Arrest on the medicine ward

Arrest on the medicine ward

Learning Objectives:

1. Describe the primary ABCD survey.

2. Identify ventricular tachycardia by ECG criteria.

3. Describe the treatment of pulseless ventricular tachycardia.

Primary ABCD Survey:

A. Airway - open airway, assess breathing.

B. Breathing - give two breaths.

C. Circulation - assess circulation, if absent start chest compressions.

D. Defibrillation - attach AED or monitor/defibrillator when available.

ECG Criteria for Ventricular Tachycardia:

1. The heart rate is fast and the rhythm is regular for monomorphic ventricular tachycardia, irregular for polymorphic v tach.

2. The QRS complex is wide.

3. P waves are not apparent. P waves are sometimes identifiable but they bear no relationship to the QRS complexes.

4. The relationship between the P waves and QRS complexes cannot be defined since P waves cannot be identified.

5. Ventricular tachycardia is present with three or more beats of ventricular origin in a row.

6. It can be difficult to distinguish ventricular tachycardia from supraventricular tachycardia with aberrant conduction. When in doubt assume the rhythm is ventricular tachycardia.

Treatment for Pulseless V Tach:

(Same as for ventricular fibrillation)

1. If the patient does not respond to the initial electrical defibrillation attempts, you must treat hypoxia. Establish an airway (intubation is ideal), ventilate with supplemental oxygen, and perform chest compressions.

2. Reassess to ensure adequate ventilation and pulse with CPR.

3. Establish intravenous access. Try to interrupt CPR as little as possible. Peripheral IV access is adequate.

4. Epinephrine or vasopressin should be administered to increase perfusion pressure. Administer epinephrine (1 mg IV bolus) or vasopressin 40 U IV and shock again. Repeat epinephrine every 3-5 minutes.

Epinephrine in V Fib and Pulseless V Tach Treatment:

1. Epinephrine is administered as a vasoconstrictor to improve coronary and cerebral perfusion.

2. There is indeterminate evidence that it is helpful.

3. The recommended dose is 1 mg IV every 3-5 minutes.

4. Higher doses are acceptable but may be harmful.

Vasopressin in V Fib and Pulseless V Tach Treatment:

1. Vasopressin is an acceptable alternative vasoconstrictor during ventricular fibrillation and pulseless ventricular tachycardia resuscitation.

2. The recommended dose is 40 U IV push once, as a substitute for the first dose of epinephrine.

3. If there is no response a couple minutes after vasopressin, it is acceptable to use epinephrine boluses.