A -year-old man with a history of prior myocardial infarction and ischemic cardiomyopathy is brought to the emergency department after a witnessed episode of near-syncope at home. Upon arrival, he appears pale and lethargic but withdraws to painful stimuli. His vital signs show a temperature of (), a heart rate of , a blood pressure of , and a respiratory rate of . Continuous cardiac monitoring reveals a regular, wide-complex tachycardia. His oxygen saturation is on room air.
Based on the Advanced Cardiovascular Life Support (ACLS) guidelines, arrange the following acute management steps in the correct sequential order for this patient.
- 1Rapid assessment of airway patency and confirmation of hemodynamic instability
- 2Administration of procedural sedation
- 3Delivery of synchronized electrical cardioversion
- 4Administration of an intravenous antiarrhythmic infusion
Answer
The correct sequence for managing this unstable wide-complex tachycardia is to first assess for instability, administer procedural sedation, perform synchronized electrical cardioversion, and utilize antiarrhythmic infusions if the rhythm is refractory.
According to the ACLS Tachycardia with a Pulse algorithm, the first step is to assess the clinical condition and identify signs of instability (e.g., hypotension, altered mental status). This patient is hypotensive () and lethargic, confirming instability. Because he is responsive to pain, procedural sedation is indicated next to minimize the trauma of the shock. This is immediately followed by synchronized electrical cardioversion, the definitive treatment for unstable tachycardia. Antiarrhythmic drugs are only administered subsequently if the cardioversion fails to maintain a normal rhythm.
Step-by-Step Solution
Key Concept
The management of unstable wide-complex tachycardia requires immediate synchronized electrical cardioversion following procedural sedation. Antiarrhythmic therapy is reserved for refractory cases or hemodynamically stable patients.
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