Wide complex tachycardia resident survival guide: Difference between revisions

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* Treat the patient as having a [[ventricular tachycardia]] when the diagnosis of [[supraventricular tachycardia]] can not be made.<ref name="pmid14563598">{{cite journal| author=Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ et al.| title=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. | journal=J Am Coll Cardiol | year= 2003 | volume= 42 | issue= 8 | pages= 1493-531 | pmid=14563598 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14563598  }} </ref>
* Treat the patient as having a [[ventricular tachycardia]] when the diagnosis of [[supraventricular tachycardia]] can not be made.<ref name="pmid14563598">{{cite journal| author=Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ et al.| title=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. | journal=J Am Coll Cardiol | year= 2003 | volume= 42 | issue= 8 | pages= 1493-531 | pmid=14563598 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14563598  }} </ref>
* Suspect [[ventricular tachycardia]] in a patient with wide complex tachycardia and previous [[myocardial infarction]] or a history of structural heart disease.<ref name="pmid14563598">{{cite journal| author=Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ et al.| title=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. | journal=J Am Coll Cardiol | year= 2003 | volume= 42 | issue= 8 | pages= 1493-531 | pmid=14563598 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14563598  }} </ref>
* Suspect [[ventricular tachycardia]] in a patient with wide complex tachycardia and previous [[myocardial infarction]] or a history of structural heart disease.<ref name="pmid14563598">{{cite journal| author=Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ et al.| title=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. | journal=J Am Coll Cardiol | year= 2003 | volume= 42 | issue= 8 | pages= 1493-531 | pmid=14563598 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14563598  }} </ref>
* Use [[beta blockers]] with caution in pulmonary diseases or [[congestive heart failure]].


==Dont's==
==Dont's==

Revision as of 19:48, 2 March 2014

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

Definition

Wide complex tachycardia 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.[1]

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Wide complex tachycardia may be a life-threatening condition and must be treated as such irrespective of the causes.

Common Causes

Management

Shown below is an algorithm depicting the management of wide complex tachycardia according to the 2003 ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias and the 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.[1][2]

 
 
 
 
 
 
 
 
 
 
 
Characterize the symptoms:
❑ Asymptomatic PalpitationsDyspnea
Fatigue Chest discomfort Lightheadedness
Syncope

Characterize the timing of the symptoms:
❑ Onset
❑ Duration
❑ Frequency

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Identify possible triggers:
InfectionCaffeineAlcohol
Nicotine ❑ Recreational drugsHypovolemia
Hyperthyroidism
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Examine the patient
❑ Order an EKG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Wide complex tachycardia
QRS ≥ 120ms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Do the following simultaneously:
❑ Assess and support ABC's as needed
❑ Give oxygen
❑ Monitor ECG, BP, oxymetry
❑ Establish IV access
❑ Identify and treat reversible causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Determine if the patient has any of the following:
Chest pain
Congestive heart failure
Hypotension
Loss of consciousness
Seizures
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Determine the regularity of the rhythm
 
 
 
 
 
 
 
 
 
 
 
 
❑ Perform immediate synchronized cardioversion
❑ 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
 
❑ Attempt vagal maneuvers
❑ 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


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]

Management of wide complex tachycardia
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)
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
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)

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

Do's

Dont's

  • Don't rely on the hemodynamic status of the patient and the heart rate to differenciate SVT from VT.

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 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. "Part 7.3: Management of Symptomatic Bradycardia and Tachycardia". Retrieved 2 March 2014.

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