Sandbox tachy

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Tachycardia

Pulse

No Pulse

Evaluate and treat instability:

Pulseless tachycardia

❑  12-lead ECG, don't delay therapy ❑  IV/IO access ❑  Ventilation ❑  Supplementary oxygen if hypoxemic ❑  Check heart rate and blood pressure ❑  Check signs of end-organ hypoperfusion ❑  Altered mental status ❑  Cold extremities ❑  Cyanosis ❑  Oliguria (urine output <0.5 mL/kg/h) ❑  Sustained hypotension (≥30 min) ❑  SBP <90 mm Hg or ❑  MAP ↓ >30 mm Hg below baseline ❑  Ischemic chest discomfort ❑  Acute heart failure

Proceed to ACLS Cardiac Arrest Algorithm

Hemodynamic stable

Hemodynamic unstable

Check duration of QRS

Synchronized cardioversion: Consider sedation If regular narrow complex, consider adenosine

Wide complex tachycardia (≥120 ms)

Narrow complex tachycardia (<120 ms)

❑  Doses/details of synchronized cardioversion: ❑  Narrow regular: 50-100 Joule ❑  Narrow irregular: 120-200 Joule biphasic or 200 Joule monophasic ❑  Wide regular 100 Joule ❑  Wide irregular: defibrillation dose (Not synchronized) ❑  Adenosine IV dose: ❑  First dose: 6mg rapid IV push; follow with NS flush ❑  Second dose: 12mg if required

Consider expert consultation Consider antiarrhythmic infusion Consider adenosine only if monomorphic and regular

Vagal maneuvers Beta-Blockers or calcium channel blocker Consider expert consultation Adenosine if regular

Proceed to Hemodynamic instability resident survival guide

❑  Antiarrhythmic infusion for stable wide-QRS tachycardia: ❑  Procainamide IV Dose: ❑  20-50mg/min until arrhythmia suppressed, hypotension ensues, QRS duration increases 50%, or maximum dose 17mg/kg given. ❑  Maintenance infusion: 1-4 mg/min. ❑  Avoid if prolonged QT or CHF. ❑  Amiodarone IV Dose: ❑  First dose: 150mg over 10 minutes. Repeat as needed if VT recurs. ❑  Follow by maintenance infusion by 1mg/min for first 6 hours. ❑  Sotalol IV Dose: ❑  100mg (1.5mg/kg) over 5 minutes. ❑  Avoid if prolonged QT.

Proceed to Narrow complex tachycardia resident survival guide

Proceed to Wide complex tachycardia resident survival guide