ACLS: Tachycardia
3 questions
- Is the pt in a sinus rhythm?
- Is the QRS wide or narrow?
- Is the rhythm regular or irregular?
Narrow Regular
- See also Tachycardia (Narrow)
- Sinus 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
- If adenosine fails initiate rate control with CCB or BB
- Synchronized Cardioversion (50-100J)
Narrow Irregular
- MAT
- Treat underlying cause (hypoK, hypomag)
- Sinus Tachycardia w/ frequent PACs
- A fib / A Flutter w/ variable conduction
- Rate control with:
- Dilt
- MTP (good in setting of ACS)
- Amiodarone (good in setting of hypotension, CHF)
- Digoxin (good in setting of CHF)
- Synchronized cardioversion (120-200 J)
- Rate control with:
Wide Regular
- If unstable: shock (synchronized 100J)
- Hhypotension, AMS, shock, ischemic chest discomfort, acute heart failure)
- If stable:
- Meds
- Procainamide
- 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
- Amiodarone
- 150mg over 10min (repeat as needed); then maintenance infusion of 1mg/min x6hr
- Adenosine
- May be considered for diagnosis and treatment only if rhythm is regular and monomorphic
- Procainamide
- Synchronized cardioversion (100J)
- Meds
Wide Irregular
- DO NOT use AV nodal blockers
- Can precipitate V-Fib
- A fib w/ preexcitation
- 1st line - Electric cardioversion
- 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