Download case 9: stable tachycardia

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ACLS STUDY GUIDE
Unacceptable Actions
Recognize sinus tachycardia, AVNRT, AVRT, AT, junctional tachycardia, monomorphic VT, polymorphic VT, and wide-complex
tachycardia of unknown origin
Give O2, start an IV, obtain vital signs, attach a pulse oximeter and
cardiac monitor, obtain a 12-lead ECG
Obtain a history and perform a physical exam, recognizing a symptomatic tachycardia
Know the actions, indications, dosages, side effects, and contraindications for the drugs used in the treatment of a narrow-QRS or
wide-QRS tachycardia
Deliver the correct type of energy (synchronized cardioversion versus defibrillation) and the correct energy level for the tachycardia if
electrical therapy is indicated
Demonstrate safe operation of the defibrillator, including turning
off the O2 flow during each shock if electrical therapy is indicated
Perform synchronized cardioversion as indicated
Recognize the need to change from synchronized cardioversion to
defibrillation if the patient goes into pulseless VT or VF
Failure to use personal protective equipment
Failure to start an IV
Failure to correctly identify the ECG rhythm
Inability to quickly determine if the patient is stable or unstable
Failure to press the sync control after delivery of an initial synchronized shock to deliver additional synchronized shocks (if necessary)
Medication errors
Failure to monitor the cardiac rhythm in any patient who displays
an abnormal respiratory rate or effort, abnormal heart rate, perfusion, BP, or acute altered mental status
C AS E 9 : STA B L E TA CH YCARDIA
Objective
Skills to Master
Rhythms to Master
Medications to Master
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Given a patient situation, describe and demonstrate the initial
emergency care for a stable but symptomatic patient with a narrow
or wide-QRS tachycardia.
Primary and secondary surveys
Supplemental O2 delivery devices
Attachment and use of ECG monitoring leads
IV access
IV drug administration
Sinus tachycardia
AVNRT
AVRT
AT
Junctional tachycardia
Monomorphic VT
Polymorphic VT
Wide-complex tachycardia of unknown origin
O2
Adenosine
Amiodarone
Beta-blockers
Diltiazem
Magnesium sulfate
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CHAPTER 9 ■
Related Text Chapters
Case Studies
539
Procainamide
Sotalol
Verapamil
Chapter 1: The ABCDs of Emergency Cardiac Care
Chapter 2: Airway Management: Oxygenation and Ventilation
Chapter 3: Rhythm Recognition
Chapter 4: Electrical Therapy
Chapter 5: Vascular Access and Medications
Chapter 8: Putting It All Together
CASE 9: QUESTIONS
SCENARIO: A 67-year-old man presents with a complaint of a “racing heart.” You have
four ALS personnel to assist you. Emergency equipment is available. The scene is safe.
1. As you put on personal protective equipment and form a first impression, you see an anxious-appearing man sitting in a chair. His breathing is unlabored. His skin appears pink.
How would you like to proceed?
2. As you approach, the patient immediately begins speaking to you. He tells you that his
heart is racing and he is worried that he is going to die. The patient’s respiratory rate is 18
and unlabored. His radial and carotid pulses are strong but too fast to count accurately.
You estimate the rate to be about 200/min. His skin is cool, pale, and moist. What should
be done now?
3. The patient’s vital signs are as follows: BP 156/90, heart rate is 214, and respirations 20.
Breath sounds are clear and equal bilaterally. The patient’s SpO2 on room air was 95%
and is now 98% on O2 by nonrebreather mask. The patient has been placed on the cardiac monitor (see SAMPLE history and physical examination tables). What is the rhythm
on the monitor? How would you like to proceed?
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ACLS STUDY GUIDE
TABLE 9-17. CASE 9
SAMPLE History
Signs/symptoms
“Racing heart”
Allergies
Bactrim
Medications
Glyburide, Prevacid
Past medical history
Diabetes, hypertension
Last oral intake
Sugar-free 2 hours ago
Events prior
Sudden onset of “racing heart”; symptoms started 40 minutes ago.
TABLE 9-18. CASE 9
Physical Examination Findings
Head, ears, eyes, nose, and throat
No abnormalities noted.
