Wide complex tachycardia medical therapy
Wide complex tachycardia Microchapters |
Diagnosis |
---|
Treatment |
Case Studies |
Wide complex tachycardia medical therapy On the Web |
American Roentgen Ray Society Images of Wide complex tachycardia medical therapy |
Risk calculators and risk factors for Wide complex tachycardia medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Rim Halaby
Overview
The management of wide complex tachycardia should begin by assessing the patient's ABC's and stability. If the patient is unstable, as in the cases of hypotension, altered mental status, chest pain, heart failure or seizures, immediate synchronized cardioversion should be attempted. If the patient is stable, the medical treatment depends on identifying the specific type of of wide complex tachycardia for which a targeted treatment is initiated.
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? | 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 ACLS guidelines for the management of tachycardia.
- 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