Adult tachycardia

approach on adult tachycardia and tachyarrhythmia

1. ADULT TACHYCARDIA : ADULT TACHYCARDIA :
AN OVERVIEWAN OVERVIEW
Faez Baherin
Emergency Physician
ED Hospital Melaka

2. OUTLINE
•Definition and introduction
•Approach to tachycardia
1. Pulseless algorithm
2. Stable tachycardia
3. Unstable tachycardia
•Cardioversion
•Take-home message

3. Introduction
•A heart rate of more than 100 beats per
minute (BPM) in adults is called TACHYCARDIA
•Tachyarrhythmia is part of tachycardia – it
deviates from normal heart rhythm
•Definition varies

4. Introduction
•Tachycardia can be classified in several ways,
based on the appearance of
–Heart rate
–QRS complex – wide or narrow complexes
–Regularity – regular vs irregular

5. Approach to tachycardia
•The first question that should be asked when
initiating the ACLS tachycardia algorithm is:
“Is the patient stable or unstable?”
•The answer to this question will determine
which path of the tachycardia algorithm is
executed.

6. Approach to tachycardia
•When encountering patients with tachycardia,
efforts should be made to determine whether
the tachycardia is the primary cause of the
presenting symptoms or secondary to an
underlying condition

8. Approach to tachycardia
A patient with tachycardia, check if patient :
1.Pulseless or with pulse
2.stable or unstable
THEN treat the patient based on the patient's
condition and rhythm.

9. Approach to tachycardia :
Pulseless algorithm
•If the patient does not have a pulse, follow the
ACLS Pulseless Arrest Algorithm.

11. Stable Tachycardia

12. Approach to tachycardia :
Stable Tachycardia
•For a diagnosis of stable tachycardia, the
patient meets the following criteria:
–The patient's heart rate is greater than 100 bpm.
–The patient does not have any serious signs or
symptoms as a result of the increased heart rate.
–Symptoms / signs : altered mental status, ongoing
chest pain, hypotension, other signs of shock.

13. Approach to tachycardia :
Stable Tachycardia
•Many experts suggest that when HR is < 150
bpm, it is unlikely that symptoms of instability
are caused primarily by the tachycardia unless
there is impaired ventricular function

14. Approach to tachycardia :
Stable Tachycardia
•Does the patient have a pulse?
•Yes, the patient has a pulse.
Complete the following:
–ABC
–Give oxygen and monitor oxygen saturation
–Get an ECG
–Identify rhythm
–Check blood pressure
–Identify and treat reversible causes

15. Approach to tachycardia :
Stable Tachycardia
•Yes, the patient is stable.
–IV access
–Analyze ECG

16. Approach to tachycardia :
Narrow regular tachycardia
•Is the QRS complex wide or narrow?
If the patient's QRS is narrow and rhythm is regular.
↓
1)Try vagal maneuvers + modified Valsalva
2)Give adenosine 6 mg rapid IV push
3)If patient does not convert, give adenosine 12 mg
rapid IV push.
Alternative of adenosine ?

17. Approach to tachycardia :
Narrow regular tachycardia
•If the patient's rhythm convert, it was
probably reentry supraventricular tachycardia.
At this point, watch for a recurrence.
•If the tachycardia resumes, treat with longer-
acting AV nodal blocking agents, such Ca
channel blocker(verapamil or diltiazem) or
beta-blockers.

18. Approach to tachycardia :
Narrow irregular tachycardia
•If the rhythm pattern is irregular narrow-
complex tachycardia, it is probably atrial
fibrillation, possible atrial flutter, or multi-
focal atrial tachycardia.
↓
Control patient's rate with diltiazem or beta-
blockers. Use beta-blockers with caution for
patients with pulmonary disease or CCF.

