Wide-complex tachycardia

Background

• Consider Hyperkalemia & Dig Toxicity

Diagnosis

• V Tach vs. SVT

Treatment

1. Pulseless - Unsynchronized cardioversion 200J
2. Unstable - shock (synchronized 100J -200J monophasic, 50-100J biphasic)
3. Stable
   1. Regular (tx as presumed V-tach)
      1. 1st Line
         1. Procainamide (20mg/min)
         2. Amiodarone (150mg over 10min, then 1mg/min gtt x 6hrs)
            1. Agent of choice in setting of AMI or LV dysfunction
      2. 2nd Line
         1. Lidocaine 1-1.5mg/kg IV q5min, repeat prn until up to 300mg/hr
      3. Torsades De Pointes
         1. Mag 1-2gm IV over 60-90s, then infuse 1-2gm/hr
      4. Synchronized cardioversion (100 J)
   2. Irregular (tx as presumed preexcited A-fib)
      1. Procainamide (20mg/min)
      2. Amiodarone (150mg over 10min, then 1mg/min gtt x 6hrs)
      3. Sotalol (100 mg IV over 5 minutes)
      4. Unsynchronized cardioversion (200J)

DDx Regular

1. V-tach
2. SVT w/ BBB (fixed or rate related)
3. SVT w/ accessory pathway
4. A flutter w/ BBB
5. Sinus tachycardia with BBB (fixed or rate related)

DDX Irregular

1. A-fib/flutter w/ variable AV conduction AND BBB (fixed or rate-related)
2. A-fib/flutter w/ variable AV conduction AND accessory pathway
3. A-fib + hyperkalemia
4. Polymorphic v-tach/torsades

Disposition

• Admit all pts (even if converted to NSR with adenosine)

See Also

• Tachycardia (with Pulse)
• ACLS (Main)
• V Tach vs. SVT

Source

Rosen's