Wide complex tachycardia resident survival guide

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Wide Complex Tachycardia Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]; Amr Marawan, M.D. [3]

Overview

Wide complex tachycardia (WCT) is characterized by a heart rate more than 100 beats per minute associated with a QRS interval of more than 120 ms. When wide complex tachycardia is present, it is important to determine whether the tachycardia is of a supraventricular or a ventricular origin. The diagnosis of wide complex tachycardia is very challenging as there is no fixed criteria to accurately determine the cause and type of the WCT. Hemodynamically unstable patients should receive urgent synchronized cardioversion. If the QRS complex and the T wave can't be distinguished in unstable patients, then the patient should receive unsynchronized cardioversion.[1]

Causes

Life Threatening Causes

Wide complex tachycardia may be a life-threatening condition and must be treated as such irrespective of the underlying cause.

Common Causes

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.[1][2]

Boxes in salmon color signify that an urgent management is needed.

 
 
 
 
 
 
 
 
 
 
 
 
Identify cardinal findings that increase the pretest probability of wide complex tachycardia
Palpitations
QRS complex > 120 ms
Heart rate > 150 beats/min

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any of the following findings that require urgent cardioversion?

❑ Hemodynamic instability

Hypotension
Cold extremities
Peripheral cyanosis
Mottling
Altered mental status

Chest discomfort suggestive of ischemia

Decompensated heart failure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with immediate cardioversion
Perform the following without delaying cardioversion
❑ Maintain patent airway; assist breathing as necessary
❑ Adminster oxygen (if the patient is hypoxemic)
❑ Cardiac monitor to identify rhythm; monitor blood pressure and oximetry
❑ Give IV sedation if the patient is conscious
❑ Don't delay cardioversion to sedate the patient
❑ Consider expert consultation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unsynchronized cardioversion
❑ If a patient has polymorphic VT and is unstable, treat the rhythm as VF and deliver high-energy unsynchronized shocks
❑ Provide an initial shock of 200 Joules
❑ Increase the dose if no response to the first shock (eg, 300 J, 360 J, 360 J)
 
 
Synchronized cardioversion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Atrial fibrillation with aberrancy
❑ Provide an initial dose of biphasic cardioversion of 120-200 Joules (Class IIa, level of evidence A)
❑ If the initial shock fails, increase the dose in a stepwise fashion
 
Arial flutter and other SVTs with aberrancy
❑ Provide an initial dose of biphasic cardioversion of 50-100 Joules (Class IIa, level of evidence B)
❑ If the initial shock fails, increase the dose in a stepwise fashion
❑ If monophasic wave form is used, begin at 200 Joules and increase in stepwise fashion if not successful
 
Monomorphic VT (regular form and rate)
❑ Provide an initial dose of biphasic cardioversion of 100 Joules (Class IIb, level of evidence C)
❑ If the initial shock fails, increase the dose in a stepwise fashion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

If you can't determine the type of arrhythmia or you aren't sure, go for immediate unsynchronized cardioversion

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[1][2]

Abbreviations: ECG: Electrocardiogram; VT: Ventricular tachycardia; VF: Ventricular fibrillation; ICD: Implantable cardioverter-defibrillator; BPM: Beat per minute; AT: Atrial tachycardia; RBBB: Right bundle branch block; LBBB: Left bundle branch block; SVT: Supraventricular tachycardia; AP: Accessory pathway; AVRT: Atrioventricular reentrant tachycardia; SR: Sinus rhythm; A: Atrial; V: Ventricular

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Characterize the symptoms:

Palpitations
Lightheadedness
Dyspnea
Diaphoresis
Chest discomfort
Syncope
Seizures
Altered mental status
Characterize the timing of the symptoms:
❑ Onset

❑ First episode
❑ Recurrent

❑ Duration
❑ Frequency
❑ Termination of the episode

❑ Spontaneous
❑ Medication use
❑ Not terminated

Inquire about the use of proarrhythmic drugs:
❑ Medications that prolong QT interval (click here for the complete list of drugs)
Digoxin at plasma concentration of 2.0 ng/ml (especially with hypokalemia)

Diuretics can cause hypokalemia and hypomagnesemia leading to torsade de pointes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Examine the patient:
Vitals
❑ Pulse

