Tachycardia With A Pulse Algorithm

Algorithm Notes

Management of Persistent Tachyarrhythmias

This algorithm outlines a structured approach for assessing and managing patients presenting with persistent tachyarrhythmias, a condition where the heart rate is typically ≥ 150/min. The approach is designed to rapidly identify life-threatening conditions associated with tachyarrhythmias and to implement appropriate interventions.

Initial Assessment and Stabilization

Maintain Patent Airway: Ensure that the patient’s airway is open and assist breathing as necessary.

Oxygen Administration: Provide oxygen if the patient is hypoxemic to maintain adequate oxygen saturation.

Cardiac Monitoring: Attach the patient to a cardiac monitor to identify the rhythm, continuously monitor blood pressure, and check oximetry.

Identify and Treat Underlying Causes

Assess Symptoms and Stability: Determine if the tachyarrhythmia is causing hypotension, acutely altered mental status, signs of shock, ischemic chest discomfort, or acute heart failure.

IV Access and 12-Lead ECG: Establish IV access and perform a 12-lead ECG if available to further assess the cardiac rhythm and underlying causes.

Specific Treatment Based on QRS Duration

Narrow QRS Complex (<0.12 seconds):

Vagal Maneuvers: Attempt vagal maneuvers to decrease heart rate.

Adenosine: If the rhythm is regular, administer a rapid IV push of adenosine (6 mg followed by a saline flush, and if needed, a second dose of 12 mg).

Beta-Blockers or Calcium Channel Blockers: Consider these medications to control heart rate and rhythm.

Synchronized Cardioversion: Consider if the rhythm is regular and adenosine is ineffective. Start with a dose of 50-100 joules for narrow regular rhythms.

Wide QRS Complex (≥0.12 seconds):

Antiarrhythmic Infusion: If the tachycardia is monomorphic and regular, consider administering antiarrhythmics such as procainamide, amiodarone, or sotalol.

Procainamide: Administer at a rate of 20-50 mg/min until the arrhythmia is suppressed, hypotension occurs, QRS duration increases by more than 50%, or a maximum dose of 17 mg/kg is reached.

Amiodarone: Give 150 mg over 10 minutes, repeat as needed if ventricular tachycardia (VT) recurs. Follow with a maintenance infusion of 1 mg/min for the first 6 hours.

Sotalol: Administer 100 mg (1.5 mg/kg) over 5 minutes, avoiding if there is a prolonged QT interval.

Synchronized Cardioversion: For wide regular tachycardias, start with 100 joules. For irregular wide complexes, use a defibrillation dose (not synchronized).

Expert Consultation and Continued Monitoring

Consider Expert Consultation: Always consider consulting a cardiology specialist when managing complex cases or when initial treatments fail.

Continuous Monitoring: Monitor the patient’s response to treatment and adjust therapies based on clinical response and ongoing monitoring data.