Airway management in patients with a broadcomplex tachycardia requiring electrical cardioversion: a postal survey

Abstract

This study was to determine whether or not ED and ICU consultants would intubate an unstarved, haemodynamically unstable patient with a BCT requiring electrical cardioversion, and to determine the incidence of complications for both intubating and not intubating based on the responders personal experience. 174 postal questionnaires were sent to ED and ICU consultants in the Wessex and South West regions of England. They were asked whether or not they would intubate a patient that required electrical cardioversion for a BCT with hypotension. 139 responded: 77 (56%) elected to intubate the patient always or most of the time, 34 (24%) would rarely or never intubate the patient, and 28 (20%) would only do so sometimes. Responders were aware of significant complications from both intubating and not intubating such a patient. Intubation for an unstarved patient with a haemodynamically compromising BCT would seem to occur on a variable basis. ED consultants were more likely to sedate such a patient without intubation whereas ICU consultants were more likely to intubate them. It is a well established anaesthetic practice that unstarved patients require intubation when anaesthesia is required urgently in order to protect the airway from regurgitated stomach contents during a procedure.1 However, our personal experience of the airway management for unstarved, haemodynamically unstable patients because of a broadcomplex tachycardia (BCT) seems to vary between clinical practitioners. The United Kingdom Resuscitation Council guidelines 2001 2 state that for a BCT ''anaesthesia or appropriate sedation'' is necessary to facilitate electrical cardioversion. However, there is no further explanation for how this should be achieved. The UK Academy of Medical Colleges published a report on safe sedation, which states that if sedation is used, and verbal responsiveness is lost, the patient requires a level of care identical to that needed for general anaesthesia. 3 We reviewed the literature and found no papers that addressed this scenario.The aim of our survey was to determine whether Emergency Department (ED) and Intensive Care Unit (ICU) consultants would intubate an unstarved, unstable patient with a BCT. METHODSA questionnaire was posted to all ED and ICU consultants in the Wessex and South West regions of England in September 2003. The ED consultants were identified using the BAEM 2002 directory. The ICU consultants were identified by contacting the switchboard of all hospitals in this region and asking them for the names of the current intensive care consultants.The questionnaire described a hypothetical scenario in which a 76 year old male with a BCT was hypotensive. He was not starved, but predicted to be an easy intubation and had a potassium level of 4.5 mmol/l. He specifically required electrical cardioversion.The questionnaire asked if the responder would intubate the patient always, most of the time, sometimes, rarely, or never. Subsequent questions asked about complications they had experienced or known about from int...

Anaesthesia for cardioversion

“…This issue was investigated by means of a postal survey, when it was found that only a one-third of emergency physicians, and significantly only two-thirds of intensive care physicians (mainly anaesthetists) would adopt a tracheal intubation strategy in such scenarios. 18 In the authors' opinion both approaches should be considered acceptable and the anaesthetic technique tailored to individual patient circumstances. If the patient is obese, has recently ingested a large meal, has a history of oesophageal reflux and is relatively cardiovascularly stable then a RSI approach would seem prudent.…”