❑ Rate
Tachycardia (> 100 bpm)
❑ Rhythm
❑ Regular (suggestive of VT and SVT with aberrancy)
❑ Irregular (suggestive of afib with aberrancy)
❑ Strength
❑ Weak
Pulsus alternans (suggestive of afib with aberrancy)

Respiration

Tachypnea

Blood pressure

Hypotension (suggestive of hemodynamic instability)
❑ Marked fluctuation of blood pressure (suggestive of AV dissociation in VT)

Neck

❑ Canonn A waves on examining the jugular venous pressure of the neck (suggestive of AV dissociation in VT)

Cardiovascular examination
❑ Inspection

❑ Midsternal incision (suggestive of previous cardiothoracic surgery)

❑ Palpation

Pacemaker or ICD are usually palpable on the left pectoral area

❑ Auscultation

Heart sounds
❑ Rapid regular or irregular beats
Murmurs (suggestive of valvular diseases)
❑ Variability in the occurrence and the intensity of heart sounds especially S1 (suggestive of AV dissociation in VT)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order labs and tests:
❑ Order and monitor the ECG

Perform urgent cardioversion in unstable patients
❑ Chest x ray

Cardiomegaly (suggestive of heart disease)
Pacemaker and ICD appear in the x ray

❑ Invasive electrophysiological studies
❑ Serum electrolytes

Hypomagnesemia
Hypokalemia

❑ Plasma concentration of drugs (eg, digoxin, quinidine or procainamide)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Wide QRS complex tachycardia
(QRS duration greater than 120 ms)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Regular or irregular?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Regular
 
 
 
 
 
 
 
 
 
 
 
Irregular
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is QRS identical to that during SR?
If yes, consider:
- SVT and BBB
- Antidromic AVRT
 
 
 
 
 
 
 
 
Atrial fibrillation
Atrial flutter / AT with variable
conduction and:
a) BBB or
b) Antegrade conduction via AP
 
 
 
 
 
 
 
Vagal maneuvers or
adenosine
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Previous myocardial infarction or structural heart disease? If yes, VT is likely.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1 to 1 AV relationship?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes or unknown
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
V rate faster than A rate
 
A rate faster than V rate
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
QRS morphology in precordial leads
 
 
 
 
 
 
 
 
 
VT
 
Atrial tachycardia
Atrial flutter
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Typical RBBB
or LBBB
 
Precordial leads:
- Concordant
- No R/S pattern
- Onset of R to nadir longer than 100ms
 
RBBB pattern:
- qR, Rs or Rr' in V1
- Frontal plane axis range
from +90 degrees to -90 degrees
 
LBBB pattern:
- R in V1 longer than 30 ms
- R to nadir of S in V1 greater than 60 ms
- qR or qS in V6
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
SVT
 
VT
 
VT
 
VT
 
 
 
 
 
 
 
 
 
 


The above algorithm is adapted from the 2003 American College of Cardiology.[1]

Click here for more details about classification of wide complex tachycardia.

Treatment

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[1][2]

CAB: Circulation, airway and breathing; Afib: Atrial fibrillation; BBB: Bundle branch block; LV: Left ventricle; SVT: Supraventricular tachycardia; VT: Ventricular tachycardia; WPW: Wolff Parkinson White

 
 
 
 
 
 
 
 
Wide complex tachycardia
QRS ≥ 120ms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Begin initial management
❑ Assess and support CAB as needed

❑ Give oxygen
❑ Monitor ECG, blood pressure, oxymetry
❑ Establish IV access

❑ Identify and treat reversible causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Determine if the patient has any unstable sign or symptom
Chest pain

Congestive heart failure
Hypotension
Loss of consciousness

Seizures
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Determine the regularity of the rhythm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Irregular rhythm
 
 
 
 
 
 
 
 
Regular rhythm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
VT or uncertain rhythm

Procainamide (Class IIa, level of evidence B)

❑ Adminster 20-50 mg/min IV untill arrhythmia suppressed, hypotension ensues, QRS duration increase by 50 %, or maximum dose of 17 mg/kg is given
❑ Maintenance infusion: 1-4 mg/min
❑ Avoide procainamide if prolonged QT interval or CHF

