ACLS: Tachycardia

3 questions

  1. Is the patient in a sinus rhythm?
  2. Is the QRS wide or narrow?
  3. Is the rhythm regular or irregular?

Narrow complex tachycardia

Algorithm for tachycardia with a pulse (Adapted from ACLS 2010)

Narrow Regular Tachycardia

Narrow Irregular Tachycardia

Wide complex tachycardia

Wide Regular Tachycardia[1]

Pulseless: see Adult pulseless arrest

  • Unstable: Hypotension, altered mental status, shock, ischemic chest discomfort, acute heart failure
  • Stable:
    1. Medications
      • Procainamide (first-line drug of choice)
        • 20-50mg/min until arrhythmia suppressed (max 17mg/kg or 1 gram); then, maintenance infusion of 1-4mg/min x 6hr
          • Alternative administration: 100 mg q5min at max rate of 25-50 mg/min[2]
        • Stop if QRS duration increases >50% or hypotension
        • Avoid if prolonged QT or CHF
        • Favored over Amiodarone in PROCAMIO trial; termination of tachycardia in 67% of procainamide group vs 38% of amiodarone group, adverse cardiac events 9% vs 41%, respectively [3]
      • Amiodarone (agent of choice in setting of AMI or LV dysfunction)
        • 150 mg over 10min (15 mg/min), followed by 1 mg/min drip over 6hrs (360 mg total)[4]
        • Then 0.5 mg/min drip over next 18 hrs (540 mg total)
        • Oral dosage after IV infusion is 400 -800 mg PO daily
      • Consider adenosine
    2. Synchronized Cardioversion (100J)

Wide Irregular Tachycardia

DO NOT use AV nodal blockers as they can precipitate V-Fib
Pulseless: see Adult pulseless arrest

See Also

External Links



  1. American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – Part 7: Adult Advanced Cardiovascular Life Support.
  2. Procainamide. GlobalRPH.
  3. Ortiz M, Martín A, Arribas F, et al. Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. Eur Heart J. 2017 May 1;38(17):1329-1335
  4. Amiodarone. GlobalRPH.