Wide-complex tachycardia
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Background
- Consider Hyperkalemia, Dig Toxicity, severe metabolic acidosis
- Sustained ventricular tachycardia is VT > 30 seconds
- Less than 30 seconds, 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
- Regular (treat as presumed V-tach)
- Procainamide (20mg/min)
- Amiodarone (150mg over 10min, then 1mg/min drip 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 drip x 6hrs)
- Sotalol (100mg IV over 5 minutes)
- Magnesium 1-2gm IV over 60-90s, then infuse 1-2gm/hr (for Torsades De Pointes)
- Regular (treat as presumed V-tach)
- Refractory
- ≥3 episodes within 24 hours considered electrical storm and may require alternate treatment (i.e. beta blockade, sedation, ablation)
Disposition
- Admit all patients (even if converted to NSR with adenosine)
See Also
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.