Wide-complex tachycardia: Difference between revisions

Revision as of 01:40, 16 February 2016

Background

Consider Hyperkalemia & Dig Toxicity
Sustained ventricular tachycardia is VT > 30 seconds
Less than 30 seconds, non-sustained VT

Differential Diagnosis

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)

Regular
- Monomorphic ventricular tachycardia
- PSVT with aberrant conduction:
  - PSVT with bundle branch block^
  - PSVT with accessory pathway
  - Atrial flutter with bundle branch block^
- Sinus tachycardia with bundle branch block^
- Accelerated idioventricular rhythm (consider if less than or ~120 bpm)
- Metabolic
  - Hyperkalemia
  - Digoxin toxicity
  - Severe metabolic acidosis
Irregular
- Atrial fibrillation/atrial flutter with variable AV conduction AND bundle branch block^
- Atrial fibrillation/atrial flutter with variable AV conduction AND accessory pathway (e.g. WPW)
- Atrial fibrillation + hyperkalemia
- Polymorphic ventricular tachycardia
  - Torsades de pointes
  - Nonsustained ventricular tachycardia

^Fixed or rate-related

Diagnosis

Ventricular tachycardia

Assume ventricular tachycardia until proven otherwise
See V Tach vs. SVT
If less than or ~120 bpm, consider Accelerated Idioventricular Rhythm

Treatment

Pulseless: see Adult pulseless arrest

Unstable:
- Regular: Synchronized cardioversion 100-200J
- Irregular: Unsynchronized cardioversion (defibrillation) 200J
Stable
- Regular (treat as presumed V-tach)
  - Procainamide (20mg/min)
  - Amiodarone (150mg over 10min, then 1mg/min gtt x 6hrs)
    - Agent of choice in setting of AMI or LV dysfunction
  - Lidocaine 1-1.5mg/kg IV q5min, repeat prn until up to 300mg/hr
- Irregular (treat as presumed preexcited A-fib)
  - Procainamide (20mg/min)
  - Amiodarone (150mg over 10min, then 1mg/min gtt x 6hrs)
  - Sotalol (100 mg IV over 5 minutes)
  - Magnesium 1-2gm IV over 60-90s, then infuse 1-2gm/hr (for Torsades De Pointes)
Refractory
- ≥3 episodes within 24 hours considered electrical storm and may require alternate treatment (i.e. beta blockade, sedation, ablation)

Disposition

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

Source

Rosen's

Authors:

@@ Line 11: / Line 11: @@
 *Assume ventricular tachycardia until proven otherwise
 *See [[V Tach vs. SVT]]
+*If less than or ~120 bpm, consider [[Accelerated Idioventricular Rhythm]]
 ==Treatment==