2-4 UNSTABLE TACHYCARDIA

Symptomatic dysrhythmia may be indicated by:  acute altered mental status, ongoing severe ischemic chest pain, congestive heart failure, hypotension, or other signs of shock that persist despite adequate airway and breathing.  Any patient requiring ACLS care should have an ALS intercept if logistically possible.

EMR - Emergency Medical Responder

1. Begin initial medical care
2. Administer oxygen
3. Assist ventilations if RR < 8 or > 35
4. Assess for hypotension/ shock (HR >130, cap refill > 2 seconds) & follow shock protocol
5. Call for ALS intercept

EMT- Emergency Medical Technician  Perform/Confirm All Above Interventions

1. Assure ALS intercept is en route
2. Transport as early as possible
3. Reassess VS often during transport
4. Apply ECG monitor & run strip (if trained, if time allows and after all other interventions are completed)
5. Perform 12-lead ECG (if trained) as indicated

CONTACT MEDICAL CONTROL

AEMT – Advanced Emergency Medicine Tech   Perform/Confirm All Above Interventions

1. Start IV access en route, NS TKO (do not delay transport)
2. Administer NS fluid bolus, as directed

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Intermediate   Perform/Confirm All Above Interventions

1. Attach cardiac monitor if not already done, confirm rhythm via 12 lead ECG
2. Observation and transport for asymptomatic tachycardia
3. Reassess VS and rhythm frequently.
4. For symptomatic Sinus Tachycardia
   1. Assess for sepsis, hypovolemia, hypoxia, pain, drug ingestion, pneumothorax, cardiac tamponade, pulmonary embolism
   2. Give NS fluid bolus 500 mL if lungs are clear and indicated
5. For symptomatic Wide Complex Tachycardia
   1. Synchronized cardioversion at 100 J
   2. If unsuccessful, reset sync and give max J (or biphasic equivalents) between each attempt
   3. Use defibrillation if there is a significant delay in synchronization or deterioration of condition
      1. If unsuccessful consider repositioning of the defib pads
   4. May repeat total of 3 attempts and if still unsuccessful:
      1. CONTACT MEDICAL CONTROL
      2. Consider hyperkalemia as a cause, and the possible need for Calcium Chloride
      3. Consider administration of amiodarone (Cordarone) 150 mg slow IV over 10 min; May repeat (evaluate rhythm very closely, amiodarone may be contraindicated for torsades de point)
   5. If pulseless at any time, reassess rhythm and go to appropriate algorithm.
6. For Narrow Complex Tachycardia (SVT) HR>150
   1. If patient unstable, HR > 150 and instability is due to the tachycardia, consider immediate synchronized cardioversion
      1. Synchronized cardioversion at 100 J;
   2. If HR>150 and patient condition allows; Give adenosine (Adenocard) rapid IV push followed by rapid saline flush, as near to IV site as possible
      1. Give 6 mg adenosine (Adenocard) & assess underlying rhythm; Transport without more adenosine if underlying rhythm is junctional, ectopic, or multifocal atrial tachycardia.
      2. Give 12 mg adenosine (Adenocard) if refractory SVT; may repeat 12 mg if still refractory SVT
      3. Expedite transport if adenosine is unsuccessful

CONTACT MEDICAL CONTROL

Paramedic   Perform/Confirm All Above Interventions

1. Attach cardiac monitor if not already done, confirm rhythm via 12 lead ECG
2. Observation and transport for asymptomatic tachycardia
3. Reassess VS and rhythm frequently.
4. For symptomatic Sinus Tachycardia
   1. Assess for sepsis, hypovolemia, hypoxia, pain, drug ingestion, pneumothorax, cardiac tamponade, pulmonary embolism
   2. Give NS fluid bolus 500 mL if lungs are clear and indicated
5. For symptomatic Wide Complex Tachycardia
   1. Sedate with midazolam (Versed) 2 mg slowly IV/IO if indicated; May repeat to max dose of 4 mg
   2. Synchronized cardioversion at 100 J
   3. If unsuccessful, reset synchronization and give max J (or biphasic equivalents) between each attempt
   4. Use defibrillation if there is a significant delay in synchronization or deterioration of condition
      1. If unsuccessful consider repositioning of the defib pads
   5. May repeat total of 3 attempts and if still unsuccessful:
      1. CONTACT MEDICAL CONTROL
      2. Consider hyperkalemia as a cause, and the possible need for Calcium Chloride
      3. Consider administration of amiodarone (Cordarone) 150 mg slow IV/IO over 10 min; May repeat (evaluate rhythm very closely, amiodarone may be contraindicated for torsades de point)
      4. If pulseless at any time, reassess rhythm and go to appropriate algorithm.
6. For Narrow Complex Tachycardia (SVT) HR>150
   1. If patient unstable, HR > 150 and instability is due to the tachycardia, consider immediate synchronized cardioversion
      1. Sedate with midazalom (Versed) 2 mg slowly IV/IO if indicated; May repeat to max dose of 4 mg
      2. Synchronized cardioversion at 100 J;
   2. If HR>150 and patient condition allows; Give adenosine (Adenocard) rapid IV/IO push followed by rapid saline flush, as near to IV site as possible
      1. Give 6 mg adenosine (Adenocard) & assess underlying rhythm; Transport without more adenosine if underlying rhythm is junctional, ectopic, or multifocal atrial tachycardia.
      2. Give 12 mg adenosine (Adenocard) if refractory SVT; may repeat 12 mg if still refractory SVT
      3. Expedite transport if adenosine is unsuccessful

CONTACT MEDICAL CONTROL