Wide-complex tachycardia: Difference between revisions

(Created page with "*Consider hyperkalemia & dig OD ==TREATMENT (WIDE)== I. Pulseless --> shock (sync 360J) II. Unstable --> shock (prefer sync/100J, 200J) III. Stable A. Regular* ...")
 
 
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*Consider hyperkalemia & dig OD
==Background==
*3 wide complexes in a row is considered ventricular tachycardia
**Non-sustained if lasts < 30 seconds
**Sustained if lasts >30 seconds


===Etiology<ref>Gupta AK, Thakur RK. Wide QRS complex tachycardias. Med Clin North Am. 2001;85(2):245–66– ix–x.</ref><ref>Akhtar M, Shenasa M, Jazayeri M, Caceres J, Tchou PJ. Wide QRS complex tachycardia. Reappraisal of a common clinical problem. Ann Intern Med. 1988;109(11):905–912.</ref><ref>Stewart RB, Bardy GH, Greene HL. Wide complex tachycardia: misdiagnosis and outcome after emergent therapy. Ann Intern Med. 1986;104(6):766–771.</ref>===
*Due to true ventricular tachycardia in 80% of cases
**For patients with underlying cardiac disease, increases to > 90%
*Consider:
**[[Hyperkalemia]]
**[[Digoxin toxicity]]
**Severe metabolic acidosis


==TREATMENT (WIDE)==
==Clinical Features==
*Depends on etiology
*Range from asymptomatic/[[palpitations]] to [[cardiac arrest]]


==Differential Diagnosis==
{{Tachycardia (narrow) DDX}}
{{Tachycardia (wide) DDX}}


I. Pulseless --> shock (sync 360J)
==Evaluation==
[[File:Electrocardiogram of Ventricular Tachycardia.png|thumb|Wide ''regular'' tachycardia consistent with ventricular tachycardia]]
*Assume ventricular tachycardia until proven otherwise
**'''See [[rhythm diagnosis in regular wide complex tachycardia]]'''


II. Unstable --> shock (prefer sync/100J, 200J)
==Management==
{{ACLS Wide Regular Tachycardia}}
{{ACLS Wide Irregular Tachycardia}}


III. Stable
===Recurrent===
*≥3 episodes within 24 hours considered [[electrical storm]] and may require alternate treatment (i.e. beta blockade, sedation, ablation)


    A. Regular*
===Other considerations===
*True [[Vtach]] generally has rate >120bpm. If rate <120bpm or refractory to other therapy, consider other causes
*When in doubt, use cardioversion for treatment of regular WCT. In irregular WCT, consider Afib with [[WPW]] in which [[Procainamide]] is the treatment of choice
*In very wide complex (>0.2 msec) and <120 bpm in a patient with significant history, consider giving [[Calcium chloride|calcium chloride]] to treat [[Hyperkalemia|hyperkalemia]]
*Consider [[Acidosis]]
*Sodium channel blockade (e.g. from [[Benadryl|benadryl]], [[TCA toxicity|TCA]], or [[Cocaine toxicity|cocaine]] toxicity) may cause very wide complex (>0.2msec) tachycardia with rate <120bpm
**Treat with [[Bicarbonate|sodium bicarbonate]]
**[[Lidocaine]], [[Procainamide]], [[Amiodarone]] all block Na channels and may result in asystole in patients with intrinsic or extrinsic Na-channel blockade


          i. Tx as presum V.Tach
==Disposition==
*Admit all patients (even if converted to normal sinus rhythm in ED)


          ii. Amiodarone (150mg over 10min, then 1mg/min gtt x 6hrs)
==See Also==
*[[ACLS: Tachycardia]]
*[[ACLS (Main)]]
*[[Rhythm diagnosis in regular wide complex tachycardia]]
*[[Paroxysmal supraventricular tachycardia]]
*[[Nonsustained ventricular tachycardia]]
*[[Polymorphic ventricular tachycardia]]
*[[Electrical storm]]
*[[In-Training Exam Review]]


          iii. May cardiovert
==External Links==


          iv. See Refractory
==References==
 
<references/>
    B. Irregular**
[[Category:Cardiology]]
 
          i. HR <200
 
              -Presum aberrant a. fib**
 
          ii. HR 200-250
 
          iii. HR >250
 
 
==*DDx Regular==
 
 
1) V. tach
 
2) Tachycardia + BBB
 
3) Tachycardia + rate related BBB
 
4) Hyperkalemia, meds (e.g. procainamide, flecainide, TCAs, dig)
 
5) Pacemaker
 
6) Tachycardia + Accessory pathway
 
 
==V-TACH (BRUGADA CRITERIA)==
 
 
*Regular rhythms only
 
Any 1 of the following = Vtach:
 
(matters only if stable, for drug choice)
 
1) Absence of RS complex in all precordial leads
 
2) RS >100ms (>2.5mm) in any precordial
 
3) AV dissociation (fusion beats)
 
4) Morphology criteria for VT in V1 or V6 (clear R/L-BB pattern)
 
 
==**DDX Irregular==
 
 
1) A.fib + BBB
 
2) A.fib + rate related BBB
 
(QRS widest with shortest R-R)
 
3) V. tach (see Brugada Criteria)
 
4) A.fib + hyperkalemia or meds
 
6) Accessory pathway***
 
 
**The danger = A.fib + aberrant pathway (in WPW)
 
--> do not use adenosine, beta blockers, dilt, or dig
 
--> changing morphology of QRS = inc poss
 
--> consider procainamide or ibutilide (amiodarone?)
 
