Arrest on the post-op surgery ward

Arrest on the post-op surgery ward

Learning Objectives:

1. Describe treatment for pulseless ventricular tachycardia.

2. State the antiarrhythmic agent with the best evidence-based support for pulseless ventricular tachycardia and the dose.

3. Discuss the role of sodium bicarbonate in prolonged ventricular tachycardia.

4. Discuss the role of other antiarrhythmics in treating ventricular tachycardia.

Treatment for Pulseless V Tach:

(Same as 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.

Amiodarone

1. Amiodarone has better evidence-based support than any other antiarrhythmic agent for v fib and pulseless v tach.

2. Administer 300 mg IV push in cardiac arrest.

3. Consider second dose of 150 mg if ventricular fibrillation recurs.

Sodium Bicarbonate

1. Sodium bicarbonate 1 meq/kg is definitely helpful if the patient has preexisting hyperkalemia.

2. Sodium bicarbonate is probably helpful with tricyclic overdose and to alkalinize urine in drug overdoses.

3. Sodium bicarbonate is possibly helpful if intubated with continued long arrest, and upon return of spontaneous circulation following long arrest.

4. Sodium bicarbonate may be harmful in hypoxic lactic acidosis.

Other Medications in Pulseless Ventricular Tachycardia:

1. Lidocaine administration is acceptable but of indeterminate value. The dose is 1-1.5 mg/kg IV push, repeat in 3-5 min to total loading dose of 3 mg/kg.

2. Magnesium sulfate 1-2 grams IV in Torsades or suspected hypomagnesemic state or refractory VF.

3. Procainamide 30 mg/min in intermittent or recurrent VF is acceptable.

4. Bretylium is no longer recommended due to high incidence of side effects and limited supply.

5. Multiple antiarrhythmics may produce a proarrhythmic effect.