Wide-complex tachycardia: Difference between revisions

m (Rossdonaldson1 moved page Tachycardia (wide) to Wide complex tachycardia over redirect)
(24 intermediate revisions by 3 users not shown)
Line 1: Line 1:
==Background==
==Background==
*3 wide complexes in a row is considered ventricular tachycardia; non-sustained if lasts less than 30 seconds
*3 wide complexes in a row is considered ventricular tachycardia
*Sustained ventricular tachycardia is ventricular tachycardia >30 seconds
**Non-sustained if lasts < 30 seconds
**Sustained if lasts >30 seconds


===Etiology<ref>Gupta AK, Thakur RK. Wide QRS complex tachycardias. Med Clin North Am. 2001;85(2):245–66– ix–x.</ref><ref>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.</ref><ref>Stewart RB, Bardy GH, Greene HL. Wide complex tachycardia: misdiagnosis and outcome after emergent therapy. Ann Intern Med. 1986;104(6):766–771.</ref>===
===Etiology<ref>Gupta AK, Thakur RK. Wide QRS complex tachycardias. Med Clin North Am. 2001;85(2):245–66– ix–x.</ref><ref>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.</ref><ref>Stewart RB, Bardy GH, Greene HL. Wide complex tachycardia: misdiagnosis and outcome after emergent therapy. Ann Intern Med. 1986;104(6):766–771.</ref>===
*WCT is due to true ventricular tachycardia in 80% of cases
*Due to true ventricular tachycardia in 80% of cases
*For patients with underlying cardiac disease, this number increases to > 90%
**For patients with underlying cardiac disease, increases to > 90%
*Multiple other causes must be considered, including [[Hyperkalemia]], [[Digoxin toxicity]], severe metabolic acidosis, and others
*Consider:
**[[Hyperkalemia]]
**[[Digoxin toxicity]]
**Severe metabolic acidosis
 
==Clinical Features==
*Depends on etiology
*Range from asymptomatic/[[palpitations]] to [[cardiac arrest]]


==Differential Diagnosis==
==Differential Diagnosis==
{{Tachycardia (narrow) DDX}}
{{Tachycardia (wide) DDX}}
{{Tachycardia (wide) DDX}}


Line 14: Line 23:
[[File:Lead II rhythm ventricular tachycardia Vtach VT.jpg|thumb|Ventricular tachycardia]]
[[File:Lead II rhythm ventricular tachycardia Vtach VT.jpg|thumb|Ventricular tachycardia]]
*Assume ventricular tachycardia until proven otherwise
*Assume ventricular tachycardia until proven otherwise
*See [[V Tach vs. SVT]]
*See also [[rhythm diagnosis in regular wide complex tachycardia]]


==Management==
==Management==
''Pulseless: see [[Adult pulseless arrest]]''
{{ACLS Wide Regular Tachycardia}}
===Unstable===
{{ACLS Wide Irregular Tachycardia}}
*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%
**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 <ref>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</ref>
*[[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


===Recurrent===
===Recurrent===
Line 37: Line 33:


===Other considerations===
===Other considerations===
*True Vtach generally has rate >120bpm. If rate <120bpm or refractory to other therapy, consider other causes
*True [[Vtach]] generally has rate >120bpm. If rate <120bpm or refractory to other therapy, consider other causes
*When in doubt, use cardioversion for treatment of regular WCT. In irregular WCT, consider Afib with [[WPW]] in which [[Procainamide]] is the treatment of choice.
*When in doubt, use cardioversion for treatment of regular WCT. In irregular WCT, consider Afib with [[WPW]] in which [[Procainamide]] is the treatment of choice.
*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]]  
*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]]  
Line 46: Line 42:


==Disposition==
==Disposition==
*Admit all patients (even if converted to NSR in ED)
*Admit all patients (even if converted to normal sinus rhythm in ED)


==See Also==
==See Also==
*[[ACLS: Tachycardia]]
*[[ACLS: Tachycardia]]
*[[ACLS (Main)]]
*[[ACLS (Main)]]
*[[V Tach vs. SVT]]
*[[Rhythm diagnosis in regular wide complex tachycardia]]
*[[Paroxysmal supraventricular tachycardia]]
*[[Paroxysmal supraventricular tachycardia]]
*[[Nonsustained ventricular tachycardia]]
*[[Nonsustained ventricular tachycardia]]
*[[Polymorphic ventricular tachycardia]]
*[[Polymorphic ventricular tachycardia]]
*[[Electrical storm]]


==Video==
{{#widget:YouTube|id=wXgqct8B2tk}}
==References==
==References==
<references/>
<references/>
[[Category:Cardiology]]
[[Category:Cardiology]]

Revision as of 06:27, 5 April 2019

Background

  • 3 wide complexes in a row is considered ventricular tachycardia
    • Non-sustained if lasts < 30 seconds
    • Sustained if lasts >30 seconds

Etiology[1][2][3]

  • Due to true ventricular tachycardia in 80% of cases
    • For patients with underlying cardiac disease, increases to > 90%
  • Consider:

Clinical Features

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

Evaluation

Ventricular tachycardia

Management

Wide Regular Tachycardia[4]

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[5]
      • 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 [6]
    • 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)[7]
      • 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

Recurrent

  • ≥3 episodes within 24 hours considered electrical storm and may require alternate treatment (i.e. beta blockade, sedation, ablation)

Other considerations

  • True Vtach generally has rate >120bpm. If rate <120bpm or refractory to other therapy, consider other causes
  • When in doubt, use cardioversion for treatment of regular WCT. In irregular WCT, consider Afib with WPW in which Procainamide is the treatment of choice.
  • In very wide complex (>0.2 msec) and <120 bpm in a patient with significant history, consider giving calcium chloride to treat hyperkalemia
  • Consider Acidosis
  • Sodium channel blockade (e.g. from benadryl, TCA, or cocaine toxicity) may cause very wide complex (>0.2msec) tachycardia with rate <120bpm

Disposition

  • Admit all patients (even if converted to normal sinus rhythm in ED)

See Also

Video

{{#widget:YouTube|id=wXgqct8B2tk}}

References

  1. ↑ Gupta AK, Thakur RK. Wide QRS complex tachycardias. Med Clin North Am. 2001;85(2):245–66– ix–x.
  2. ↑ 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.
  3. ↑ Stewart RB, Bardy GH, Greene HL. Wide complex tachycardia: misdiagnosis and outcome after emergent therapy. Ann Intern Med. 1986;104(6):766–771.
  4. ↑ American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – Part 7: Adult Advanced Cardiovascular Life Support. ECCguidelines.heart.org
  5. ↑ Procainamide. GlobalRPH. http://www.globalrph.com/procainamide_dilution.htm.
  6. ↑ 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
  7. ↑ Amiodarone. GlobalRPH. http://www.globalrph.com/amiodarone_dilution.htm.
Retrieved from "https://www.wikem.org/w/index.php?title=Wide-complex_tachycardia&oldid=211260"