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Synchronized cardioversion ·          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 Note 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.   Indications ·          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. Note Cardioversion is less likely to be effective for treatment of junctional tachycardia or ectopic or multifocal atrial tach

Note 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

Adenosine ·          6mg rapid IV over 2-3sec. ·          Repeat Adenosine at 12mg rapid IV over 2-3sec. ·          Reduce dosage in patients using Tegretol or dipyridamole ·          Relatively contraindicated in patient with asthma Note 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 ·          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)

Precautions for Carotid Sinus Massage ·          Avoid carotid massage in older adults ·          Never perform bilateral carotid massage ·          Listen for bruits before carotid massage- contraindicated if bruits are present ·          Should not be continued for more than 10 sec. ·          Patient should be on cardiac monitor ·          Should have IV access before attempting vagal maneuvers Procedure for carotid sinus massage ·          Turn head to the left ·          Apply firm pressure over the right carotid bifurcation near the angle of the jaw ·          If unsuccessful, repeat with a 5- to 1- second rotary “massage motion” ·          If unsuccessful, turn the head to the right side and perform left carotid massage Contraindications ·          Avoid in elderly ·          Carotid bruits ·          History of CVA ·          Recent MI or myocardial ischemia Medications Used to Treat Stable (symptomatic) SVT ·          Adenosine

Evaluate Rhythm ·          Obtain 12 lead EKG ·          Determine if QRS complex is ≥0.12 second ·          Determine treatment options. Note :   Stable patients may await expert consultation because treatment has the potential for harm Narrow Complex Tachycardias ·          Atrial fibrillation ·          Atrial flutter ·          AV nodal reentry ·          Accessory pathway–mediated tachycardia ·          Atrial tachycardia (including automatic and reentry forms) ·          Multifocal atrial tachycardia (MAT) ·          Junctional tachycardia (rare in adults) Note :   Irregular narrow-complex tachycardias are likely atrial fibrillation or MAT; occasionally atrial flutter is irregular Wide Complex Tachycardias ·          Ventricular tachycardia (VT ·          SVT with aberrancy ·          Pre-excited tachycardias (Wolff-Parkinson-White [WPW] syndrome)   Note :   Because ACLS providers may be unable to distinguish betwee

Management of SVT Mnemonic for Treating SVT P rimary Survey R ecognize symptoms of instability E valuate rhythm- EKG V agal Maneuvers A denosine D irect cardioversion E xpert consultation Primary Survey ·          Airway- supplemental oxygen ·          Breathing ·          Circulation ·          Check VS ·          Assess pulse ·          Attach defibrillator/monitor ·          12 lead EKG ·          IV access Recognize Symptom of Instability? ·          Evaluate the patient: symptomatic or unstable ·          Identify potential reversible causes of the tachycardia Note: Many experts suggest that when a heart rate is <150 beats per minute, it is unlikely that symptoms of instability are caused primarily by the tachycardia unless there is impaired ventricular function. Symptomatic Tachycardia ·          Symptomatic implies that an arrhythmia is causing symptoms, such as palpitations, lightheadedness, or dyspnea, but t

Tension Pneumothorax ·          Hx trauma, recent pacemaker or central line insertion, ventilator patient ·          Assess for tracheal deviation ·          Needle decompression 2nd intercostal space midclavicular line ·          Chest tube Thrombosis, Coronary ·          MONA ·          Follow ACS algorithm References Aehlert, Barbara. ACLS Quick Review Study Guide, 2 nd edition.   Mosby, inc.   St. Louis, Mo. 1994. 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

Hypokalemia ·          Slow rhythm with ST segment depression, flattened waves, prominent U wave ·          Potassium replacement either orally or IV ·          No IV push boluses! Tablets ·          Assess for drug overdose ·          Assess for hx of drug use ·          Consult poison control Tablets: Calcium Channel Blockers ·          Hypotension ·          Bradycardia with variable heart block ·          Altered mental status ·          EKG: slow rate, prolonged PRI, AV blocks ·          Rx Calcium chloride 10% 1-4G slow IV ·          Fluid resuscitation, vasopressor agents, atropine, transvenous pacing Tablets: Beta blockers ·          Hypotension ·          Bradycardia with variable heart block ·          EKG: slow rate, prolonged PRI ·          Rx Glucagon 3-10mg IV bolus followed by infusion 2-5mg/hr Tablets: Tricyclic Antidepressants ·          Amitriptyline, Doxepine, Trazadone, Nortriptyline ·          Prolonged QT, Widened