Wide-complex tachycardia

Consider hyperkalemia & dig OD

TREATMENT (WIDE)

I. Pulseless --> shock (sync 360J)

II. Unstable --> shock (prefer sync/100J, 200J)

III. Stable

    A. Regular*

         i. Tx as presum V.Tach

         ii. Amiodarone (150mg over 10min, then 1mg/min gtt x 6hrs)

         iii. May cardiovert

         iv. See Refractory

    B. Irregular**

         i. HR <200

              -Presum aberrant a. fib**

         ii. HR 200-250

         iii. 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

(QRS widest with shortest R-R)

3) V. tach (see Brugada Criteria)

4) A.fib + hyperkalemia or meds

6) Accessory pathway***

- The danger = A.fib + aberrant pathway (in WPW)

--> do not use adenosine, beta blockers, dilt, or dig

--> changing morphology of QRS = inc poss

--> consider procainamide or ibutilide (amiodarone?)

--> shock if becomes unstable

REFRACTORY V-TACH

Overdrive pacing

Lidocaine

Magnesium

Electrolytes

?dilantin

Source

8/07 DONALDSON (adapted from EM, Rosen)

Authors: