Wide-complex tachycardia

Background

• Consider Hyperkalemia & Dig Toxicity

Diagnosis

• V Tach vs. SVT

Treatment

1. Pulseless - Unsynchronized cardioversion 200J
2. Unstable - shock (synchronized 100J -200J monophasic, 50-100J biphasic)
3. Stable
   1. Regular (tx as presumed V-tach)
      1. 1st Line
         1. Procainamide (20mg/min)
         2. Amiodarone (150mg over 10min, then 1mg/min gtt x 6hrs)
            1. Agent of choice in setting of AMI or LV dysfunction
      2. 2nd Line
         1. Lidocaine 1-1.5mg/kg IV q5min, repeat prn until up to 300mg/hr
      3. Torsades De Pointes
         1. Mag 1-2gm IV over 60-90s, then infuse 1-2gm/hr
      4. Synchronized cardioversion (100 J)
   2. Irregular (tx as presumed preexcited A-fib)
      1. Procainamide (20mg/min)
      2. Amiodarone (150mg over 10min, then 1mg/min gtt x 6hrs)
      3. Sotalol (100 mg IV over 5 minutes)
      4. Unsynchronized cardioversion (200J)

DDx Regular

1. V-Tach
2. SVT with aberrancy
3. Tachycardia + BBB
4. Tachycardia + rate related BBB
5. Hyperkalemia, meds (e.g. procainamide, flecainide, TCAs, dig)
6. Pacemaker

DDX Irregular

1. A-fib + BBB
2. A-fib + rate related BBB
   1. QRS widest with shortest R-R
3. Polymorphic v-tach/torsades
4. A-fib + hyperkalemia or meds
5. Accessory pathway
   1. The danger = A-fib + aberrant pathway (in WPW)
      1. Do not use adenosine, beta blockers, dilt, or dig
      2. Changing morphology of QRS = inc poss
      3. Consider procainamide or ibutilide
      4. Shock if becomes unstable

See also

• ACLS (2010 Guidelines)
• V Tach vs. SVT

Disposition

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

Source

Rosen's