Ventricular tachycardia

Background

  • 3 wide complexes in a row is considered ventricular tachycardia
    • Non-sustained if lasts < 30 seconds
    • Sustained if lasts >30 seconds

Clinical Features

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)

^Fixed or rate-related

Evaluation

Ventricular tachycardia

Management

Wide Regular Tachycardia[1]

Pulseless: see Adult pulseless arrest

  • Unstable: Hypotension, altered mental status, shock, ischemic chest discomfort, acute heart failure
  • Stable:
  • 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
  • Synchronized Cardioversion (100J)

Wide Irregular Tachycardia

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

Recurrent

  • ≥3 episodes within 24 hours considered electrical storm and may require alternate treatment (i.e. beta blockade, sedation, ablation)

Other considerations

  • True Vtach generally has rate >120bpm. If rate <120bpm or refractory to other therapy, consider other causes
  • When in doubt, use cardioversion for treatment of regular WCT. In irregular WCT, consider Afib with WPW in which Procainamide is the treatment of choice.
  • In very wide complex (>0.2 msec) and <120 bpm in a patient with significant history, consider giving calcium chloride to treat hyperkalemia
  • Consider Acidosis
  • Sodium channel blockade (e.g. from benadryl, TCA, or cocaine toxicity) may cause very wide complex (>0.2msec) tachycardia with rate <120bpm

Disposition

  • Admit all patients (even if converted to normal sinus rhythm in ED)

See Also

Video

References

  1. American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – Part 7: Adult Advanced Cardiovascular Life Support. ECCguidelines.heart.org
  2. Procainamide. GlobalRPH. http://www.globalrph.com/procainamide_dilution.htm.
  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. http://www.globalrph.com/amiodarone_dilution.htm.

Authors:

Ross Donaldson