TACHYCARDIA

The Tachycardias: Overview Algorithm

Evaluate patient
Is patient stable or unstable?
Are there serious signs or symptoms?
Are signs and symptoms due to tachycardia?

Stable Unstable

Stable patient: no serious signs or symptoms Unstable patient: serious signs or symptoms
Initial assessment identifies 1 of 4 types of Establish rapid heart rate as cause of signs and
tachycardias symptoms
Rate-related signs and symptoms occur at many rates,
seldom < 150 bpm
Prepare for immediate cardioversion (see Fig. 10)

1. Atrial fibrillation 2. Narrow-complex 3. Stable wide-complex 4. Stable monomorphic VT

Atrial flutter tachycardia tachycardia: unknown type and/or polymorphic VT

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Evaluation focus: 4 clinical Attempt to establish a Attempt to establish a
features specific diagnosis specific diagnosis
1. Patient clinically unstable? 12-lead ECG 12-lead ECG
2. Cardiac function impaired? Clinical information Esophageal lead
3. WPW present? Vagal maneuvers Clinical information
4. Duration <48 or >48 hours? adenosine

Treatment focus: clinical Diagnostic efforts yield

evaluation Ectopic atrial tachycardia
1. Treat unstable patients urgently Multifocal atrial tachycardia
2. Control the rate Paroxysmal supraventricular
3. Convert the rhythm tachycardia (PSVT)
4. Provide anticoagulation

Treatment of Treatment of SVT Confirmed Wide-complex Confirmed Treatment of stable

atrial (see narrow-complex SVT tachycardia of stable monomorphic and
fibrillation/ tachycardia algorithm) unknown type VT polymorphic VT
atrial flutter (see stable VT:
(see following Preserved Ejection fraction <40% monomorphic and
table) cardiac function Clinical CHF polymorphic algorithm)

DC cardioversion DC cardioversion
or or
Procainamide Amiodarone
or
Amiodarone
 Tachycardia: Atrial Fibrillation and Flutter
Control of Rate and Rhythm (Continued from Tachycardia Overview)
Atrial fibrillation/ 1. Control Rate 2. Convert Rhythm
atrial flutter with
Normal heart
Impaired heart Heart Function Impaired Duration <48 Duration >48 Hours or
WPW Preserved Heart EF Hours Unknown
<40% or CHF
Note: If AF>48 hours (Does not Consider Avoid nonemergent
duration, use agents apply) DC carioversion cardioversion unless
with potential to anticoagulation or clot
convert rhythm with precautions are taken (see
extreme caution in Use only 1 of the below).
patients not receiving following agents Note: Conversion of AF to
adequate (see note below ): NSR with drugs or shock may
anticoagulation Amiodarone cause embolization of atrial
because of possible (Class lla) thrombi unless patient has
embolic Ibutilide (Class lla) adequate anticoagulation.
complications. Use antiarrhythmic agents
Flecainide
(Class lla) with extreme caution if AF >48
Use only 1 of the hours duration (see note
following agents (see Propafenone above).
note below): (Class lla) or
Calcium channel Procainamide Delayed cardioversion
blockers (Class I) (Class lla) Anticoagulation x 3 weeks at
-Blockers (Class I) proper levels
Cardioversion, then
Anticoagulation x 4 weeks
more
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 For additional For additional Early cardiovesrsion
drugs that are drugs that are Begin IV heparin at once
Class IIb Class IIb TEE to exclude atrial clot
recommendation recommendation
s, Then
s , see
see Guidelines Guidelines or Cardioversion within 24 hours
or ACLS text ACSL text Then
Anticoagulation x 4 more weeks

Impaired (Does not apply) Note: If AF>48 hours Consider Aviod nonemergent
heart (EF duration, use agents DC cardioversion unless
<40% or with potential to convert Cardioversion anticoagulation or clot
CHF) rhythm with extreme Or precautions are taken (see
caution in patients not above).
receiving adequate Amiodarone
(Class IIb) Anticoagulation as described
anticoagulation because above, follow by
of possible embolic DC cardioversion
complications.

