ACLS Tachycardia Algorithm, Management of SVT, Narrow Complex Tachycardia treatment
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| Tachyarrythmias Management |
THIS ARTICLE IS FOR ONLY HEALTHCARE PROFESSIONALS FOR EDUCATIONAL PURPOSES
PSVT Management:
Initial Assessment and Stabilization:
The protocol begins by assessing and supporting the patient’s airway, breathing, and circulation (ABCs), providing oxygen, monitoring their ECG to identify the rhythm, checking blood pressure and oximetry, and identifying and treating any reversible causes. If symptoms persist, the provider must immediately evaluate whether the patient is stable or unstable. Signs of instability include altered mental status, ongoing chest pain, hypotension, or other signs of shock.
Unstable Pathway:
If the patient is unstable, the clinician must perform immediate synchronized cardioversion. While preparing for this, IV access should be established and sedation provided if the patient is conscious, but these steps must not delay cardioversion.
Stable Pathway:
Narrow vs. Wide QRS
If the patient is stable, the clinician establishes IV access, obtains a 12-lead ECG or rhythm strip, and determines if the QRS complex is narrow (less than 0.12 seconds) or wide (greater than or equal to 0.12 seconds).
Narrow QRS Complex:
The next step is to determine if the rhythm is regular or irregular.
If regular, the clinician should attempt vagal maneuvers and administer adenosine (starting with a 6 mg rapid IV push, followed by a 12 mg rapid IV push if it does not convert, which can be repeated once). If the rhythm converts, it is a probable reentry supraventricular tachycardia (SVT), and the clinician should observe for recurrence or treat it with adenosine or longer-acting AV nodal blocking agents like diltiazem or beta-blockers. If the rhythm does not convert, it suggests possible atrial flutter, ectopic atrial tachycardia, or junctional tachycardia; management focuses on controlling the rate with diltiazem or beta-blockers (with caution in pulmonary disease or CHF), treating the underlying cause, and considering expert consultation.
If irregular, it is an irregular narrow-complex tachycardia (such as atrial fibrillation, possible atrial flutter, or multifocal atrial tachycardia), which requires expert consultation and rate control via diltiazem or beta-blockers.
Wide QRS Complex:
Expert consultation is advised, and the clinician evaluates if the rhythm is regular or irregular.
If regular, and presenting as ventricular tachycardia or an uncertain rhythm, the protocol indicates administering amiodarone (150 mg IV over 10 minutes, repeatable up to a maximum of 2.2 g in 24 hours) and preparing for elective synchronized cardioversion; if it is SVT with aberrancy, adenosine may be given.
If irregular, it could be atrial fibrillation with aberrancy (managed like irregular narrow tachycardia) or pre-excited atrial fibrillation (AF + WPW). For pre-excited AF, AV nodal blocking agents like adenosine, digoxin, diltiazem, and verapamil must be avoided, and antiarrhythmics such as amiodarone should be considered. If recurrent polymorphic VT occurs, expert consultation is required, and if torsades de pointes develops, magnesium should be administered (1–2 g loaded over 5–60 minutes, followed by an infusion).
Ongoing Evaluation:
Throughout the evaluation process, clinicians are instructed to secure and verify the airway and vascular access when possible, consider expert consultation, and prepare for cardioversion if needed. They must also actively treat contributing factors, 5H and 5Ts to check, which include
The 5 H's
- Hypovolemia
- Hypoxia
- Hydrogen ion (Acidosis)
- Hypo- / Hyperkalemia
- Hypothermia (Note: Hypoglycemia is also a critical reversible cause to check)
The 5 T's
- Toxins
- Tamponade (Cardiac)
- Tension Pneumothorax
- Thrombosis (Coronary)
- Thrombosis (Pulmonary / PE)
If a stable patient becomes unstable at any point during this evaluation, the clinician must immediately switch to the unstable pathway and perform synchronized cardioversion.
Prevention:
Prevention of frequent attacks can be achieved by calcium channel blockers, beta-blockers, or antiarrhythmics like
verapamil, diltiazem, digoxin, class IC agent, or if necessary catheter ablation
Summary of the Management of Paroxysmal
Supraventricular Tachycardia
Acute Termination
Vagal maneuvers
IV adenosine: 6–12 mg or 0.1–0.3 mg/kg (rapid bolus)
IV verapamil/diltiazem: 5–15 mg or 0.1–0.2 mg/kg (over 1–2 min)
Long-term Rx
Verapamil
β-blockers
Flecainide/Propafenone
Primary Diagnosis:
A 67 year-old female patient presents to the emergency department with severe substernal chest pain radiating to left hand, and shortness of breath, k/c/o HTN ECG taken:
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| ECG: what is your diagnosis? |
What is the most accurate diagnosis?
A) Acute Inferior STEMI
B) Acute Extensive Anterior STEMI
C) Acute Pericarditis
D) Left Ventricular Hypertrophy (LVH) with strain pattern
Reference
Cardiac Arrhythmias and conduction abnormalities by sudeep Viswanathan and Marin kollef
Supraventricular Tachycardia by vora
Chapter 1 Cardiovascular Diseases
Current essential of medicine
By Lawrence M. Tierney, Jr., MD
Sanjay Saint, MD, MPH
Mary A. Whooley, MD
Tachyarrythmias from Harrison manual of medicine
THIS ARTICLE IS FOR ONLY HEALTHCARE PROFESSIONALS FOR EDUCATIONAL PURPOSES PLEASE TAKE EXPERT OPINION AND DO NOT EXPERIMENT.
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