Difference between revisions of "ACLS: Tachycardia"

(Tachycardia (with Pulse))
(Differential Diagnosis)
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''This page is for <u>adult</u> patients; for pediatric patients see [[PALS: Tachycardia]]''
==3 questions==
==3 questions==
#Is the pt in a sinus rhythm?
[[File:ACLS-tachycardia.png|thumb|Algorithm for tachycardia with a pulse<ref>Adapted from ACLS 2010</ref>]]
#Is the patient in a sinus rhythm?
#Is the QRS wide or narrow?
#Is the QRS wide or narrow?
#Is the rhythm regular or irregular?
#Is the rhythm regular or irregular?
==Narrow Regular==
==[[Narrow-complex tachycardia|'''Narrow'''-complex tachycardia]]==
#'''See also [[Tachycardia (Narrow)]]'''
{{ACLS Narrow Regular Tachycardia}}
# Sinus Tachycardia
{{ACLS Narrow Irregular Tachycardia}}
##Treat underlying cause
# [[SVT]]
##Vagal maneuvers (convert up to 25%)
##Adenosine 6mg IVP (can follow with 12mg if initially fails)
###If adenosine fails initiate rate control with CCB or BB
####Diltiazem 15-20mg IV, followed by infusion of 5-15mg/hr
####Metoprolol 5mg IVP x 3 followed by 50mg PO
##Synchronized cardioversion (50-100J)
==Narrow Irregular ==
==[[Wide-complex tachycardia|'''Wide'''-complex tachycardia]]==
{{ACLS Wide Regular Tachycardia}}
##Treat underlying cause (hypoK, hypomag)
{{ACLS Wide Irregular Tachycardia}}
# Sinus Tachycardia w/ frequent PACs
# [[A fib]] / A Flutter w/ variable conduction
##Rate control with:
###MTP (good in setting of ACS)
###Amiodarone (good in setting of hypotension, CHF)
###Digoxin (good in setting of CHF)
##Synchronized cardioversion (120-200 J)
==Wide Regular==
==Differential Diagnosis==
*If unstable: shock (synchronized 100J)
{{Tachycardia (narrow) DDX}}
**Hhypotension, AMS, shock, ischemic chest discomfort, acute heart failure)
{{Tachycardia (wide) DDX}}
*If stable:
****20-50mg/min; then maintenance infusion of 1mg/min x6hr
****Tx until arrhythmia suppressed, QRS duration increases >50%, hypotension, 17m/kg given
****Avoid if prolonged QT or CHF
****150mg over 10min (repeat as needed); then maintenance infusion of 1mg/min x6hr
****May be considered for diagnosis and treatment only if rhythm is regular and monomorphic
**Synchronized cardioversion (100J)
==Wide Irregular==
==See Also==
*DO NOT use AV nodal blockers
*[[ACLS (Main)]]
**Can precipitate V-Fib
*[[Wide complex tachycardia]]
*[[Narrow complex tachycardia]]
# A fib w/ preexcitation
==External Links==
##1st line - Electric cardioversion
*[http://ddxof.com/simplified-acls-algorithms/ DDxOf: Simplified ACLS Algorithms]
##2nd line - Procainamide, amiodarone, or sotalol
# A fib w/ aberrancy
# Polymorphic V-Tach / Torsades
##Emergent defibrillation (NOT synchronized)
##Correct electrolyte abnormalities
###HypoK, hypoMag
##Stop prolonged QT meds
==See Also==
*[[ACLS (Main)]]
{{#widget:YouTube|id= EiIxCguDf8o}}
*[[Tachycardia (Wide)]]
{{#widget:YouTube|id= wXgqct8B2tk}}
*[[Tachycardia (Narrow)]]
[[Category:Critical Care]]

Latest revision as of 06:28, 5 April 2019

This page is for adult patients; for pediatric patients see PALS: Tachycardia

3 questions

Algorithm for tachycardia with a pulse[1]
  1. Is the patient in a sinus rhythm?
  2. Is the QRS wide or narrow?
  3. Is the rhythm regular or irregular?

Narrow-complex tachycardia

Narrow Regular Tachycardia

  • Sinus tachycardia
    • Treat underlying cause
  • SVT
    • Vagal maneuvers (convert up to 25%)
    • Adenosine 6mg rapid IV push if patient hemodynamically stable (unstable should proceed directly to electrical cardioversion)
      • Can follow with repeat dose of 6 mg or 12mg if initially fails
      • If adenosine fails, initiate rate control with calcium channel blocker or beta blocker or use synchronized cardioversion
        • Diltiazem 15-20mg IV, followed by infusion of 5-15mg/hr
        • Metoprolol 5mg IVP x 3 followed by 50mg PO
    • Synchronized cardioversion (50-100J)
      • Provide sedation prior to synchronized cardioversion if patient is hemodynamically stable
  • Atrial flutter
    • Stable: Consider rate control to HR < 110 bpm
    • Unstable: Synchronized cardioversion; start at 50J

Narrow Irregular Tachycardia

  • Multi-focal atrial tachycardia (MAT)
    • Treat underlying cause (hypokalemia, hypomagnesemia)
    • Consider diltiazem
    • Avoid beta blockers unless they are already known to be tolerated, as airway disease often co-morbid
    • If not symptomatic and rate < 110/120 bpm, may not require treatment (e.g., patient with MAT secondary to COPD)
  • Sinus Tachycardia with frequent PACs
    • Treat underlying cause
  • A fib / A Flutter with variable conduction (see also Atrial Fibrillation with RVR)
    • Check if patient has taken usual rate-control meds
      • If missed dose, may provide dose of home medication and observe for resolution
    • Determine whether patient is better candidate for rate control or rhythm control [2]
      • Rate control preferred with:
        • Persistent A fib
        • Less symptomatic patients
        • Age 65 or older
        • Hypertension
        • No heart failure
        • Previous failure to cardiovert
        • Patient preference
      • Rhythm control preferred with:
        • Paroxismal or new A fib
        • More symptomatic patients
        • Age < 65 years
        • Heart failure clearly exacerbated by A fib
        • No history of rhythm control failure
        • Patient preference
    • Rate control with:
    • Rhythm conversion with:

Wide-complex tachycardia

Wide Regular Tachycardia[3]

Pulseless: see Adult pulseless arrest

  • Unstable: Hypotension, altered mental status, shock, ischemic chest discomfort, acute heart failure
  • Stable:
  • Medications
    • Procainamide (first-line drug of choice)
      • 20-50mg/min until arrhythmia suppressed (max 17mg/kg or 1 gram); then, maintenance infusion of 1-4mg/min x 6hr
        • Alternative administration: 100 mg q5min at max rate of 25-50 mg/min[4]
      • Stop if QRS duration increases >50% or hypotension
      • Avoid if prolonged QT or CHF
      • Favored over Amiodarone in PROCAMIO trial; termination of tachycardia in 67% of procainamide group vs 38% of amiodarone group, adverse cardiac events 9% vs 41%, respectively [5]
    • 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)[6]
      • Then 0.5 mg/min drip over next 18 hrs (540 mg total)
      • Oral dosage after IV infusion is 400 -800 mg PO daily
    • Consider adenosine
  • Synchronized Cardioversion (100J)

Wide Irregular Tachycardia

DO NOT use AV nodal blockers as they can precipitate V-Fib
Pulseless: see Adult pulseless arrest

Differential Diagnosis

Narrow-complex tachycardia

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)

^Fixed or rate-related

See Also

External Links



  1. Adapted from ACLS 2010
  2. Frankel, G. et al. (2013) Rate versus rhythm control in atrial fibrillation. Canadian Family Physician 59(2), 161 - 168
  3. American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – Part 7: Adult Advanced Cardiovascular Life Support. ECCguidelines.heart.org
  4. Procainamide. GlobalRPH. http://www.globalrph.com/procainamide_dilution.htm.
  5. Ortiz M, Martín A, Arribas F, et al. Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. Eur Heart J. 2017 May 1;38(17):1329-1335
  6. Amiodarone. GlobalRPH. http://www.globalrph.com/amiodarone_dilution.htm.