Wide complex tachycardia medical therapy: Difference between revisions
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{{familytree | | | | | | | | | | | | | | | A01 | | | | | A01='''Wide complex tachycardia'''<br>[[QRS]] ≥ 120ms}} | {{familytree | | | | | | | | | | | | | | | A01 | | | | | A01='''Wide complex tachycardia'''<br>[[QRS]] ≥ 120ms}} | ||
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | }} | {{familytree | | | | | | | | | | | | | | | |!| | | | | | | }} | ||
{{familytree | | | | | | | | | | | | | | | A02 | | | | | | A02='''Do the following simultaneously:'''<br>- Assess and support ABC's as needed<br>- Give [[oxygen therapy|oxygen]]<br>- Monitor [[ECG]], [[BP]], [[oxygen saturation|oxymetry]]<br>- Identify and treat reversible causes}} | {{familytree | | | | | | | | | | | | | | | A02 | | | | | | A02='''Do the following simultaneously:'''<br><br>- Assess and support ABC's as needed<br>- Give [[oxygen therapy|oxygen]]<br>- Monitor [[ECG]], [[BP]], [[oxygen saturation|oxymetry]]<br>- Identify and treat reversible causes}} | ||
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | }} | {{familytree | | | | | | | | | | | | | | | |!| | | | | | | }} | ||
{{familytree | | | | | | | | | | | | | | | A03 | | | | | | A03='''Is the patient stable?'''<br>Unstable signs include:<br>- [[Chest pain]]<br>- [[Congestive heart failure]]<br>- [[Hypotension]]<br>- [[Loss of consciousness]]<br>- [[Seizures]]}} | {{familytree | | | | | | | | | | | | | | | A03 | | | | | | A03='''Is the patient stable?'''<br><br>Unstable signs include:<br>- [[Chest pain]]<br>- [[Congestive heart failure]]<br>- [[Hypotension]]<br>- [[Loss of consciousness]]<br>- [[Seizures]]}} | ||
{{familytree | | | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|-|.| | | | | | }} | {{familytree | | | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|-|.| | | | | | }} | ||
{{familytree | | | | | | | | B01 | | | | | | | | | | | | | B02 | | | B01=Yes|B02=No}} | {{familytree | | | | | | | | B01 | | | | | | | | | | | | | B02 | | | B01=Yes|B02=No}} | ||
{{familytree | | | | | | | | |!| | | | | | | | | | | | | | |!| | | | }} | {{familytree | | | | | | | | |!| | | | | | | | | | | | | | |!| | | | }} | ||
{{familytree | | | | | | | | C01 | | | | | | | | | | | | | C02 | | | C01='''Is the rhythm regular?'''|C02='''Immediate [[synchronized cardioversion]]'''<br>-Establish IV access | {{familytree | | | | | | | | C01 | | | | | | | | | | | | | C02 | | | C01='''Is the rhythm regular?'''|C02='''Immediate [[synchronized cardioversion]]'''<br><br>-Establish IV access<br>- Give IV [[sedation]] if the patient is conscious<br>- Consider expert consultation}} | ||
{{familytree | | | | | | |,|-|^|-|-|-|-|-|-|-|-|-|.| | | | }} | {{familytree | | | | | | |,|-|^|-|-|-|-|-|-|-|-|-|.| | | | }} | ||
{{familytree | | | | | | D01 | | | | | | | | | | D02 | | | D01=Regular| D02=Irregular}} | {{familytree | | | | | | D01 | | | | | | | | | | D02 | | | D01='''Regular rhythm'''| D02='''Irregular rhythm'''}} | ||
{{familytree | | | | |,|-|^|-|.| | | |,|-|-|-|v|-|^|-|v|-|-|-|.| |}} | {{familytree | | | | |,|-|^|-|.| | | |,|-|-|-|v|-|^|-|v|-|-|-|.| |}} | ||
{{familytree | | | | E01 | | E02 | | E03 | | E04 | | E05 | | E06 | E01='''[[Ventricular tachycardia]] or uncertain rhythm?'''<br><br>'''Amiodarone''' 150 mg IV over 10 min<br>Repeat as needed for a maximal dose of 2.2g/24h<br><br>Prepare for elective synchronized cardioversion|E02='''[[SVT]] with aberrancy?'''<br><br>'''[[Adenosise]]''' 6 mg rapid IV push<br><br>If no [[conversion]] give 12 mg IV push<br><br>May repeat 12 mg dose once|E03='''[[Afib]] with aberrancy?'''