unstable and ABC’s should be addressed immediately, including airway and breathing assessment, establishing IV, and monitor. Additionally, at this time, the etiology of the hypotension and hypo perfusion is unknown so adenosine, cardiology consult and cardioversion can’t be considered at this point.
An IV is being established. Initial EKG demonstrates the following:
What is the initial treatment?
Defibrillation
All of the above
Cardioversion
Amiodarone
For unstable wide complex tachycardia, i.e. with signs of poor perfusion, synchronized cardioversion is the initial choice of management. While Amiodarone may be considered with stable or unstable ventricular tachycardia, the initial management of unstable would be cardioversion, to hopefully convert back to sinus rhythm.
The answer is:
100J via synchronized cardioversion
20J via unsynchronized defibrillation
80J via synchronized cardioversion
20J via synchronized cardioversion
The initial J/kg for cardioversion is 0.5 - 1J/kg. For patients with a pulse, it is imperative the defibrillator be turned to the SYNCHRONIZED mode to avoid delivering electricity to the heart during cardiac repolarization (or during the T wave). Delivering electricity during this time (during the T wave), can precipitate ventricular fibrillation. With synchronized cardioversion, the machine senses the native QRS complex and attempts to deliver electricity during the peak of the QRS (or depolarization of the ventricle).
Rhythm strip is unchanged:
What is the next step in management?
Administration of epinephrine
The patient is in pulseless ventricular tachycardia and like ventricular fibrillation, deliverance of rapid defibrillation can be life-saving. Initiate CPR until the machine is ready to defibrillate. Make sure everyone is “clear” prior to delivering shock.
Which of the following correctly describes the appropriate medication and dosing to be administered in pulseless ventricular tachycardia?
1mg epinephrine, consider 300mg amiodarone during subsequent round of CPR
1mg atropine, consider epinephrine during subsequent round of CPR
6mg adenosine, consider 150mg amiodarone during subsequent round of CPR
1mg epinephrine, consider 150mg amiodarone during subsequent round of CPR
For ventricular fibrillation or pulseless ventricular tachycardia, the mainstay of treatment is rapid defibrillation with administration of effective CPR. During this time, you can administer epinephrine, 1mg, and consider giving Amiodarone 300mg. The initial dose of amiodarone in a pulseless/coding patient is 300mg, followed by 150mg if additional doses are required. For a patient that is stable ventricular tachycardia (has a pulse, is not hypo perfused), the initial dose of amiodarone is 150mg bolus over 10 minutes.
