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In this scenario, we will be covering both stable and unstable tachycardia. Your patient is a conscious and alert 35-year-old male. You start by asking him how he feels. Your primary assessment reveals that he is responsive, his airway's open, and he's breathing rapidly. The patient was at work during a very stressful day when the symptoms abruptly started about an hour ago. The patient's chief complaint is that his heart's racing, he feels dizzy and weak. Now, since the patient does not immediately have any life threatening conditions, we direct a team member to get a set of vitals. The vitals are as follows, the pulse is 188, respirations are 24, blood pressure is 110 over 70, and the skin is cool and pale, and the O2 sat is 92%. Now, based on the O2 sat, we need to start oxygen, and we're gonna do so at four liters via nasal cannula. The goal is to titrate oxygen to keep an O2 sat of at least 94% or better. After the oxygen has been started, we need to get an ECG monitor on this patient. When the monitor is applied, we see a narrow complex supraventricular tachycardia. Since the patient's stable, we direct the team member to try vagal maneuvers first. But this didn't work, so we opt for drug therapy next. We direct a team member to start an antecubital IV, 18 gauge with normal saline at a TKO rate. Now that the IV is established, we decide to try adenosine six mg rapid IV push. Remember, a second dose of 12 mg can be given one to two minutes later if the first dose does not work and the patient is still stable. So, for the first dose, you direct a team member to give six mg adenosine rapid IV push. Remind the team member to flush the line with 20 ml of saline afterwards to be able to get that right into the body. As you look at the monitor, you see that the patient is still in SVT. We direct the team member to get another set of vitals. Vitals are as follows, pulse is still 174 and weak, respirations are 18 and shallow, with a blood pressure now of 94 over 70, the skin is cool and pale, O2 sat is 94%. As we begin to think about getting a 12 lead EKG, the patient goes unconscious. Now that you have an unstable patient, you direct the defib team member to perform a synchronized cardioversion. The pads are applied and the defibrillator is set for a synchronized shock at 50 joules. The defibrillator team member says, "Clear, charging, shocking at 50 joules on three, "one, two, three, shock delivered." As you look at the monitor, you see a normal sinus rhythm of 80 breaths per minute. The rhythm has been successfully converted. The patient becomes conscious after a few seconds. And at this time, you direct a team member to get another set of vitals and continue to monitor the patient.
In this lesson, we're going to let you play the role of team leader during a cardiac emergency – stable and unstable tachycardia. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations.
In this scenario, you've been presented with a 35-year-old male patient who is conscious and alert. You begin by asking him how he feels. During your primary assessment, you find him to be responsive, his airway open, and his breathing is rapid.
He tells you that symptoms began while he was at work. It was a very stressful day and symptoms began about an hour before you saw him. His chief complaints are that his heart feels like it's racing, he's experiencing some dizziness, and also some weakness.
Your initial assessment recap:
Since the patient doesn't appear to have any life-threatening conditions, you direct a team member to get a good set of vitals. A member of your team a few minutes later tells you that the patient's vital signs are:
Based on his O2 saturation, you decide to start oxygen immediately and you do so at 4 liters via nasal cannula. Your goal is to titrate oxygen to keep his O2 saturation level at 94 percent or higher.
After oxygen has been started, you then decide that you need to get an ECG reading. You ask a team member to do this and after an ECG has been attached and you look at the readout, you see a narrow complex supraventricular tachycardia (SVT).
Since the patient is stable, you direct a team member to first try vagal maneuvers. However, that didn't work, so you now opt for drug therapy and direct a team member to start an antecubital IV 18 gauge with normal saline at a TKO rate.
Now that you have the IV established, you decide to try administering adenosine at 6mg via rapid IV push. You remind the team member in charge of medications to flush the line with 20ml of saline after giving the adenosine, so the medication gets completely into the central circulatory system.
You begin to consider a second dose of adenosine at 12mg in 1 to 2 minutes if this first dose doesn't work and if the patient is still stable.
After that first dose of adenosine, you take a look at the monitor and see that the patient is still in SVT. You direct a team member to get a new set of vitals. The team member comes back with the following information:
As you begin to consider getting a 12 lead ECG attached to the patient, he suddenly goes unconscious. Now that you have an unstable patient, that possible second dose of adenosine is off the table, so you direct the defibrillator team to perform synchronized cardioversion.
The defibrillator pads are applied, and the defibrillator is set for a synchronized shock of 50 joules. A defibrillator team member announces, Clear, charging, shocking at 50 joules on 3 – 1,2,3, and delivers a shock to the patient.
You again look at the monitor to see if there are any changes in the patient's rhythm, and this time, you see a normal sinus rhythm at 80 beats per minute. The patient's rhythm has been successfully converted.
The patient begins to regain consciousness after a few seconds. As he is becoming more responsive, you direct a team member to get a new set of vitals, as you continue to monitor the patient for changes.