Option 1: Unstable tachycardia

The patient has signs of unstable tachycardia. She is hypotensive and confused. The nurse states that the patient's condition has deteriorated since they sent the page a few minutes ago. You confirm that the patient is full code and ask the nurse to call the rapid response team. With more help on the way, your team begins stabilizing the patient. The senior resident and attending allow you to take the lead.

Question: What do you do next?

Make your choice, then click on the explanation bubble to reveal the answer.

• Begin chest compressions.
• Examine the ECG to determine the rhythm.
• Perform an ABCDE survey.

The first step when assessing a decompensating patient is always an ABCDE survey.

You perform an ABCDE survey and determine that the patient has a pulse. What comes next?

Question: What are your initial steps for managing this patient's unstable tachycardia?

Do the following steps concurrently. Click on the explanation bubbles for more information.

• Ensure the patient is placed on continuous telemetry and pulse oximetry.
• Ask the patient's nurse to bring a crash cart, defibrillator, suction, bag-mask ventilation device, and intubation equipment to the bedside.
• Initiate supplemental oxygen if needed.
• Obtain IV access and send laboratory studies (e.g., troponin, electrolytes, venous blood gas).
• Perform immediate electrical cardioversion if tachycardia is determined to be the cause of the patient's unstable condition.

Preparation is key. For patients with tachycardia, ensure speedy delivery of potentially necessary equipment (e.g., defibrillator, intubation equipment) to the bedside, even if you don't know whether you'll need to use it.

While all patients with instability due to tachycardia will require immediate electrical cardioversion regardless of the underlying rhythm, it is still helpful to know the rhythm. Knowing the rhythm will help you determine management once the patient is stabilized.

ECG interpretation

Take some time to practice interpreting the cardiac rhythm for the following ECGs.

Your stepwise approach to management allows you to quickly stabilize the patient, and your senior resident, attending, and medical students all seem thoroughly satisfied . For a detailed dive into the appropriate approach to the tachycardic patient, see “Management of tachycardia.”

Related resources

• Management of unstable tachycardia with pulse
• Synchronized electrical cardioversion
• Defibrillation

Want to explore the other scenario? Jump over to “Option 2: Stable tachycardia.” You can also return to the main module; see “Heart in overdrive wrap-up.”