Amiodarone (Class IIb, level of evidence B)

❑ Give amiodarone 150 mg IV over 10 min
❑ Repeat amiodarone as needed for a maximal dose of 2.2g/24h

Sotalol (Class IIb, level of evidence B)

❑ Adminster 100 mg (1.5 mg/kg) IV over 5 minutes
❑ Avoid if patients has prolonged QT
❑ Prepare for elective synchronized cardioversion
 
SVT with aberrancy
❑ Attempt vagal maneuvers

❑ Give adenosine 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
 
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

Torsade de pointes
❑ Polymorfic VT associated with familial long QT syndrome: treated with IV magnesium, pacing and/or beta blockers
❑ Polymorfic VT associated with myocardial ischemia: IV amiodarone and beta blockers can be used
❑ Catecholamenercic VT and Brugada syndrome
 
Torsade de pointes(polymorphic VT associated with long QT syndrome)
❑ Load with magnesium 1-2 g over 5-60 min, then infusion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Differentiating SVT from VT

Shown below is a table summarizing some clues that help differentiate SVT from VT.[1]

Clues Type of arrhythmia
Irregularly irregular rhythm Atrial fibrillation or atrial flutter with aberrancy
Previous myocardial infarction or structural heart disease Ventricular tachycardia
Ventricular rate faster than atrial rate Ventricular tachycardia
Typical RBBB or LBBB Supraventricular tachycardia
Precordial leads:
❑ Concordant
❑ No R/S pattern
❑ Onset of R to nadir longer than 100ms
Ventricular tachycardia
RBBB pattern:
❑ qR, Rs or Rr' in V1
❑ Frontal plane axis range from +90 degrees to -90 degrees
Ventricular tachycardia
LBBB pattern:
❑ R in V1 longer than 30 ms
❑ R to nadir of S in V1 greater than 60 ms
❑ qR or qS in V6
Ventricular tachycardia

For more details about differentiating VT from SVT, click here

Antiarrhythmics

Shown below is a table summarizing the choices of the antiarrhythmic drugs for the different types of tachycardia according to the 2003 ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias.[1]

BBB: Bundle branch block; LV: Left ventricle; SVT: Supraventricular tachycardia

Management of wide complex tachycardia
Ventricular tachycardia or wide QRS tachycardia of unknown origin
Procainamide (Class I, level of evidence B)
OR
Sotalol (Class I, level of evidence B)
OR
Amiodarone (Class IIb, level of evidence B)
OR
Cardioversion (Class I, level of evidence B)
OR
Lidocaine (Class IIb, level of evidence B)
OR
Adenosine (Class IIb, level of evidence C)
OR
Beta blocker (Class III, level of evidence C)
OR
Verapamil (Class III, level of evidence B)
Wide QRS tachycardia of unknown origin + poor LV function
Amiodarone (Class I, level of evidence B)
OR
Cardioversion (Class I, level of evidence B)
SVT + BBB
Vagal maneuvers (Class I, level of evidence B)
OR
Adenosine (Class I, level of evidence A)
OR
Verapamil (Class I, level of evidence A)
OR
Diltiazem (Class I, level of evidence A)
OR
Beta blocker (Class IIb, level of evidence C)
OR
Amiodarone (Class IIb, level of evidence C)
OR
Digoxin (Class IIb, level of evidence C)
SVT or atrial fibrillation + Preexcitation
Flecainide (Class I, level of evidence B)
OR
Ibutilide (Class I, level of evidence B)
OR
Procainamide (Class I, level of evidence B)
OR
Cardioversion (Class I, level of evidence C)

Do's

Dont's

  • Don't rely on the hemodynamic status of the patient and the heart rate to differenciate SVT from VT and this might lead to inappropriate dangerous therapy.
  • Don't delay cardioversion to sedate or to establish an IV line to the patient.
  • Don't adminster verapamil for wide complex tachycardia unless known to be of supraventricular origin.[2]

References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 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.
  2. 2.0 2.1 2.2 2.3 2.4 "Part 7.3: Management of Symptomatic Bradycardia and Tachycardia". Retrieved 2 March 2014.

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