TACHYCARDIAS WITH

PULSE

Lela Tabidze, MD, 2019

CLASSIFICATION
 Atrial fibrillation  Venricular
tachycardia
 Atrial flutter
- monomorphic
- polimorphic
 Supraventricular
tachycardia

supraventricular ventricular
RE-ENTRY MECHANISM
 Type of “slow-fast”re-entry circuit is found in
90% of patients with atrioventricular nodal
re-entrant tachycardia.
 SVT FEATURES:
 Rhythm: regular
 Rate: 150-250 bpm AD
ULT
S
 PR interval: not measurable
 P wave: often buried in the T waves
 Narrow QRS complex
 Sudden onset
ECG SAMPLES:
ATRIAL FIBRILLATION
ECG criteria:

 Rate: >350 bpm

 Rhythm: irregular *

 P waves: absent, fine baseline f wave oscillation

 QRS complex: narrow

* At very fast heart rates AF may look regular, which

makes it difficult to separate from SVT or VT
ATRIAL FLUTTER
ECG criteria:

 Rate: >250 bpm

 Rhythm: regular

 P waves: present, coarse flutter F waves – broad saw-

toothed, best seen in the inferior leads and in lead V1

 QRS complex: narrow

ATRIAL FIBRILLATION VS ATRIAL FLUTTER
 VENTRICULAR TACHYCARDIA
 The appearance of all the beats match each other in
each lead of a surface ECG

 Scar-related monomorphic ventricular tachycardia is

the most common type and a frequent cause of death
in patients having survived a heart attack or
myocardial infarction, especially if they have weak
heart muscle.
VENTRICULAR FLUTTER
ECG Criteria:

 A sinusoidal waveform without clear definition

of the QRS and T waves

 HR - over 250-300 bpm

 SIGNS OF TACHYCARDIA
 Agitation
 Poor feeding
 Tachypnea
 Increased work of breathing
 Unusual sleepiness or lethargy
 Vomiting
 Pallor Adults
 Mottling
 Cyanosis
 Grunting
COMPENSATORY TACHYCARDIA
When HR is less than 150 bpm, consider
alternate causes:

 Fever
 Anemia
 Anxiety
 Dehydration
 Hypoxia
 Pulmonary Embolus
 Response to Medication
 THE KEY PRINCIPLES OF
MANAGEMENT
 Use these questions to guide your
assessment:

1. Does the patient have symptoms?

2. Is the tachycardia causing the symptoms?
3. Is the patient stable or unstable?
4. Is the QRS complex narrow or wide?
5. Is the rhythm regular or irregular?
6. Is the rhythm sinus tachycardia?
IS THE PATIENT STABLE?
 Look for:
- altered mental status,
- ongoing chest pain,
- hypotension,
- decreased oxygen saturation,
- or other signs of shock.

 Remember: Rate-related symptoms are

uncommon if heart rate is < 150 bpm.
 MANAGEMENT
 ABC
 Give oxygen and monitor oxygen saturation
 Get an ECG
 Identify rhythm
 Establish IV line
 Check vital signs
 Identify and treat reversible causes
MANAGEMENT
Stabile patient with narrow complex tachycardia
and regular rhythm:

1. Vagal maneuvers
2. Medications
3. Synchronize cardioversion
- if previous steps fails,
- IV/IO access isn’t available
- if Adenosine ineffective
VAGAL MANEUVERS
 Ice to the face - preferred method for infants

 Valsalva maneuver – blowing through the narrow straw

 Carotid sinus massage

 Ocular pressure no longer used

MEDICATIONS
Adenosine administration

 Initial bolus given rapidly over 1-3 seconds

followed by NS bolus of 20 ml then
elevate extremity

 Second bolus can be given after 1-2

minutes if needed
MEDICATIONS
Adenosine Dosage:

 In adults: 6 mg (first dose)

12 mg (second dose)
MANAGEMENT
Synchronized cardioversion

 In adults: Narrow regular rhythm 50-100 J

MANAGEMENT
Stabile patient with narrow complex and irregular
rhythm:

1. Medications – Beta blockers, Calcium

channel blockers

2. Syncronised Cardioversion
- if previous steps fails,
- IV/IO access isn’t available
- if Adenosine ineffective
MANAGEMENT
Unstabile patient with narrow complex and
irregular rhythm:
 Synchronise cardioversion for narrow irregular rhythm

- 120-200 J if biphasic
- 200J if monophasic
MANAGEMENT
Stabile patient with broad complex and regular
rhythm:
1. Adenosine – to exclude SVT with aberrancy

2. Digoxin – 150 mg diluted in 5% dextrose within 10 min

followed by maintenance infusion 1 mg/min during 6 hours

3. Procainamide – 20-50 mg/min until arrhythmia supressed,

followed by maintenance infusion 1-4 mg/min (avoid if
long QT or CHF)

4. Sotalol – 100 mg (1.5 mg/kg) over 5 minutes (avoid if long

QT)
MANAGEMENT
Unstabile patient with broad complex and regular
rhythm:

 Synchronize cardioversion for wide regular

rhythm - 100 J

 Synchronize cardioversion for wide irregular

rhythm – defibrillation dose
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