Wide-complex tachycardia

Background

• Consider Hyperkalemia & Dig Toxicity

Differential Diagnosis

Regular

• V-tach
• SVT w/ BBB (fixed or rate related)
• SVT w/ accessory pathway
• A flutter w/ BBB
• Sinus tachycardia with BBB (fixed or rate related)

Irregular

• A-fib/flutter w/ variable AV conduction AND BBB (fixed or rate-related)
• A-fib/flutter w/ variable AV conduction AND accessory pathway
• A-fib + Hyperkalemia
• Polymorphic v-tach/torsades

Diagnosis

Ventricular tachycardia

• Assume ventricular tachycardia until proven otherwise
• See V Tach vs. SVT

Treatment

Pulseless: see Adult pulseless arrest

• Unstable:
  • Regular: Synchronized cardioversion 100-200J
  • Irregular: Unsynchronized cardioversion (defibrillation) 200J
• Stable
  • Regular (treat as presumed V-tach)
    • Procainamide (20mg/min)
    • Amiodarone (150mg over 10min, then 1mg/min gtt x 6hrs)
      • Agent of choice in setting of AMI or LV dysfunction
    • Lidocaine 1-1.5mg/kg IV q5min, repeat prn until up to 300mg/hr
  • Irregular (treat as presumed preexcited A-fib)
    • Procainamide (20mg/min)
    • Amiodarone (150mg over 10min, then 1mg/min gtt x 6hrs)
    • Sotalol (100 mg IV over 5 minutes)
    • Magnesium 1-2gm IV over 60-90s, then infuse 1-2gm/hr (for Torsades De Pointes)
• Refractory
  • ≥3 episodes within 24 hours considered electrical storm and may require alternate tx, ie beta blockade, sedation, ablation

Disposition

• Admit all pts (even if converted to NSR with adenosine)

See Also

• ACLS: Tachycardia
• ACLS (Main)
• V Tach vs. SVT
• SVT

Source

• Rosen's