Wide complex tachycardia physical examination: Difference between revisions
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== Physical Examination == | == Physical Examination == | ||
===Vital Signs=== | ===Vital Signs=== | ||
====Blood Pressure==== | ====Blood Pressure==== | ||
*Vitals should be obtained to assess hemodynamic stability and guide therapy. If the patient is [[hemodynamically unstable]] (i.e. [[hypotensive]]), they should undergo immediate [[cardioversion]]. | *Vitals should be obtained to assess hemodynamic stability and guide therapy. If the patient is [[hemodynamically unstable]] (i.e. [[hypotensive]]), they should undergo immediate [[cardioversion]]. | ||
*If the [[systolic blood pressure]] varies from beat to beat this is suggestive of ventricular tachycardia ([[VT]]). | *If the [[systolic blood pressure]] varies from beat to beat this is suggestive of ventricular tachycardia ([[VT]]) ([[sensitivity]] = 61%, [[specificity]] = 71%, and [[positive predictive value]] ([[PPV]]) = 70%). | ||
===Neck=== | ===Neck=== | ||
* [[cannon a waves|Cannon "a waves"]] are a manifestation of [[AV dissociation]] and suggest [[VT]]. | * [[cannon a waves|Cannon "a waves"]] are a manifestation of [[AV dissociation]] and suggest [[VT]] ([[sensitivity]] = 96%, [[specificity]] = 75%, and [[positive predictive value]]([[PPV]]) = 82%). | ||
* [[Carotid sinus massage]] ([[CSM]]) and / or [[Valsalva maneuvers]] may help in determining the underlying rhythm responsible for the wide complex tachycardia: | * [[Carotid sinus massage]] ([[CSM]]) and / or [[Valsalva maneuvers]] may help in determining the underlying rhythm responsible for the wide complex tachycardia: | ||
:*[[Sinus tachycardia]] may gradually slow. | :*[[Sinus tachycardia]] may gradually slow. | ||
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=== Cardiac=== | === Cardiac=== | ||
*If there is a irregular intensity of the first heart sound ([[S1]]), this is suggestive of [[ventricular tachycardia]] ([[VT]]). | *If there is a irregular intensity of the [[first heart sound]] ([[S1]]), this is suggestive of [[ventricular tachycardia]] ([[VT]]) ([[sensitivity]] = 58%, [[specificity]] = 100%, and [[positive predictive value]] ([[PPV]]) = 100%). | ||
==References== | ==References== | ||
Revision as of 21:35, 4 August 2013
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Risk calculators and risk factors for Wide complex tachycardia physical examination |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Initial assessment of the ABCs (airway, breathing, and circulation) is critical in the management of the patient with wide complex tachycardia. Patients who are hemodynamically unstable should undergo immediate cardioversion. Hemodynamic stability does not reliably differentiate VT from SVT. Patients with ventricular tachycardia can often be hemodynamically stable, and stable vital signs do not rule out ventricular tachycardia. This is often a major mistake on the part of clinicians and can lead to inappropriate treatment of VT as SVT with poor outcomes. [1]
Physical Examination
Vital Signs
Blood Pressure
- Vitals should be obtained to assess hemodynamic stability and guide therapy. If the patient is hemodynamically unstable (i.e. hypotensive), they should undergo immediate cardioversion.
- If the systolic blood pressure varies from beat to beat this is suggestive of ventricular tachycardia (VT) (sensitivity = 61%, specificity = 71%, and positive predictive value (PPV) = 70%).
Neck
- Cannon "a waves" are a manifestation of AV dissociation and suggest VT (sensitivity = 96%, specificity = 75%, and positive predictive value(PPV) = 82%).
- Carotid sinus massage (CSM) and / or Valsalva maneuvers may help in determining the underlying rhythm responsible for the wide complex tachycardia:
- Sinus tachycardia may gradually slow.
- Multifocal atrial tachycardia, atrial flutter, and even atrial fibrillation may transiently slow with carotid sinus massage or Valsalva maneuvers.
- A wide complex tachycardia that conducts via an AV nodal reentrant circuit may terminate.
- AV dissociation may become more apparent with carotid sinus massage and / or vagal maneuvers in ventricular tachycardia (VT).
- It should be noted that even ventricular tachycardia (VT) can terminate with carotid sinus massage and / or Valsalva maneuvers.
Cardiac
- If there is a irregular intensity of the first heart sound (S1), this is suggestive of ventricular tachycardia (VT) (sensitivity = 58%, specificity = 100%, and positive predictive value (PPV) = 100%).
References
- ↑ Morady F, Baerman JM, DiCarlo LA, DeBuitleir M, Krol RB, Wahr DW (1985). "A prevalent misconception regarding wide-complex tachycardias". JAMA : the Journal of the American Medical Association. 254 (19): 2790–2. PMID 4057488. Retrieved 2013-08-04. Unknown parameter
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