Neck
Trachea midline, no jugular venous distention
Chest
Breath sounds are clear bilaterally.
Abdomen
No abnormalities noted.
Pelvis
No abnormalities noted.
Extremities
No abnormalities noted.
Posterior body
No abnormalities noted.
4. An IV has been started. A 12-lead ECG has been ordered. How would you like to proceed?
5. A cardiology consult has been requested. The cardiologist is en route and is expected to
arrive in about 20 minutes. Amiodarone has been given as ordered. What would you like
to do next?
6. The monitor now shows the following rhythm (see SAMPLE history and physical examination tables). The patient’s BP is 134/70, his heart rate is 94, and respirations are 16. His
skin is now warm, pink, and dry. The patient states he “feels great.” What should be done
now?
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CASE 9: ANSWERS
1. Approach the patient and begin a primary survey.
2. Ask a team member to attach a pulse oximeter and place the patient on a cardiac monitor.
Ask your team members to place the patient on O2 by nonrebreather mask and obtain the
patient’s baseline vital signs while you obtain a SAMPLE history and perform a focused
physical examination.
3. The monitor shows monomorphic VT. Ask the airway team member to place the patient on
O2 by nonrebreather mask. Ask the IV team member to start an IV of normal saline. Order
a 12-lead ECG.
4. It is best to consult a cardiologist when treating a patient who has a wide-QRS tachycardia. Stable but symptomatic patients whose signs and symptoms are due to a wide-QRS
tachycardia are treated with O2, IV access, and ventricular antiarrhythmics (such as amiodarone) to suppress the rhythm.
5. Repeat the primary survey, obtain another set of vital signs, and check the cardiac monitor
to assess the patient’s response to your treatment.
6. The monitor now shows a sinus rhythm. Continue to monitor the patient’s ECG and vital
signs closely. Because amiodarone converted the rhythm from VT to a sinus rhythm, consult with the cardiologist about starting a continuous IV infusion of amiodarone.
CASE 9: SCENARIO SHEET
SCENARIO: A 67-year-old man presents with a complaint of a “racing heart.” You have
four ALS personnel to assist you. Emergency equipment is available.
EMERGENCY
ACTIONS STEPS
Scene Survey
NECESSARY TASKS
I am putting on personal protective equipment. Is the scene safe
to enter?
Coach: The scene is safe.
INITIAL ASSESSMENT
First Impression
As I approach the patient and form a first impression (assessing
the patient’s appearance, work of breathing, and circulation),
what do I see?
Coach: You see an anxious appearing man sitting in a chair. His
breathing is unlabored. His skin appears pink. How would you like
to proceed?
PRIMARY SURVEY
Responsiveness/Airway
Breathing
Circulation
Defibrillation
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I will approach the patient and begin a primary survey. Is the patient
aware of my approach? Does he respond when I speak his name?
Coach: As you approach, the patient immediately begins speaking
to you. He tells you that his heart is racing and he is worried that he
is going to die.
What is the rate and quality of the patient’s breathing?
Coach: The patient’s respiratory rate is 18 and unlabored.
What is his pulse rate and quality? What is his skin condition?
Coach: His radial and carotid pulses are strong but too fast to count
accurately. You estimate the rate to be about 200/min.His skin is
cool, pale, and moist.
I will assist the patient to a supine position and make sure a defibrillator is within reach.
Coach: A biphasic defibrillator is available to you.
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SECONDARY SURVEY/FOCUSED HISTORY & EXAM
Vital Signs/History
Airway, Breathing,
Circulation
Differential Diagnosis,
Evaluates Interventions
I want a team member to attach a pulse oximeter and place the
patient on a cardiac monitor. I will ask the airway team member to
place the patient on oxygen by nonrebreather mask. I want a
team member to obtain the patient’s baseline vital signs while I
obtain a SAMPLE history from the patient and perform a focused
physical exam. What are the patient’s vital signs?