--> shock if becomes unstable
 
 
==REFRACTORY V-TACH==
 
 
Overdrive pacing
 
Lidocaine
 
Magnesium
 
Electrolytes
 
?dilantin
 
 
==See also==
 
 
Cards: V TACH Vs. Aberant SVT
 
 
==Source ==
 
 
8/07 DONALDSON (adapted from EM, Rosen)
 
 
 
 
[[Category:Cards]]

Latest revision as of 16:53, 30 July 2025

Background

  • 3 wide complexes in a row is considered ventricular tachycardia
    • Non-sustained if lasts < 30 seconds
    • Sustained if lasts >30 seconds

Etiology[1][2][3]

  • Due to true ventricular tachycardia in 80% of cases
    • For patients with underlying cardiac disease, increases to > 90%
  • Consider:

Clinical Features

Differential Diagnosis

Narrow-complex tachycardia

Wide-complex tachycardia

Assume any wide-complex tachycardia is ventricular tachycardia until proven otherwise (it is safer to incorrectly assume a ventricular dysrhythmia than supraventricular tachycardia with abberancy)

^Fixed or rate-related

Evaluation

Wide regular tachycardia consistent with ventricular tachycardia

Management

Wide Regular Tachycardia[4]

Wide Regular Tachycardia (consistent with ventricular tachycardia).

Pulseless: see Adult pulseless arrest

  • Unstable: Hypotension, altered mental status, shock, ischemic chest discomfort, acute heart failure
  • Stable:
  • Medications
    • Procainamide (first-line drug of choice)
      • 20-50 mg/min until arrhythmia suppressed (max 17mg/kg or 1 gram); then, maintenance infusion of 1-4mg/min x 6hr
        • Alternative administration: 100 mg q5min at max rate of 25-50 mg/min[5]
      • Stop if QRS duration increases >50% or hypotension
      • Avoid if prolonged QT or CHF
      • Favored over Amiodarone in PROCAMIO trial; termination of tachycardia in 67% of procainamide group vs 38% of amiodarone group, adverse cardiac events 9% vs 41%, respectively [6]
    • Amiodarone (agent of choice in setting of AMI or LV dysfunction)
      • 150 mg over 10min (15 mg/min), followed by 1 mg/min drip over 6hrs (360 mg total)[7]
      • Then 0.5 mg/min drip over next 18 hrs (540 mg total)
      • Oral dosage after IV infusion is 400 -800 mg PO daily
    • Consider adenosine
    • Synchronized cardioversion (100J)

Wide Irregular Tachycardia

Wide Irregular Tachycardia (consistent with Torsades De Pointes).
DO NOT use AV nodal blockers as they can precipitate V-Fib
Pulseless: see Adult pulseless arrest

Recurrent

  • ≥3 episodes within 24 hours considered electrical storm and may require alternate treatment (i.e. beta blockade, sedation, ablation)

Other considerations

  • True Vtach generally has rate >120bpm. If rate <120bpm or refractory to other therapy, consider other causes
  • When in doubt, use cardioversion for treatment of regular WCT. In irregular WCT, consider Afib with WPW in which Procainamide is the treatment of choice
  • In very wide complex (>0.2 msec) and <120 bpm in a patient with significant history, consider giving calcium chloride to treat hyperkalemia
  • Consider Acidosis
  • Sodium channel blockade (e.g. from benadryl, TCA, or cocaine toxicity) may cause very wide complex (>0.2msec) tachycardia with rate <120bpm

Disposition

  • Admit all patients (even if converted to normal sinus rhythm in ED)

See Also

External Links

References

  1. ↑ Gupta AK, Thakur RK. Wide QRS complex tachycardias. Med Clin North Am. 2001;85(2):245–66– ix–x.
  2. ↑ Akhtar M, Shenasa M, Jazayeri M, Caceres J, Tchou PJ. Wide QRS complex tachycardia. Reappraisal of a common clinical problem. Ann Intern Med. 1988;109(11):905–912.
  3. ↑ Stewart RB, Bardy GH, Greene HL. Wide complex tachycardia: misdiagnosis and outcome after emergent therapy. Ann Intern Med. 1986;104(6):766–771.
  4. ↑ American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – Part 7: Adult Advanced Cardiovascular Life Support. ECCguidelines.heart.org
  5. ↑ Procainamide. GlobalRPH. http://www.globalrph.com/procainamide_dilution.htm.
  6. ↑ Ortiz M, Martín A, Arribas F, et al. Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. Eur Heart J. 2017 May 1;38(17):1329-1335
  7. ↑ Amiodarone. GlobalRPH. http://www.globalrph.com/amiodarone_dilution.htm.
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