Wide complex tachycardia resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

Management

Diagnostic Approach

Characterize the symptoms: ❑ Asymptomatic ❑ Palpitations ❑ Dyspnea ❑ Fatigue ❑ Chest discomfort ❑ Lightheadedness ❑ Syncope Characterize the timing of the symptoms: ❑ Onset ❑ Duration ❑ Frequency

Identify possible triggers: ❑ Infection ❑ Caffeine ❑ Alcohol ❑ Nicotine ❑ Recreational drugs ❑ Hypovolemia ❑ Hyperthyroidism

❑ Examine the patient

❑ Order an EKG

Therapeutic Approach

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?

Torsade de pointes?

- Give amiodarone 150 mg IV over 10 min - Repeat amiodarone as needed for a maximal dose of 2.2g/24h - Prepare for elective synchronized cardioversion

- Give adenosine 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

Load with Magnesium 1-2 g over 5-60 min, then infusion

Algorithm based on the 2003 ACLS guidelines for the management of tachycardia.

Do's

• Refer the patient to an arrhythmia specialist in case the tachycardia causes syncope or dyspnea as well as the wide complex tachycardia is of unknown cause.ref name="pmid14563598">Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ; et al. (2003). "ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary. a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society". J Am Coll Cardiol. 42 (8): 1493–531. PMID 14563598.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link) </ref>
• Place an ambulatory 24 hour Holter when the tachycardia is frequent and transient.ref name="pmid14563598">Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ; et al. (2003). "ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary. a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society". J Am Coll Cardiol. 42 (8): 1493–531. PMID 14563598.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link) </ref>