19. Approach to tachycardia :
Stable Atrial fibrillation
1. Less than 48 hours
-Amiodarone
-CCB
-B-Blocker
2. Persistent or permanent AF
-CCB
-B-Blocker
-Digoxin

20. Approach to tachycardia :
Wide regular/ irregular tachycardia
•If the patient has wide QRS complex
–Obtain 12 lead ECG to evaluate rhythm
–Determine if the rhythm is regular or irregular
•A regular wide-complex tachycardia is likely to be VT or
SVT with abberancy
•An irregular wide-complex tachycardia may be AF with
abberancy, pre-excited AF or polymorphic VT/torsade
de pointes
–Consider the need to obtain expert consultation

21. Approach to tachycardia :
Wide regular/ irregular tachycardia
•If the etiology of the rhythm cannot be
determined, the rate is regular, and the QRS is
wide and monomorphic, IV adenosine is
relatively safe – both prognostic and
therapeutic
•Adenosine should not be given for unstable or
for irregular or polymorphic wide complex
tachycardia as it may cause degeneration of
the arrhythmia to VF

22. Approach to tachycardia :
Wide regular/ irregular tachycardia
•If the wide-complex tachycardia proves to be
SVT with aberrancy, adenosine will transiently
slowed or converted to SR
•If due to VT there will be no effect on rhythm
•In stable VT : Amiodarone, procainamide,
sotalol

23. Unstable Tachycardia

24. Approach to tachycardia :
Unstable Tachycardia
•Two keys to managing patients with unstable
tachycardia
–quickly recognizing that the patient has significant
symptoms and is unstable
–recognize that the patient's signs and symptoms
are caused by the tachycardia.

25. Approach to tachycardia :
Unstable Tachycardia
•Assess pt
•Look for altered mental status, ongoing chest
pain, hypotension, or other signs of shock.
•If the patient is unstable and has a wide-
complex tachycardia, assume the rhythm is VT
until proven otherwise.

26. Approach to tachycardia :
Unstable Tachycardia
•Perform immediate synchronized
cardioversion.
–IV access
–Give sedation if the patient is conscious.
–Do not delay cardioversion.
–Consider expert consultation

27. Cardioversion
•Function : deliver a stimulus to stun the heart
in hoping that the rhythm will start back from
the SA
•Synchronized cardioversion is shock delivery
that is timed (synchronized) with the QRS

28. Cardioversion
•This synchronization avoids shock delivery
during the relative refractory period of the
cardiac cycle when a shock could produce VF

29. Cardioversion
•Synchronized cardioversion is recommended
to treat
(1) unstable SVT
(2) unstable atrial fibrillation
(3) unstable atrial flutter
(4) unstable monomorphic (regular) VT.

30. Cardioversion
•The recommended initial biphasic energy dose
for cardioversion of atrial fibrillation is 120 to
200 J
•If the initial shock fails, increase the dose in a
stepwise fashion
•Cardioversion with monophasic waveforms
should begin at 200 J and increase in stepwise
fashion if not successful

31. Cardioversion
•Cardioversion of atrial flutter and other SVTs
generally requires less energy, an initial
energy of 50 J to 100 J is often sufficient.
•Arrhythmias with a polymorphic QRS
appearance (such as torsades de pointes) will
usually not permit synchronization. Thus, if a
patient has polymorphic VT, treat the rhythm
as VF and deliver high-energy unsynchronized
shocks

32. Cardioversion

33. Possible Underlying Reversible Causes
H’s
•Hypovolemia
•Hypoxia
•Hydrogen ion (acidosis)
•Hyperkalemia/
hypokalemia/ metabolic
disorders
•Hypothermia/
hyperthermia
T’s
•Toxins/tablets
(drug overdose)
•Tamponade, cardiac
•Tension pneumothorax
•Thrombosis, coronary
•Thrombosis, pulmonary

35. Take-home message
•Learn the AHA tachycardia algorithm by heart
•Pulseless vs with pulse
•Stable vs unstable
•Narrow vs wide complex
•Regular vs irregular
•Underlying reversible cause
•Early referrals, interdepartmental
management