Wide-complex tachycardia

Background

Consider hyperkalemia & dig OD!

TREATMENT (WIDE)

1. Pulseless --> shock (sync 360J)
2. Unstable --> shock (sync 100J -200J monophasic, or 50-100J biphasic)
3. Stable
   1. Regular^
      1. Tx as presum V.Tach
         1. Amiodarone (150mg over 10min, then 1mg/min gtt x 6hrs)
         2. Procainamide (15-18mg/kg over 30 min)
      2. May cardiovert
      3. See Refractory
   2. Irregular^^
      1. HR <200
         1. Presum aberrant a. fib^^
      2. HR 200-250
      3. HR >250

^DDx Regular

1. V. tach
2. Tachycardia + BBB
3. Tachycardia + rate related BBB
4. Hyperkalemia, meds (e.g. procainamide, flecainide, TCAs, dig)
5. Pacemaker
6. Tachycardia + Accessory pathway

V-TACH (BRUGADA CRITERIA)

Regular rhythms only

Any 1 of the following = Vtach:

(matters only if stable, for drug choice)

1. Absence of RS complex in all precordial leads
2. RS >100ms (>2.5mm) in any precordial
3. AV dissociation (fusion beats)
4. Morphology criteria for VT in V1 or V6 (clear R/L-BB pattern)

^^DDX Irregular

1. A.fib + BBB
2. A.fib + rate related BBB
   1. (QRS widest with shortest R-R)
3. V. tach (see Brugada Criteria)
4. A.fib + hyperkalemia or meds
5. Accessory pathway***

1. The danger = A.fib + aberrant pathway (in WPW)
   1. do not use adenosine, beta blockers, dilt, or dig
   2. changing morphology of QRS = inc poss
   3. consider procainamide or ibutilide (amiodarone?)
   4. shock if becomes unstable

REFRACTORY V-TACH

1. Overdrive pacing
2. Lidocaine
3. Magnesium
4. Electrolytes
5. ?dilantin

See also

Cards: V TACH Vs. Aberrant SVT

Source

8/07 DONALDSON (adapted from EM, Rosen)