Wide-complex tachycardia

Background

Consider hyperkalemia & dig toxicity

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. 1st Line
            1. Amiodarone (150mg over 10min, then 1mg/min gtt x 6hrs)
               1. Agent of choice in setting of AMI or LV dysfunction
            2. Procainamide (15-18mg/kg over 30 min)
         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
      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
7. See V Tach vs. SVT

DDX Irregular

1. A.fib + BBB
2. A.fib + rate related BBB
   1. QRS widest with shortest R-R
3. V. tach
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

ACLS (2010 Guidelines)

V Tach vs. SVT

Source

Rosen's