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 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 ventricular tachycardia or supraventricular tachycardia with aberrancy. The diagnosis of wide complex tachycardia is very challenging as there is no fixed criteria to accurately determine the cause and type of the wide complex tachycardia. Hemodynamically unstable patients should receive urgent synchronized cardioversion unless the patient has polymorphic ventricular tachycardia for which unsynchronized cardioversion should be performed. 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 red 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
❑ Administer oxygen (if the patient is hypoxemic)
❑ Monitor the cardiac rhythm
❑ Monitor blood pressure and oximetry
❑ Administer IV sedation if the patient is conscious
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
What is the type of arrhythmia?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
VT/VF presenting as cardiac arrest
 
Polymorphic VT or undetermined rhythm
 
Atrial fibrillation with aberrancy
 
Atrial flutter and other SVTs with aberrancy
 
Monomorphic VT (regular form and rate)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unsynchronized cardioversion

❑ Immediately 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

❑ 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
 
Synchronized cardioversion

❑ 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
 
Synchronized cardioversion

❑ 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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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: Afib: Atrial fibrillation; AP: Accessory pathway; AT: Atrial tachycardia; AVRT: Atrioventricular reentrant tachycardia; BPM: Beat per minute; ECG: Electrocardiogram; ICD: Implantable cardioverter defibrillator; LBBB: Left bundle branch block; RBBB: Right bundle branch block; S1: First heart sound; SVT: Supraventricular tachycardia; SR: Sinus rhythm; VT: Ventricular tachycardia; VF: Ventricular fibrillation

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 (eg, quinidine, anti-psychotic and azithromycin)
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)

Extremities
Cold extremities (suggestive of hemodynamic instability)
Peripheral cyanosis (suggestive of hemodynamic instability)
Mottling (suggestive of hemodynamic instability)
Cardiovascular examination
❑ Inspection

❑ Midsternal incision (suggestive of previous cardiothoracic surgery)

❑ Palpation

Pacemaker or ICD are usually palpable on the left pectoral area

❑ Auscultation

❑ 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)

Neurologic
Altered mental status (suggestive of hemodynamic instability)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the rhythm regular?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Atrial fibrillation

Atrial flutter / atrial tachycardia with variable conduction and:

BBB or
❑ Antegrade conduction via accessory pathway
 
 
 
 
 
 
 
 
Is there a 1 to 1 atrium to ventricle relationship?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes or unknown
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
QRS morphology in precordial leads
 
 
 
 
 
 
 
 
 
Ventricular rate faster than atrial rate
 
Atrial rate faster than ventricular rate
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If the patient shows 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
 
VT
 
Atrial tachycardia
Atrial flutter
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
SVT
 
VT
 
VT
 
VT
 
 
 
 
 
 
 
 
 
 

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

Treatment

Shown below is an algorithm depicting the treatment of wide complex tachycardia.[1][2][3]

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

 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Begin initial management
❑ Assess and support circulation, airway, and breathing as needed

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

❑ Identify and treat reversible causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Determine the type of arrhythmia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ventricular tachycardia or wide QRS tachycardia of unknown origin
 
Wide QRS tachycardia of unknown origin + poor LV function
 
Recurrent polymorphic VT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider one of the following:[1]

Procainamide (Class I, level of evidence B)

❑ Administer 20-50 mg/min IV until arrhythmia suppressed, hypotension ensues, QRS duration increase by 50 %, or maximum dose of 17 mg/kg is given
❑ Maintenance infusion: 1-4 mg/min


Sotalol 100 mg (1.5 mg/kg) IV over 5 minutes (Class I, level of evidence B)

Amiodarone (Class I, level of evidence B)

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

Cardioversion (Class I, level of evidence B)

Lidocaine (Class IIb, level of evidence B)

Adenosine (Class IIb, level of evidence C)

Beta blocker (Class III, level of evidence C)

Verapamil (Class III, level of evidence B)
 
 

Torsade de pointes (polymorphic VT associated with long QT syndrome)

Magnesium 1-2 g over 5-60 min, then infusion[4]

❑ Polymorphic VT associated with familial long QT syndrome

Magnesium, pacing and/or beta blockers[4]

❑ Polymorphic VT associated with myocardial ischemia:

Amiodarone and beta blockers[4]
 
 

Avoid the use of AV node blocking agents such as digoxin, calcium channel blockers, beta blockers and adenosine.

Consider one of the following:[1]
Procainamide 100 mg infusion diluted to 100mg/ml at a rate of 25-50 mg/min every 5 minutes (Class I, level of evidence B)

❑ Administer until the arrhythmia is suppressed or until 500 mg has been administered
❑ Wait 10 minutes or longer to administer new dosage


Ibutilide 1 mg IV infusion over 10 minutes (Class I, level of evidence B)

❑ Repeat the dosage if the tachycardia continues


Flecainide 50 mg every 12 hours (Class I, level of evidence B)

❑ Increase 50mg BID every four days until efficacy is achieved
❑ Maximum dose recommended for SVT is 300 mg/day


DC cardioversion (Class I, level of evidence C)
 

Avoid the use of AV node blocking agents such as digoxin, calcium channel blockers, beta blockers and adenosine.

Consider one of the following:[3]
Procainamide 100 mg infusion diluted to 100mg/ml at a rate of 25-50 mg/min every 5 minutes

❑ Administer until the arrhythmia is suppressed or until 500 mg has been administered
❑ Wait 10 minutes or longer to administer new dosage


Ibutilide 1 mg IV infusion over 10 minutes

❑ Repeat the dosage if the tachycardia continues


Flecainide 50 mg every 12 hours

❑ Increase 50mg BID every four days until efficacy is achieved
❑ Maximum dose recommended for SVT is 300 mg/day
 

Do's

Don'ts

References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 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.
  3. 3.0 3.1 g/cite&retmode=ref&cmd=prlinks&id=23545139 "Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a rep t of the American College of Cardiology/American Heart Association Task Force on practice guidelines" Check |url= value (help). Circulation. 127 (18): 1916–26. 2013. doi:10.1161/CIR.0b013e318290826d. PMID 23545139. Unknown parameter |auth= ignored (help)
  4. 4.0 4.1 4.2 "Part 8: Adult Advanced Cardiovascular Life Support". Retrieved 25 April 2014.



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