Sandbox/WCT 1

Identify cardinal findings that increase the pretest probability of wide complex tachycardia ❑ Palpitations ❑ QRS complex > 120 ms ❑ Heart rate > 150 beats/min

Does the patient have any of the following findings that require urgent cardioversion? ❑ Hemodynamic instability ❑ Hypotension ❑ Cold extremities ❑ Peripheral cyanosis ❑ Mottling ❑ Altered mental status ❑ Chest discomfort suggestive of ischemia ❑ Decompensated heart failure

❑ Yes

❑ No

❑ Continue with the complete diagnostic approach below

Prepare the patient for immediate cardioversion and simultaneously do the following: ❑ Maintain patent airway; assist breathing as necessary ❑ Adminster oxygen (if the patient is hypoxemic) ❑ Cardiac monitor to identify rhythm; monitor blood pressure and oximetry ❑ Give IV sedation if the patient is conscious (don't delay cardioversion to sedate the patient) ❑ Consider expert consultation

VT/VF in the form of cardiac arrest Click here for Cardiac arrest resident survival guide

Unsynchronized cardioversion ❑ If a patient has polymorphic VT and is unstable, treat the rhythm as VF and deliver high-energy unsynchronized shocks ❑ Provide an initial shock of 200 Joules ❑ Increase the dose if no response to the first shock (eg, 300 J, 360 J, 360 J)

Synchronized cardioversion

❑ Urgent synchronized cardioversion ❑ Provide an initial shock of 100 Joules ❑ If there is no response to the first shock, increase the dose in a stepwise fashion (eg, 100 J, 200 J, 300 J, 360 J) ❑ If a patient has polymorphic VT and is unstable, treat the rhythm as VF and deliver high-energy unsynchronized shocks ❑ Provide an initial shock of 200 Joules ❑ Increase the dose if no response to the first shock (eg, 300 J, 360 J, 360 J)

❑ After the stabilization of the patient, continue with the complete diagnostic approach below