Use only 1 of the

following agents (see
note below):
Digoxin (Class IIb)
Ditiazem (Class IIb)
Amiodarone (Class IIb)
 Tachycardia: Atrial Fibrillation and flutter
Atrial fibrillation/ 1. Control Rate 2. Convert Rhythm
atrial flutter with
Normal heart
Impaired heart Heart Function Impaired Heart EF Duration <48 Hours Duration >48
WPW Preserved <40% or CHF Hours or Unknown

WPW Note: If AF >48 Note: If AF >48 hours DC cardioversion Avoid

hours duration, use duration, use agents Or nonemergent
agents with potential with potential to Primary Cardioversion
to convert rhythm convert rhythm with antiarrhythmic agents unless
with extreme caution extreme caution in anticoagulation or
in patients not patients not receiving Use only 1 of the
following agents (see clot precautions are
receiving adequate adequate taken (see above).
anticoagulation anticoagulation note below):
Amiodarone Anticolagulation
because of possible because of possible as described above,
embolic embolic (Class IIb) followed by
complications complications. Flecainide DC cardioversion
DC cardioversion DC cardioversion (Class IIb)
Or Or Procainamide
Primary Amiodarone (Class IIb)
antiarrhytmic (Class IIb)
agents Propafenone
(Class IIb)
Sotalol
(Class IIb ) Next slide
 Use only 1 of the Class III
following agents (can be harmful)
(see note below): Adenosine
Amiodarone (Class -Blockers
IIb)
Calcium blockers
Flecainide
Digoxin
(Class IIb)
Procainamide
(Class IIb) Impaired heart
Profenone (EF <40% or CHF)
(Class IIb) DC cardioversion
Sotalol (Class IIb) Amiodarone (Class
IIb)
Class III
(can be harmful)
Adenosine
-Blockers
Calcium blockers
Digoxin

WPW indicates Wolff-Parkinson-White syndrome: AF, atrial fibrillation; NSR, normal sinus rhythm; TEE, transesophageal
echocardiogram; and EF, ejection fraction.
Note: Occasionally 2 of the named antiarrithmic agents may be used, but use of these agents in combination may have
proarrhythmic potential. The classes listed represent the Class of Recommendation rather than the Vaughn-Williams
classification of antiarrhythmics.
 Narrow-Complex Tachycardia

Narrow-Complex SupraventricularTachycardia, Stable

Attempt therapeutic diagnostic maneuver

Vagal stimulation
Adenosine
Preserved
Heart function - Blocker
Ca+ channel blocker
Junctionalnct
tachycardia Amiodarone
NO DC cardioversion!

EF <40%, CHF
Amiodarone
NO DC cardiversion!

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 Priority order:
AV nodal blockade
-Blocker
Preserved Ca2+ channel blocker
heart function Digoxin
DC cardioversion
Antiarrhythmics:
consider procainamide,
Paroxyamal supraventricular amiodarone, sotalol
tachycardia
Priority order:
DC cardioversion
EF <40%, CHF Digoxin
Amiodarone
Diltiazem

Preserved -Blocker
Heart function Ca2+ channel blocker
Amiodarone
NO DC cardioversion!
Ectopic or multifocal
atrial tachycardia
Amiodarone
Diltiazem
EF <40%, CHF NO DC cardioversion!
 Stable Ventricular Tachycardia: Monomorphic and Polymorphic

Stable Ventricular Tachycardia

Monomorphic or Polymorphic?

Note!
Monomorphic VT Polymorphic VT
May go direcly to
Is cardiac function impaired Is Baseline QT interval prolonged?
cardioversion
Preserved Normal baseline Prolonged baseline
heart function Poor ejection fraction QT interval QT interval(suggests torsades)

Normal baseline QT Interval Long baseline QT interval

Medications: any one
Procainamide Treat ischemia Correct abnormal electrolytes
Sotalol Correct electrolytes
Therapies: any one
Others acceptable Medications: any one Magnesium
Amiodarone -Blockers or Overdrive
Lidocaine Lidocaine or Isoproterenol
Procainamide or Phenytoin
Sotalol Lidocaine

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 Cardiac function
impaired
Amiodarone
150 mg IV over 10 minutes
or
Lidocaine
0.5 to 0.75 mg/kg IV push
Then use
Synchronized cardioversion
SELESAI