1. Hany EL-Zahaby, MD, Anesthesiologist
Unstable Tachycardia
Hany EL-Zahaby, MD,
Anesthesiologist

2. Objectives
By the end of this talk we should be able to describe or demonstrate:
1- 1ry and 2ry ABCD surveys
2- Identify unstable from stable tachycardia
3- Identify the rhythm of tachycardia
4- Determine if tachycardia is producing hemodynamic instability or the instability is producing tachycardia

3. Objectives (cont.)
5- Follow the algorithms for tachycardia and cardioversion
6- Operation of a defibrillator/monitor to perform both defibrillation and synchronized cardioversion
7- Provide post-cardioversion care

4. Case Scenario
52-year-old man presented to ED complaining of shortness of breath, palpitations, dizziness and severe chest pain. He is pale and sweaty. His Pulse rate is 178 and blood pressure is 81/50

5. Action
Check responsiveness and apply primary and secondary ABCD surveys
If not in cardiac arrest or VF and tachycardia is observed, order oxygen-IV-monitor-fluids
Identify the rhythm

6. Supraventricular Tachycardia

7. Atrial Flutter

9. Atrial Fibrillation

10. Atrial Fibrillation

11. Ventricular Tachycardia

12. Prepare for synchronized cardioversion
Prepare oxygen saturation monitor, suction device, IV line, intubation equipment, call the code team and explain to the patient if awake

13. Premedicate
Sedatives and anesthetics:
Midazolam ( mg/kg),
Diazepam ( mg/kg),
Ketamine(1-2 mg/kg),
Etomidate ( mg/kg),
Thiopentone (3-5 mg/kg),
Propofol (1-2 mg/kg)

14. Analgesics:
Fentanyl (1-3μg/kg)
Morphine ( mg/kg)
Pethidine (0.5-1 mg/kg)

15. Synchronized Cardioversion
Is it equal to defibrillation?

16. Why synchronization?

17. When not to use synchronization?
Severely unstable VT

18. Steps for synchronized cardioversion
Turn on defibrillator
Attach monitor leads to the patient
Ensure proper display of the patient’s rhythm (lead II)
Press ‘sync’ control button
Look for markers on R waves
If no markers, adjust monitor gain until markers on each R

19. Select appropriate energy level for type of arrhythmia
Apply gel to paddles and position it on patient (sternum and apex)
Announce to team-members “Charging defibrillators-stand clear”
Press charge button on apex paddle (right hand)

20. When the defibrillator is charged state firmly: “I am going to shock on three. One, I am clear. Two, you are clear. Three, everybody is clear”
Apply 25 Ib pressure on both paddles
Press the “discharge” buttons simultaneously

21. Check the monitor, if tachycardia persists, increase the joules according to the algorithm
Reset to “sync” mode after each synchronized cardioversion
If VF occurs, switch to “defibrillation” mode and follow the VF/Pulseless VT algorithm

22. Energy levels:
Standard sequence is 100 J→ 200 J → 300 J → 360 J
Exceptions:
Atrial flutter 50 J→ 100 J→ 200 J→ 300 J→ 360 J
Polymorphic VT 200 J→ 300 J → 360 J

23. Post-conversion care:
Closely monitor vital signs
Continue oxygen-IV-monitor-fluids
Search for a cause for this tachycardia and treat it
If VF occurs, recognize need to defibrillate
Documentation

24. Conclusion Always start with ABCD
Unstable means either patient or tachycardia
Unstable tachycardia is treated with synchronized cardioversion
Steps for cardioversion should be strictly followed

25. THANK YOU