Coach: The patient’s vital signs are as follows: BP 156/90, heart
rate is 214, and respirations 20. Breath sounds are clear and equal
bilaterally. The patient’s SpO2 on room air was 95% and is now
98% on O2 by nonrebreather mask. The patient has been placed
on the cardiac monitor. (See Case 9 SAMPLE history and physical
exam findings tables.) What is the rhythm on the monitor? How
would you like to proceed?
The monitor shows monomorphic ventricular tachycardia. I want
the IV team member to start an IV of normal saline and I want to
order a 12-lead ECG.
Coach: An IV has been started. A 12-lead ECG has been ordered.
Based on the patient’s history and physical findings, I believe the
patient is stable at this time. Since the rhythm is monomorphic
VT, I will ask the IV team member to give 150 mg of amiodarone
IV over 10 minutes.
Coach: Amiodarone has been given as ordered. What would you
like to do next?
POSTRESUSCITATION SUPPORT/ONGOING ASSESSMENT
Begins Postresuscitation I would like to order a cardiology consult as soon as possible. I
Support/Performs
want to repeat the primary survey and obtain another set of vital
Ongoing Assessment
signs. Has there been any change in the patient’s rhythm or in the
patient’s condition?
Coach: A cardiology consult has been requested. The cardiologist
is en route and is expected to arrive in about 20 minutes. The monitor now shows the following rhythm. The patient’s blood pressure
is 134/70, his heart rate is 94, and respirations are 16. His skin is
now warm, pink, and dry. The patient states he “feels great.” What
should be done now?
I will continue to monitor the patient’s ECG and vital signs closely.
I will consult with the cardiologist about starting a continuous IV
infusion of amiodarone.
CASE 9: ESSENTIAL ACTIONS
Essential Actions
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Ensure scene safety, use personal protective equipment
Perform primary and secondary surveys
Quickly recognize if the patient is stable or unstable
Quickly identify the ECG rhythm, determining if the QRS is narrow
or wide, regular or irregular
Give O2, start an IV, obtain vital signs, attach a pulse oximeter and
cardiac monitor, obtain a 12-lead ECG
Recognize sinus tachycardia, AVNRT, AVRT, AT, junctional tachycardia, monomorphic VT, polymorphic VT, and wide-complex
tachycardia of unknown origin
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Unacceptable Actions
Case Studies
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Know what a vagal maneuver is, types, and when they are performed
Know the actions, indications, dosages, side effects, and contraindications for the drugs used in the treatment of a narrow-QRS or
wide-QRS tachycardia
Failure to use personal protective equipment
Failure to start an IV
Failure to correctly identify the ECG rhythm
Inability to quickly determine if the patient is stable or unstable
Failure to give O2 and/or other drugs appropriate for the dysrhythmia
Medication errors
Failure to monitor the cardiac rhythm in any patient who displays
an abnormal respiratory rate or effort, abnormal heart rate, perfusion, BP, or acute altered mental status
C AS E 10 : A CUT E I S CH EM I C
S T R O KE
Objective
Skills to Master
Rhythms to Master
Medications to Master
Related Text Chapters
Given a patient situation, describe and demonstrate the initial
emergency care for a patient experiencing an acute ischemic
stroke.
Primary and secondary surveys
Supplemental O2 delivery devices
Attachment and use of ECG monitoring leads
Suctioning
Serum glucose determination
IV access
IV drug administration
Atrial fibrillation
Sinus rhythm
O2
Fibrinolytics
Dextrose (if documented hypoglycemia)
Thiamine (if malnourished or alcoholic individual)
Chapter 1: The ABCDs of Emergency Cardiac Care
Chapter 2: Airway Management: Oxygenation and Ventilation
Chapter 3: Rhythm Recognition
Chapter 5: Vascular Access and Medications
Chapter 7: Stroke and Special Resuscitation Situations
CASE 10: QUESTIONS
SCENARIO: A 76-year-old man presents with a sudden onset of difficulty speaking.
The patient’s anxious wife is present. You have four ALS personnel to assist you. Emergency equipment is available. The scene is safe.
1. As you put on personal protective equipment and form a first impression, you see a patient supine in bed. He is awake and aware of your presence. You see equal rise and fall
of his chest. His skin is pink and appears dry. How would you like to proceed?
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