Wide-complex tachycardia

Background

• Consider Hyperkalemia & Dig Toxicity

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
    • Hyperkalemia
    • Digoxin toxicity
    • Severe metabolic acidosis
• 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
    • Torsades de pointes
    • Nonsustained ventricular tachycardia

^Fixed or rate-related

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 treatment (i.e. 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