Wide complex tachycardia medical therapy: Difference between revisions

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{{Wide complex tachycardia}}
{| class="infobox" style="float:right;"
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| [[File:Siren.gif|30px|link=Wide complex tachycardia resident survival guide]]|| <br> || <br>
| [[Wide complex tachycardia resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
|}
{| class="infobox" style="float:right;"
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| [[File:Physician_Extender_Algorithms.gif|88px|link=Wide complex tachycardia physician extender algorithm]]|| <br> || <br>
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{{CMG}}; '''Associate Editor-In-Chief:''' [[User:Rim Halaby|Rim Halaby]]
{{CMG}}; '''Associate Editor-In-Chief:''' [[User:Rim Halaby|Rim Halaby]]


==Overview==
==Overview==
The management of wide complex tachycardia should begin by assessing the patient's ABC's and stability. If the patient is unstable, as in the cases of [[hypotension]], [[altered mental status]], [[chest pain]], [[heart failure]] or [[seizures]], immediate [[synchronized cardioversion]] should be attempted. If the patient is stable, the medical treatment depends on identifying the specific type of of wide complex tachycardia for which a targeted treatment is initiated.
The management of wide complex tachycardia should begin by assessing the patient's ABCs (airway, breathing, and circulation). If the patient is unstable and either [[hypotension]], [[altered mental status]], [[chest pain]], [[heart failure]] or [[seizures]] are present, then immediate synchronized [[cardioversion]] should be performed. If the patient is stable, the optimal management depends upon the differentiation of [[ventricular tachycardia]] versus [[supraventricular tachycardia]] with aberrant conduction as a cause of the wide complex tachycardia.  '''A wide complex tachycardia should be assumed to be and managed as though it is due to ventricular tachycardia until proven otherwise.  This is true even in a hemodynamically stable patient until proven otherwise (VT can often be hemodynamically stable).  The initial management strategy includes avoiding the use of a long acting [[AV nodal blocking agent]] and drugs that suppress [[left ventricular contractility]] such as [[verapamil]] which can induce [[hypotension]] in a previously stable patient.'''


