Wide complex tachycardia physical examination: Difference between revisions
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| [[Wide complex tachycardia resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] | |||
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==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. <ref name="pmid4057488">{{cite journal |author=Morady F, Baerman JM, DiCarlo LA, DeBuitleir M, Krol RB, Wahr DW |title=A prevalent misconception regarding wide-complex tachycardias |journal=[[JAMA : the Journal of the American Medical Association]] |volume=254 |issue=19 |pages=2790–2 |year=1985 |month=November |pmid=4057488 |doi= |url=http://jama.jamanetwork.com/article.aspx?volume=254&page=2790 |issn= |accessdate=2013-08-04}}</ref> | |||
== Physical Examination == | == Physical Examination == | ||
* Vitals should be obtained to assess hemodynamic stability and guide therapy | |||
* [[cannon a waves|Cannon "a waves"]] are a manifestation of [[AV dissociation]] and suggest VT | ===Vital Signs=== | ||
* [[Carotid sinus massage]] (CSM)/Valsalva: | ====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%).<ref name="pmid7994860">{{cite journal |author=Garratt CJ, Griffith MJ, Young G, Curzen N, Brecker S, Rickards AF, Camm AJ |title=Value of physical signs in the diagnosis of ventricular tachycardia |journal=[[Circulation]] |volume=90 |issue=6 |pages=3103–7 |year=1994 |month=December |pmid=7994860 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=7994860 |issn= |accessdate=2013-08-04}}</ref> | |||
===Neck=== | |||
* [[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%).<ref name="pmid7994860">{{cite journal |author=Garratt CJ, Griffith MJ, Young G, Curzen N, Brecker S, Rickards AF, Camm AJ |title=Value of physical signs in the diagnosis of ventricular tachycardia |journal=[[Circulation]] |volume=90 |issue=6 |pages=3103–7 |year=1994 |month=December |pmid=7994860 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=7994860 |issn= |accessdate=2013-08-04}}</ref> | |||
* [[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. | |||
:*It should be noted, however, that [[ventricular tachycardia]] ([[VT]]) can also terminate with [[carotid sinus massage]] and / or [[valsalva maneuvers]].<ref name="pmid6773699">{{cite journal |author=Waxman MB, Wald RW, Finley JP, Bonet JF, Downar E, Sharma AD |title=Valsalva termination of ventricular tachycardia |journal=[[Circulation]] |volume=62 |issue=4 |pages=843–51 |year=1980 |month=October |pmid=6773699 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=6773699 |issn= |accessdate=2013-08-04}}</ref><ref name="pmid2737783">{{cite journal |author=Grubb BP |title=Termination of ventricular tachycardia by carotid sinus stimulation |journal=[[International Journal of Cardiology]] |volume=23 |issue=3 |pages=397–9 |year=1989 |month=June |pmid=2737783 |doi= |url= |issn= |accessdate=2013-08-04}}</ref> | |||
:*[[AV dissociation]] may become more apparent with [[carotid sinus massage]] and / or [[vagal maneuvers]] in [[ventricular tachycardia]] ([[VT]]).<ref>Rankin AC, Oldroyd KG, Chong E. Value and limitations of adenosine in the diagnosis and treatment of narrow and board complex tachycardia. Br Heart J. 1981;46:679–682.</ref> | |||
=== 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%).<ref name="pmid7994860">{{cite journal |author=Garratt CJ, Griffith MJ, Young G, Curzen N, Brecker S, Rickards AF, Camm AJ |title=Value of physical signs in the diagnosis of ventricular tachycardia |journal=[[Circulation]] |volume=90 |issue=6 |pages=3103–7 |year=1994 |month=December |pmid=7994860 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=7994860 |issn= |accessdate=2013-08-04}}</ref> | |||
==References== | ==References== | ||
{{Reflist|2}} | |||
[[Category:Needs overview]] | [[Category:Needs overview]] | ||
[[Category:Electrophysiology]] | [[Category:Electrophysiology]] | ||
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[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
[[Category:Intensive care medicine]] | [[Category:Intensive care medicine]] | ||
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Latest revision as of 16:55, 5 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%).[2]
Neck
- Cannon "a waves" are a manifestation of AV dissociation and suggest VT (sensitivity = 96%, specificity = 75%, and positive predictive value(PPV) = 82%).[2]
- 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.
- It should be noted, however, that ventricular tachycardia (VT) can also terminate with carotid sinus massage and / or valsalva maneuvers.[3][4]
- AV dissociation may become more apparent with carotid sinus massage and / or vagal maneuvers in ventricular tachycardia (VT).[5]
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%).[2]
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
|month=ignored (help) - ↑ 2.0 2.1 2.2 Garratt CJ, Griffith MJ, Young G, Curzen N, Brecker S, Rickards AF, Camm AJ (1994). "Value of physical signs in the diagnosis of ventricular tachycardia". Circulation. 90 (6): 3103–7. PMID 7994860. Retrieved 2013-08-04. Unknown parameter
|month=ignored (help) - ↑ Waxman MB, Wald RW, Finley JP, Bonet JF, Downar E, Sharma AD (1980). "Valsalva termination of ventricular tachycardia". Circulation. 62 (4): 843–51. PMID 6773699. Retrieved 2013-08-04. Unknown parameter
|month=ignored (help) - ↑ Grubb BP (1989). "Termination of ventricular tachycardia by carotid sinus stimulation". International Journal of Cardiology. 23 (3): 397–9. PMID 2737783. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Rankin AC, Oldroyd KG, Chong E. Value and limitations of adenosine in the diagnosis and treatment of narrow and board complex tachycardia. Br Heart J. 1981;46:679–682.