<br><br>Consider expert consultation<br><br>Control rate e.g [[diltiazem]] or [[beta blocker]]s<br>Use [[beta blocker]]s with caution in [[pulmonary disease]]s or [[CHF]]|E04='''Pre-excited [[Afib]] ([[Afib]] + [[WPW]])'''<br><br>Consider expert consultation<br><br>Avoid AV nodal blocking agents<br>e.g [[adenosine]], [[digoxin]], [[diltiazem]] and [[verapamil]]<br><br>Consider [[amiodarone]] 150 mg IV over 10 min|E05='''Recurrent polymorphic [[VT]]?'''<br><br>Consider expert consultation|E06='''[[Torsades de pointes?]]'''<br><br>Magnesium<br>Load with 1-2 g over 5-60 min, then infusion}} | {{familytree | | | | E01 | | E02 | | E03 | | E04 | | E05 | | E06 | E01='''[[Ventricular tachycardia]] or uncertain rhythm?'''<br><br>- '''Amiodarone''' 150 mg IV over 10 min<br><br>Repeat as needed for a maximal dose of 2.2g/24h<br><br>- Prepare for elective synchronized cardioversion|E02='''[[SVT]] with aberrancy?'''<br><br>- '''[[Adenosise]]''' 6 mg rapid IV push<br><br>- If no [[conversion]] give 12 mg IV push<br><br>- May repeat 12 mg dose once|E03='''[[Afib]] with aberrancy?'''<br><br>- Consider expert consultation<br><br>- Control rate e.g [[diltiazem]] or [[beta blocker]]s<br>Use [[beta blocker]]s with caution in [[pulmonary disease]]s or [[CHF]]|E04='''Pre-excited [[Afib]] ([[Afib]] + [[WPW]])'''<br><br>- Consider expert consultation<br><br>- Avoid AV nodal blocking agents<br>e.g [[adenosine]], [[digoxin]], [[diltiazem]] and [[verapamil]]<br><br>- Consider [[amiodarone]] 150 mg IV over 10 min|E05='''Recurrent polymorphic [[VT]]?'''<br><br>Consider expert consultation|E06='''[[Torsades de pointes?]]'''<br><br>'''Magnesium'''<br>Load with 1-2 g over 5-60 min, then infusion}} | ||
{{familytree/end}} | {{familytree/end}} | ||
Revision as of 20:44, 3 August 2013
Wide complex tachycardia Microchapters |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Medical Therapy
Wide complex tachycardia QRS ≥ 120ms | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Do the following simultaneously: - Assess and support ABC's as needed - Give oxygen - Monitor ECG, BP, oxymetry - Identify and treat reversible causes | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Is the patient stable? Unstable signs include: - Chest pain - Congestive heart failure - Hypotension - Loss of consciousness - Seizures | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Is the rhythm regular? | Immediate synchronized cardioversion -Establish IV access - Give IV sedation if the patient is conscious - Consider expert consultation | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Regular rhythm | Irregular rhythm | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Ventricular tachycardia or uncertain rhythm? - Amiodarone 150 mg IV over 10 min Repeat as needed for a maximal dose of 2.2g/24h - Prepare for elective synchronized cardioversion | SVT with aberrancy? - Adenosise 6 mg rapid IV push - If no conversion give 12 mg IV push - May repeat 12 mg dose once | Afib with aberrancy? - Consider expert consultation - Control rate e.g diltiazem or beta blockers Use beta blockers with caution in pulmonary diseases or CHF | Pre-excited Afib (Afib + WPW) - Consider expert consultation - Avoid AV nodal blocking agents e.g adenosine, digoxin, diltiazem and verapamil - Consider amiodarone 150 mg IV over 10 min | Recurrent polymorphic VT? Consider expert consultation | Torsades de pointes? Magnesium Load with 1-2 g over 5-60 min, then infusion | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
- 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.
- Etiology uncertain
- Pronestyl 15 mg/kg load over 30 minutes then 2-6 mg/min gtt
- 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
- Ventricular tachycardia in setting of cardiomyopathy
- Positively SVT with aberrancy
- Antidromic AVRT
- Etiology uncertain
Defibrillation
Indications for defibrillation include the following:
- Chest pain
- Congestive heart failure (CHF)
- Hypotension with symptoms
- Loss of consciousness
- Seizure