Wide complex tachycardia resident survival guide

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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

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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
❑ 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

Do's

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 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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