I have been in nursing for 35 years and have worked in a variety of settings including hospice, long term care, med-surg, supervision, cath lab, ER, special procedures and critical care. I enjoy working as a float nurse because it gives me a variety of clinical experiences. I am also a CPR, ACLS, and PALS instructor at our local hospital.
·Specific timed delivery of electrical shock to the heart
·Treatment of choice for SVT, VT with a pulse and atrial flutter with evidence of poor profusion
·Provide sedation and analgesia
·Prepare to defibrillate immediately if cardioversion causes VF
Synchronized cardioversion is shock delivery that is timed (synchronized) with the QRS complex. This synchronization avoids shock delivery during the relative refractory period of the cardiac cycle when a shock could produce VF.
·All tachycardias (rate >150 bpm) with serious signs and symptoms related to the tachycardia.These include unstable SVT, atrial flutter, atrial fibrillation and unstable VT
·May give brief trial of medications based on specific arrhythmias.
Cardioversion is less likely to be effective for treatment of junctional tachycardia or ectopic or multifocal atrial tachycardia because these rhythms have an automatic focus, arising from cells that are spontaneously depolarizing at a rapid rate
·In critical conditions go to immediate unsynchronized shocks.
·Urgent cardioversion is generally not needed if heart rate is over 150 bpm.
·Reactivation of sync mode is required after each attempted cardioversion (defibrillators/cardioverters default to unsynchronized mode).
·Prepare to defibrillate immediately if cardioversion causes VF.
·Synchronized cardioversion cannot be performed unless the patient is connected to monitor leads; lead select switch must be on lead I, II, or III and not on “paddles.” Reviewed 2/28/16
For verapamil, give a 2.5 mg to 5 mg IV bolus over 2 minutes (over 3 minutes in older patients). If there is no therapeutic response and no drug-induced adverse event, repeated doses of 5 mg to 10 mg may be administered every 15 to 30 minutes to a total dose of 20 mg. An alternative dosing regimen is to give a 5 mg bolus every 15 minutes to a total dose of 30 mg
Beta blockers (class 1)
Esmolol: 0.5mg/kg bolus over 1 minutes followed by an infusion at 50mcg/kg/min for 4 minutes. If no response then repeat 0.5mg/kg bolus over 1 minute and increase maintenance infusion to 100mcg/kg/min. If inadequate response in 4 minutes, repeat 0.5mg/kg bolus over 1 minute and increase maintenance infusion to 150mcg/kg/min. If inadequate response in 4 minutes, continue repeating bolus dose and increasing maintenance infusion by 50mcg/kg/min until maximum infusion of 300mcg/kg/min has been reached.
Metoprolol: 5mg slow IV push over 5 minutes x 3 as needed to a total dose of 15mg over 15 minutes
In principle these agents exert their effect by antagonizing sympathetic tone in nodal tissue, resulting in slowing of conduction. Like calcium channel blockers, they also have negative inotropic effects and further reduce cardiac output in patients with heart failure
·Usually 0.25mg IV q4h x 4 loading dose, then oral maintenance dose
·Not useful in emergencies due to slow onset of action Reviewed 2/28/16
·Reduce dosage in patients using Tegretol or dipyridamole
·Relatively contraindicated in patient with asthma
If the rhythm does not convert within 1 to 2 minutes, give a 12 mg rapid IV push using the method above. The initial dose may be reduced to 3 mg in patients taking dipyridamole or carbamazepine, those with transplanted hearts, or if given by central venous access. Side effects with adenosine are common but transient; flushing, dyspnea, and chest discomfort are the most frequently observed.Adenosine should not be given to patients with asthma.
·Adenosine should be considered for stable monomorphic, regular wide complex tachycardia
·Adenosine should not be used for irregular wide complex tachycardia
Pause after Adenosine
Calcium channel blockers (class 1)
·Diltiazem: 0.25mg/kg over 2 minutes.If ineffective, in 15 minutes may repeat 0.35mg/kg over 2 minutes.Followed by a maintenance infusion of 5-15mg/hr
·Verapamil: 2.5-5.0mg slow IV push over 2 minutes. May repeat with 5-10mg in 15 to 30 minutes. Maximum dose 20mg
These drugs act primarily on nodal tissue either to terminate the reentry PSVTs that depend on conduction through the AV node or to slow the ventricular response to other SVTs by blocking conduction through the AV node. The alternate mechanism of action and longer duration of these drugs may result in more sustained termination of PSVT or afford more sustained rate control of atrial arrhythmias
Note:Because ACLS providers may be unable to distinguish between supraventricular and ventricular rhythms, they should be aware that most wide-complex (broad-complex) tachycardias are ventricular in origin.
·Carotid sinus massage
·Stimulation of gag reflex
·Digital rectal stimulation
·Depresses AV node and sinus node
·Terminates AV nodal reenterant tachycardia
·Performed by the patient (patient must be conscious and cooperative)
·Document the dysrhythmia before treating
·Explain the procedure to the patient
·Instruct the patient to inhale and hold their breath and:
·Bear down as if to have a bowel movement, and to hold this position for 20-30 seconds. Reviewed 2/28/16
Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS, White RD, Hess EP, Tang W, Davis D, Sinz E, Morrison LJ. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S729–S767 Reviewed 2/28/16