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ACLS

Tachycardia; Stable Wide Complex Irregular

  1. Evaluate ABC's
    • Confirm stability, pulses, adequate blood pressure, good skin signs and mentation to proceed with this algorithm.
  2. Early measures:
    • Apply oxygen
    • Make sure defibrillator present (in case stability changes)
    • Establish IV
    • Monitors (Rhythm, Oximetry, BP)
    • Obtain 12 lead EKG and confirm QRS >0.12 sec
    • Code cart
  3. Obtain history and perform physical examination and consider causes:
    • Differential diagnosis includes:
    • Consider Causes
      • Drugs that prolong QT interval
      • Acute myocardial infarction, pulmonary embolus
      • Hypovolemia/Hypoxia/Hypothermia
      • Metabolic: Thyroid disease, hyper/hypokalemia, hypercalcemia, acidosis
      • Hypoglycemia
      • Other drugs: Cocaine, Amphetamines, Decongestants, Ephedra, Ginseng
      • Pneumothorax or Tamponade
      • Cardiomyopathy/Valvular heart disease
      • Alcohol related ("Holiday heart")
      • Sepsis/Pneumonia
      • WPW [beware don't use drugs if WPW]
  4. Treatment for stable irregular wide complex tachycardia: [Afib w/ aberrancy]
    • The goal is rate control.
    • Choose 1 of the following (dosing listed below):
      • CCB's: Diltiazem or verapamil
      • Beta Blockers: Metoprolol, atenolol, esmolol, propranolol

    Note: Avoid beta blockers in patients with CHF or pulmonary disease

    Diltiazem:0.25 mg/kg [Max 20 mg] IV over 2 minutes; may repeat with 0.35 mg/kg [Max 25 mg] IV in 15 minutes. May start infusion 5-15 mg/hr after either bolus.
    Ver apamil:2.5-5 mg IV over 2 minutes; may repeat with 5-10 mg IV in 15-30 minutes until maximum cumulative dose of 20 mg given if needed.
    Metoprolol:5 mg given slow IV every 5 minutes × 3 doses.
    Atenolol:5 mg slow IV, may repeat in 10 minutes.
    Esmolol:Loading dose of 500 mcg/kg given over 1 minute then 50 mcg/kg/minute × 4 minutes. If inadequate response, reload with 500 mcg/kg given over 1 minute and follow this with an increased rate of infusion of 100 mcg/kg/minute and adjust as needed (maximum rate is 300 mcg/kg/minute).
    Propranolol:0.1 mg/kg divided into 3 equal doses, each given IV at 2-3 minute intervals. May repeat the total dose × 1 if not successful.

    Additional Treatment Note
    For Afib with Rapid Response; Magnesium 1-2 grams in D5W over 30-60 minutes may be beneficial.
    [Afib w/ WPW]
    Avoid adenosine, digoxin, diltiazem & verapamil. Consider amiodarone 150 mg IV over 10 minutes
    [Polymorphic VT]
    Polymorphic VT therapy is complicated by whether the patient has a prolonged QT when in sinus rhythm (if so, then the rhythm is likely Torsades de pointes). Polymorphic VT is likely to proceed to pulseless arrest and requires immediate treatment.
    • Torsades de pointes may be treated with 1-2 grams of Magnesium sulfate IV over 5-60 minutes followed by an infusion of 0.5-1 gram/hr. Overdrive pacing or isoproterenol are also reasonable choices.
    • In the case of no prolonged QT interval at baseline, magnesium is unlikely to be effective. Amiodarone 150 mg IV over 10 minutes followed by an infusion may be effective.
    • Any signs of instability should lead to immediate high energy defibrillation with sedation if possible (monophasic 360 J; biphasic 120, 150 or 200 J depending upon device).
    • Stop medications/toxins that prolong QT, check electrolytes
  5. Standard laboratory evaluation (if indicated):
    • CBC, Electrolytes, TSH, Cardiac enzymes and toxicology testing
    • CXR
    • EKG pre and post conversion (if conversion occurs)
  6. Consultation and admission to hospital if indicated.

Source: Circulation 2005;112. 2005 AHA Guidelines for CPR and ECC.