Wide-complex tachycardia: Difference between revisions
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==Management== | ==Management== | ||
''Pulseless: see [[Adult pulseless arrest]]'' | ''Pulseless: see [[Adult pulseless arrest]]'' | ||
===Unstable=== | |||
*Regular: Synchronized cardioversion 100-200J | |||
*Irregular: Unsynchronized cardioversion ([[defibrillation]]) 200J | |||
===Stable=== | |||
*[[Procainamide]] 100 mg q5min at max rate of 25-50 mg/min<ref>Procainamide. GlobalRPH. http://www.globalrph.com/procainamide_dilution.htm.</ref> | |||
**Until termination of arrhythmia, then start 2-6 mg/min (or 1-2 mg/min for renal/cardiac failure) | |||
**'''OR''' max 17 mg/kg total dose given (12 mg/kg if renal failure) | |||
**'''OR''' if QRS widens > 50% | |||
*[[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)<ref>Amiodarone. GlobalRPH. http://www.globalrph.com/amiodarone_dilution.htm.</ref> | |||
**Then 0.5 mg/min drip over next 18 hrs (540 mg total) | |||
**Oral dosage after IV infusion is 400 -800 mg PO daily | |||
*[[Lidocaine]] 1-1.5mg/kg IV q5min, repeat PRN until up to 300mg/hr | |||
===Refractory=== | |||
*≥3 episodes within 24 hours considered [[electrical storm]] and may require alternate treatment (i.e. beta blockade, sedation, ablation) | |||
*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]] and | |||
===Other considerations=== | |||
*Consider [[Bicarbonate]] for Na channelopathy such as [[Benadryl]], [[TCA toxicity]] or [[Cocaine]] overdose | |||
*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]] and [[Bicarbonate]] for Na channelopathy | |||
**Usually Vtach is >120 bpm | **Usually Vtach is >120 bpm | ||
**[[Hyperkalemia]] | **Also consider [[Hyperkalemia]] or [[Acidosis]] as reversible causes | ||
**[[Lidocaine]], [[Procainamide]], [[Amiodarone]] all block Na channels and may result in asystole in | **[[Lidocaine]], [[Procainamide]], [[Amiodarone]] all block Na channels and may result in asystole in patients with intrinsic or extrinsic Na-channel blockade | ||
==Disposition== | ==Disposition== | ||
Revision as of 18:40, 13 July 2017
Background
- Consider Hyperkalemia, Dig Toxicity, severe metabolic acidosis
- Sustained ventricular tachycardia is VT > 30 seconds
- 3 beats is considered VT; less than 30 seconds is non-sustained VT
Epidemiology[1][2][3]
- WCT is due to ventricular tachycardia in 80% of cases
- For patients with underlying cardiac disease, this number increases to > 90%
Differential Diagnosis
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)
- Regular
- Monomorphic ventricular tachycardia
- PSVT with aberrant conduction:
- PSVT with bundle branch block^
- PSVT with accessory pathway
- Atrial flutter with bundle branch block^
- Sinus tachycardia with bundle branch block^
- Accelerated idioventricular rhythm (consider if less than or ~120 bpm)
- Metabolic
- Irregular
- Atrial fibrillation/atrial flutter with variable AV conduction AND bundle branch block^
- Atrial fibrillation/atrial flutter with variable AV conduction AND accessory pathway (e.g. WPW)
- Atrial fibrillation + hyperkalemia
- Polymorphic ventricular tachycardia
^Fixed or rate-related
Evaluation
- Assume ventricular tachycardia until proven otherwise
- See V Tach vs. SVT
Management
Pulseless: see Adult pulseless arrest
Unstable
- Regular: Synchronized cardioversion 100-200J
- Irregular: Unsynchronized cardioversion (defibrillation) 200J
Stable
- Procainamide 100 mg q5min at max rate of 25-50 mg/min[4]
- Until termination of arrhythmia, then start 2-6 mg/min (or 1-2 mg/min for renal/cardiac failure)
- OR max 17 mg/kg total dose given (12 mg/kg if renal failure)
- OR if QRS widens > 50%
- 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)[5]
- Then 0.5 mg/min drip over next 18 hrs (540 mg total)
- Oral dosage after IV infusion is 400 -800 mg PO daily
- Lidocaine 1-1.5mg/kg IV q5min, repeat PRN until up to 300mg/hr
Refractory
- ≥3 episodes within 24 hours considered electrical storm and may require alternate treatment (i.e. beta blockade, sedation, ablation)
- In very wide complex (>0.2 msec) and <120 bpm in a patient with significant history, consider giving calcium chloride to treat hyperkalemia and
Other considerations
- Consider Bicarbonate for Na channelopathy such as Benadryl, TCA toxicity or Cocaine overdose
- Usually Vtach is >120 bpm
- Also consider Hyperkalemia or Acidosis as reversible causes
- Lidocaine, Procainamide, Amiodarone all block Na channels and may result in asystole in patients with intrinsic or extrinsic Na-channel blockade
Disposition
- Admit all patients (even if converted to NSR with adenosine)
See Also
- ACLS: Tachycardia
- ACLS (Main)
- V Tach vs. SVT
- SVT
- Nonsustained ventricular tachycardia
- Polymorphic ventricular tachycardia
References
- ↑ Gupta AK, Thakur RK. Wide QRS complex tachycardias. Med Clin North Am. 2001;85(2):245–66– ix–x.
- ↑ 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.
- ↑ Stewart RB, Bardy GH, Greene HL. Wide complex tachycardia: misdiagnosis and outcome after emergent therapy. Ann Intern Med. 1986;104(6):766–771.
- ↑ Procainamide. GlobalRPH. http://www.globalrph.com/procainamide_dilution.htm.
- ↑ Amiodarone. GlobalRPH. http://www.globalrph.com/amiodarone_dilution.htm.