Management of Tachycardia

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Management of Tachycardia
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Classification of Tachyarrhythmias

• Narrow-QRS-complex tachycardias (SVT)
• Sinus tachycardia
• AF/AFL
• AVNRT
• AVRT (WPW)
• Atrial tachycardia, Multifocal atrial tachycardia
• Junctional tachycardia
• Wide-QRS-complex tachycardias
• VT
• SVT with aberrancy
• Pre-excited tachycardias

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Initial Evaluation of Tachyarrhythmias

• Assess and support ABCs
• Give oxygen
• Monitor ECG, blood pressure, oximetry
• Identify and treat reversible causes
• Check patients status
• Mental status
• Ongoing chest pain
• Hypotension
• Other signs of shock

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Treatment of Tachycardia
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Unstable Tachyarrhythmias

• Perform immediate synchronized cardioversion
• Do not delay cardioversion
• Establish IV access
• Consider expert consultation
• Initial dose for CV
• AF 100 200 J (monophasic), 100 120 J
  (biphasic)
• AFL/SVT 50 100 J (monophasic)
• Monomorphic VT 100 J (monophasic)
• Polymorphic VT unsynchronized shock, 360 J
  (monophasic), 120 200 J (biphasic)

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Regular Narrow-Complex Tachycardia (I)

• Sinus tachycardia
• No specific drug treatment
• Identify and correct the underlying cause

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Regular Narrow-Complex Tachycardia (II)

• SVT
• Vagal maneuvers (Valsalva or CSM massage)
• Give adenosine 6 mg IV push -gt 12 mg IV push
• Treat recurrence of SVT
• Adenosine
• Verapamil
• Give 2.5 to 5 mg IV bolus over 2 minutes -gt 5 to
  10 mg every 15 30 minutes (total dose of 20 mg)
• Diltiazem
• Give 15 to 20 mg (0.25 mg/kg) IV over 2 minutes
  -gt 0.35 mg/kg in 15 minutes, maintenance dose 5
  to 15 mg/h
• Beta-blockers
• Atenolol, metoprolol, esmolol

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Irregular Narrow-Complex Tachycardias

• AF/AFL
• Consider expert consultation
• Control of rapid ventricular rate
• Diltiazem
• Beta-blockers
• Rhythm control
• In AF of less than 48 hours duration
• Antiarrhythmic drugs
• Class III drugs amiodarone, Ibutilide
• Class Ic drugs propafenone, flecainide
• MAT
• Consider expert consultation
• Control rate

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Regular Wide-Complex Tachycardias

• VT
• Amiodarone
• 150 mg IV over 10 min
• Repeat as needed to maximum dose of 2.2 g/24
  hours
• Procainamide
• Give at a rate 20 mg/min to maximum dose of 17
  mg/kg
• Maintenance infusion rate 1 4 mg/min
• Prepare for elective synchronized cardioversion
• SVT with aberrancy
• Give adenosine

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Irregular Wide-Complex Tachycardias (I)

• AF with aberrancy
• Control of rapid ventricular rate
• Diltiazem
• Beta-blockers
• Rhythm control
• In AF of less than 48 hours duration
• Antiarrhythmic drugs
• Amiodarone
• Ibutilide
• Propafenone, flecainide

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Irregular Wide-Complex Tachycardias (II)

• Pre-excited AF (AF WPW)
• Expert consultation advised
• Avoid AV nodal blocking agents
• Adenosine
• Digoxin
• Diltiazem, verapamil
• Consider Amiodarone
• 150 mg IV over 10 min

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Irregular Wide-Complex Tachycardias (III)

• Recurrent polymorphic VT
• Seek expert consultation
• Torsades de pointes
• Give magnesium
• Load with 1 2 g over 5 60 min, then infusion
• Correct and treat contributing factors
• Toxins
• Hypokalemia
• Bradycardia
• Others

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