TCP and Cardioversion

Lets discuss Trancutaneous Cardiac pacing (TCP) and Cardioversion. For TCP, we use this when our patients are experiencing symptomatic bradycarida. For cardioversion, we use this when our patients are experiencing symptomatic VTACH or SVT. TCP and cardioversion can be done without contacting medical control first (at least in my area). If at all possible, try to give medication before you attempt to TCP or Cardiovert your patient. First, we will look at the pharmacological aspect of treating a patient, then we will look at the actual TCP and Cardioversion of our patients.

Note: For this post, we are going to be referring to the LifePak 12. Make sure that you understand and know how to use your monitor.


PART 1 - Pharmacological 
Pharmacological care of the Bradycardic, VTACH, and SVT patient. Remember to always establish an IV, give oxygen, and hook patient up to monitor (12-lead)

> For the stable bradycardic patient
         -Monitor patient closely (pulse, BP, resp, ECG monitoring, etc)

> For the unstable bradycardic patient
         -Atropine 0.5mg IVP (max of 3mg)
         -Move into TCP right away if Atropine is ineffective

> For the stable VTACH or SVT patient
         -Monitor patient closely (pulse, BP, resp, ECG monitoring, etc)
         -Narrow QRS        
              -Vagal maneuvers
              -Adenosine for SVT, 6mg --> 12 mg
         -Wide QRS
              -Adenosine for SVT, 6mg --> 12 mg (only if regular)
              -Amiodarone 150mg over 10 min (in a 250mL bag of D5W, wide open)

> For the unstable VTACH or SVT patient
         -Move into Cardioversion

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PART 2 - TCP and Cardioversion 
Treating your patient by using the defibrillator in the pacing or cardioversion mode. Remember to always establish and IV, give oxygen, and attach patient to monitor and defibrillator pads as indicated.

TCP
We are able to pace a patient who is experiencing symptomatic bradycardia as occur with high-degree AV blocks, AFIB with slow ventricular response, and other significant bradycardia's. Mainly, TCP is used when pharmacological interventions, such as Atropine, have no effect, and the patient is hypotensive or hypoperfusing.

Steps for TCP

• IV Access
• Oxygen
• ECG monitoring
• Place pt supine
• Apply the electrodes to the patient and connect them (limb leads)
• Confirm symptomatic bradycardia 
• Apply the pacing pads to the patient and connect them 
• Press the "Pacer" button
• You should see a long lines once you hit the "pacer" button
• These are your pacer-markers
• Set the desired HR on the monitor
• Start at a HR of 60
• Turn the output setting to 10mAmps
• Slowly increase the output setting until you have ventricular capture 
• Every pacer-marker (long line) is followed by a QRS complex
• Once you have good capture, increase the output setting to the next level up
• Reevaluate your patient (BP, Pulse, Resp, etc.)
• Monitor your patient's response
• Rapid transport 
• Remember, you are able to pace a patient while transporting

Now let's say that everything is working fine, and you are now taking control of the patient's heart rate. But now, your patient is hypotensive. The best and fastest way to increase your patient's BP, while you are pacing them, is to increase the HR on the monitor but one setting. You can max out at a HR of 80 per the monitor setting. If still unsuccessfully, give a fluid bolus of NS.

Cardioversion

Cardioversion is used for patients who are experiencing tachycardia, or SVT. The patient MUST have a pulse. This is a synchronized circuit in the defibrillator that will interpret the QRS, and deliver a shock during the R wave of the QRS complex. Indications for cardioversion include VTACH with a pulse, and SVT.

Steps for Cardioversion

• IV Access
• Oxygen
• ECG monitoring
• Place patient supine 
• Apply electrodes to patient, and connect them (limb leads)
• Confirm VTACH or SVT on monitor
• Determine if your patient is stable or unstable 
• Apply defibrillator pads to patient, and connect them
• Press the "SYNC" button
• There should be triangular markers for every R wave in the QRS complex 
• Increase the amps as indicated
• VTACH ----> 100 J
• SVT ---------> 50 J
• Press the "Charge" button
• Press and hold the "SHOCK" button
• This will make sure that the shock is delivered during the R wave of the QRS
• Reevaluate your patient (Pulse, BP, Monitor, etc)
• If there is no change, increase the amps to the next level setting*
• BEFORE YOU CARDIOVERT AGAIN, make sure the "SYNC" button is lit*
• If it is not lit, you will do a normal shock, possibly causing your patient to go into cardiac arrest. 
• Reevaluate your patient (Pulse, BP, Monitor, etc)
• If still no change, continue to increase the amps of the monitor until you have reached 360 J
• Reevaluate your patient after EVERY synchronized shock (Pulse, BP, Monitor, etc)
• Rapid transport
• Remember, you are able to cardiovert a patient while transporting

*Always make sure that the "SYNC" button is lit. If it is not lit, you will not have a synchronized cardiovert, and you could cause your patient to go into cardiac arrest. By having the "SYNC" button lit, you are causing a synchronized cardiovert, which will deliver the shock during the R wave of the QRS only.