==Medical Therapy==  
==Medical Therapy==  
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{{familytree | | | | | | | | | | | | | | | A01 | | | | | A01='''Wide complex tachycardia'''<br>[[QRS]] ≥ 120ms}}
{{familytree | | | | | | | | | | | | | | | A01 | | | | | A01='''Wide complex tachycardia'''<br>[[QRS]] ≥ 120ms}}
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | | | | | | A02 | | | | | | A02='''Do the following simultaneously:'''<br><br>- Assess and support ABC's as needed<br>- Give [[oxygen therapy|oxygen]]<br>- Monitor [[ECG]], [[BP]], [[oxygen saturation|oxymetry]]<br>- Identify and treat reversible causes}}
{{familytree | | | | | | | | | | | | | | | A02 | | | | | A02='''Do the following simultaneously:'''<br><br>- Assess and support ABC's as needed<br>- Give [[oxygen therapy|oxygen]]<br>- Monitor [[ECG]], [[BP]], [[oxygen saturation|oxymetry]]<br>- Identify and treat reversible causes ([[hypokalemia]], [[hypomagnesemia]]}}
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | | | | | | A03 | | | | | | A03='''Is the patient stable?'''<br><br>Unstable signs include:<br>- [[Chest pain]]<br>- [[Congestive heart failure]]<br>- [[Hypotension]]<br>- [[Loss of consciousness]]<br>- [[Seizures]]}}
{{familytree | | | | | | | | | | | | | | | A03 | | | | | | A03='''Is the patient stable?'''<br><br>Unstable signs include:<br>- [[Chest pain]]<br>- [[Congestive heart failure]]<br>- [[Hypotension]]<br>- [[Loss of consciousness]]<br>- [[Seizures]]}}
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{{familytree | | | | | | | | B01 | | | | | | | | | | | | | B02 | | | B01=Yes|B02=No}}
{{familytree | | | | | | | | B01 | | | | | | | | | | | | | B02 | | | B01=Yes|B02=No}}
{{familytree | | | | | | | | |!| | | | | | | | | | | | | | |!| | | | }}
{{familytree | | | | | | | | |!| | | | | | | | | | | | | | |!| | | | }}
{{familytree | | | | | | | | C01 | | | | | | | | | | | | | C02 | | | C01='''Is the rhythm regular?'''|C02='''Immediate [[synchronized cardioversion]]'''<br><br>-Establish IV access<br>- Give IV [[sedation]] if the patient is conscious<br>- Consider expert consultation}}
{{familytree | | | | | | | | C01 | | | | | | | | | | | | | C02 | | | C01='''Is the rhythm regular?'''|C02='''Immediate synchronized [[cardioversion]]'''<br><br>-Establish IV access<br>- Give IV [[sedation]] if the patient is conscious<br>- Consider expert consultation}}
{{familytree | | | | | | |,|-|^|-|-|-|-|-|-|-|-|-|.| | | | }}
{{familytree | | | | | | |,|-|^|-|-|-|-|-|-|-|-|-|.| | | | }}
{{familytree | | | | | | D01 | | | | | | | | | | D02 | | | D01='''Regular rhythm'''| D02='''Irregular rhythm'''}}
{{familytree | | | | | | D01 | | | | | | | | | | D02 | | | D01='''Regular rhythm'''| D02='''Irregular rhythm'''}}
{{familytree | | | | |,|-|^|-|.| | | |,|-|-|-|v|-|^|-|v|-|-|-|.| |}}
{{familytree | | | | |,|-|^|-|.| | | |,|-|-|-|v|-|^|-|v|-|-|-|.| |}}
{{familytree | | | | E01 | | E02 | | E03 | | E04 | | E05 | | E06 | E01='''[[Ventricular tachycardia]] or uncertain rhythm?'''|E02='''[[SVT]] with aberrancy?'''|E03='''[[Afib]] with aberrancy?'''|E04='''Pre-excited [[Afib]] ([[Afib]] + [[WPW]])'''|E05='''Recurrent polymorphic [[VT]]?'''|E06='''[[Torsades de pointes?]]'''}}
{{familytree | | | | E01 | | E02 | | E03 | | E04 | | E05 | | E06 | E01='''[[Ventricular tachycardia]] or uncertain rhythm?'''|E02='''Confirmed [[SVT]] with aberrancy?'''|E03='''[[Afib]] with aberrancy?'''|E04='''Pre-excited [[Afib]] ([[Afib]] + [[WPW]])?'''|E05='''Recurrent polymorphic [[VT]]?'''|E06='''[[Torsade de pointes]]?'''}}
{{familytree | | | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | }}
{{familytree | | | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | }}
{{familytree | | | | E01 | | E02 | | E03 | | E04 | | E05 | | E06 | E01=- Give [[amiodarone]] 150 mg IV over 10 min<br><br>Repeat as needed for a maximal dose of 2.2g/24h<br><br>- Prepare for elective synchronized cardioversion| E02=- Give [[adenosise]] 6 mg rapid IV push<br><br>- If no [[conversion]] give 12 mg IV push<br><br>- May repeat 12 mg dose once| E03=- Consider expert consultation<br><br>- Control rate e.g [[diltiazem]] or [[beta blocker]]s<br>Use [[beta blocker]]s with caution in [[pulmonary disease]]s or [[CHF]]| E04= - Consider expert consultation<br><br>- Avoid AV nodal blocking agents<br>e.g [[adenosine]], [[digoxin]], [[diltiazem]] and [[verapamil]]<br><br>- Consider [[amiodarone]] 150 mg IV over 10 min| E05= Consider expert consultation| E06=[[Magnesium]]<br>Load with 1-2 g over 5-60 min, then infusion}}
{{familytree | | | | F01 | | F02 | | F03 | | F04 | | F05 | | F06 | F01=- Give [[amiodarone]] 150 mg IV over 10 min<br><br>- Repeat [[amiodarone]] as needed for a maximal dose of 2.2g/24h<br><br>- Prepare for elective synchronized [[cardioversion]]| F02=- If '''certain''' [[VT]] is '''not''' present, give [[adenosine]] 6 mg rapid IV push<br><br>- If no [[conversion]] give 12 mg IV push<br><br>- May repeat 12 mg dose once| F03=- Consider expert consultation<br><br>- Control rate e.g [[diltiazem]] or [[beta blocker]]s<br>Use [[beta blocker]]s with caution in [[pulmonary disease]]s or [[CHF]]| F04= - Consider expert consultation<br><br>- Avoid AV nodal blocking agents<br>e.g [[adenosine]], [[digoxin]], [[diltiazem]] and [[verapamil]]<br><br>- Consider [[amiodarone]] 150 mg IV over 10 min| F05= Consider expert consultation| F06=Load with [[Magnesium]] 1-2 g over 5-60 min, then infusion}}
{{familytree/end}}
{{familytree/end}}


''Algorithm based on ACLS guidelines for the management of tachycardia.''
''Algorithm based on the 2003 [[ACLS]] guidelines for the management of tachycardia.''<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>


