Wide complex tachycardia medical therapy

Wide complex tachycardia Microchapters
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Differentiating VT from SVT with aberrant conduction
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Medical Therapy

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• If stable: (More patients than you think)
• Do not use Ca²⁺ channel blocker, digoxin or adenosine if you don't not know the etiology of the wide complex tachycardia. Ca²⁺ channel blockers and digoxin can lead to accelerated conduction down a bypass tract and VF.
• Though ACLS guidelines recommend a diagnostic trial of adenosine, it can precipitate VF in some patients with SVT. Patients who have underlying coronary disease may become ischemic from coronary steal. Rhythm can degenerate and lead to VF that cannot be resuscitated. Furthermore, some VT (specially those with structurally normal hearts) are adenosine responsive and can terminate.

  1. Etiology uncertain

     • Pronestyl 15 mg/kg load over 30 minutes then 2-6 mg/min gtt

  2. Ventricular tachycardia with active ischemia

     • Lidocaine 1 mg/kg q5-10 min up to 3 times then 2-6 mg/min gtt
     • If unsuccessful, pronestyl as above
     • If unsuccessful, IV amiodarone 150-300 load over 15-20 min. 30-60 mg/hr gtt for total of 1 gram

  3. Ventricular tachycardia in setting of cardiomyopathy

     • Skip lidocaine and go straight to pronestyl

  4. Positively SVT with aberrancy

     • Adenosine 6 mg rapid IV bolus in large vein. May repeat with 12 mg x2.
     • Lopressor 2.5-5.0 mg IV
     • Diltiazem 10-20 mg bolus followed by gtt 5-20 mg/hr
     • Verapamil 2.5-5.0 mg bolus.
     • Avoid digoxin. Takes too long to work and can be proarrhythmic
     • Pronestyl as above

  5. Antidromic AVRT

     • If 100% positive AF is not underlying, can terminate with a nodal blocker
     • If unsure, pronestyl as above

Defibrillation

Indications for defibrillation include the following:

• Chest pain
• Congestive heart failure (CHF)
• Hypotension with symptoms
• Loss of consciousness
• Seizure