Wide complex tachycardia medical therapy

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

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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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?
 
SVT with aberrancy?
 
Afib with aberrancy?
 
Pre-excited Afib (Afib + WPW)
 
Recurrent polymorphic VT?
 
Torsades de pointes?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
- Give amiodarone 150 mg IV over 10 min

Repeat as needed for a maximal dose of 2.2g/24h

- Prepare for elective synchronized cardioversion
 
- Give adenosise 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
 
Magnesium
Load with 1-2 g over 5-60 min, then infusion


  • If stable: (More patients than you think)
  • 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 and 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

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