 
==Critical Caveats in the Management of Wide Complex Tachycardia==
* Do not use Ca<sup>2+</sup> channel blocker, [[digoxin]] or [[adenosine]] if you don't not know the etiology of the wide complex tachycardia. Ca<sup>2+</sup> channel blockers and digoxin can lead to accelerated conduction down a bypass tract and [[VF]].   
*'''[[Verapamil]] should be avoided in patients with wide complex tachycardia as it can result in hemodynamic deterioration in patients with [[ventricular tachycardia]].'''<ref name="pmid3578051">{{cite journal |author=Buxton AE, Marchlinski FE, Doherty JU, Flores B, Josephson ME |title=Hazards of intravenous verapamil for sustained ventricular tachycardia |journal=[[The American Journal of Cardiology]] |volume=59 |issue=12 |pages=1107–10 |year=1987 |month=May |pmid=3578051 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/0002-9149(87)90857-5 |issn= |accessdate=2013-08-04}}</ref>
* Do not use Ca<sup>2+</sup> channel blocker, [[digoxin]] or [[adenosine]] if you don't not know the etiology of the wide complex tachycardia. Ca<sup>2+</sup> channel blockers and [[digoxin]] can lead to accelerated conduction down a [[bypass tract]] which may in turn degenerate into [[VF]].   
* Though ACLS guidelines recommend a diagnostic trial of [[adenosine]], it can precipitate [[VF]] in some patients with SVT. Patients who have underlying coronary disease may become ischemic from coronary steal. Rhythm can degenerate and lead to [[VF]] that cannot be resuscitated. Furthermore, some [[VT]] (specially those with structurally normal hearts) are [[adenosine]] responsive and can terminate.
* Though ACLS guidelines recommend a diagnostic trial of [[adenosine]], it can precipitate [[VF]] in some patients with SVT. Patients who have underlying coronary disease may become ischemic from coronary steal. Rhythm can degenerate and lead to [[VF]] that cannot be resuscitated. Furthermore, some [[VT]] (specially those with structurally normal hearts) are [[adenosine]] responsive and can terminate.
*:# Etiology uncertain
*:# Etiology uncertain
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==References==
==References==
{{Reflist|2}}


{{Reflist|2}}
{{WH}}
{{WS}}
[[Category:Needs overview]]
[[Category:Electrophysiology]]
[[Category:Electrophysiology]]
[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Intensive care medicine]]
[[Category:Intensive care medicine]]
{{WH}}
{{WS}}

Latest revision as of 16:33, 5 August 2013



Resident
Survival
Guide
File:Physician Extender Algorithms.gif

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

Overview

The management of wide complex tachycardia should begin by assessing the patient's ABCs (airway, breathing, and circulation). If the patient is unstable and either hypotension, altered mental status, chest pain, heart failure or seizures are present, then immediate synchronized cardioversion should be performed. If the patient is stable, the optimal management depends upon the differentiation of ventricular tachycardia versus supraventricular tachycardia with aberrant conduction as a cause of the wide complex tachycardia. A wide complex tachycardia should be assumed to be and managed as though it is due to ventricular tachycardia until proven otherwise. This is true even in a hemodynamically stable patient until proven otherwise (VT can often be hemodynamically stable). The initial management strategy includes avoiding the use of a long acting AV nodal blocking agent and drugs that suppress left ventricular contractility such as verapamil which can induce hypotension in a previously stable patient.

Medical Therapy

 
 
 
 
 
 
 
 
 
 
 
 
 
 
Wide complex tachycardia
QRS ≥ 120ms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Do the following simultaneously:

- Assess and support ABC's as needed
- Give oxygen
- Monitor ECG, BP, oxymetry
- Identify and treat reversible causes (hypokalemia, hypomagnesemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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

-Establish IV access
- Give IV sedation if the patient is conscious
- Consider expert consultation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Regular rhythm
 
 
 
 
 
 
 
 
 
Irregular rhythm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ventricular tachycardia or uncertain rhythm?
 
Confirmed 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
 
- If certain VT is not present, 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

Algorithm based on the 2003 ACLS guidelines for the management of tachycardia.[1]

Critical Caveats in the Management of Wide Complex Tachycardia

  • Verapamil should be avoided in patients with wide complex tachycardia as it can result in hemodynamic deterioration in patients with ventricular tachycardia.[2]
  • Do not use Ca2+ channel blocker, digoxin or adenosine if you don't not know the etiology of the wide complex tachycardia. Ca2+ channel blockers and digoxin can lead to accelerated conduction down a bypass tract which may in turn degenerate into VF.
  • Though ACLS guidelines recommend a diagnostic trial of adenosine, it can precipitate VF in some patients with SVT. Patients who have underlying coronary disease may become ischemic from coronary steal. Rhythm can degenerate and lead to VF that cannot be resuscitated. Furthermore, some VT (specially those with structurally normal hearts) are adenosine responsive and can terminate.
    1. Etiology uncertain
      • Pronestyl 15 mg/kg load over 30 minutes then 2-6 mg/min gtt
    2. Ventricular tachycardia with active ischemia
      • Lidocaine 1 mg/kg q5-10 min up to 3 times then 2-6 mg/min gtt
      • If unsuccessful, pronestyl as above
      • If unsuccessful, IV amiodarone 150-300 load over 15-20 min. 30-60 mg/hr gtt for total of 1 gram
    3. Ventricular tachycardia in setting of cardiomyopathy
    4. Positively SVT with aberrancy
    5. Antidromic AVRT
      • If 100% positive AF is not underlying, can terminate with a nodal blocker
      • If unsure, pronestyl as above

References

  1. 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. Buxton AE, Marchlinski FE, Doherty JU, Flores B, Josephson ME (1987). "Hazards of intravenous verapamil for sustained ventricular tachycardia". The American Journal of Cardiology. 59 (12): 1107–10. PMID 3578051. Retrieved 2013-08-04. Unknown parameter |month= ignored (help)

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