Wide complex tachycardia medical therapy: Difference between revisions
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* Do not use Ca<sup>2+</sup> channel blocker, [[digoxin]] or [[adenosine]] if you don't not know the etiology of the wide complex tachycardia. Ca<sup>2+</sup> channel blockers and digoxin can lead to accelerated conduction down a bypass tract and [[VF]]. | * Do not use Ca<sup>2+</sup> channel blocker, [[digoxin]] or [[adenosine]] if you don't not know the etiology of the wide complex tachycardia. Ca<sup>2+</sup> 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. | * 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. |
Revision as of 20:53, 3 August 2013
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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? | SVT with aberrancy? | Afib with aberrancy? | Pre-excited Afib (Afib + WPW) | Recurrent polymorphic VT? | Torsades de pointes? | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
- Give amiodarone 150 mg IV over 10 min Repeat as needed for a maximal dose of 2.2g/24h - Prepare for elective synchronized cardioversion | - Give adenosise 6 mg rapid IV push - If no conversion give 12 mg IV push - May repeat 12 mg dose once | - Consider expert consultation - Control rate e.g diltiazem or beta blockers Use beta blockers with caution in pulmonary diseases or CHF | - Consider expert consultation - Avoid AV nodal blocking agents e.g adenosine, digoxin, diltiazem and verapamil - Consider amiodarone 150 mg IV over 10 min | Consider expert consultation | Magnesium Load with 1-2 g over 5-60 min, then infusion | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
- 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