Tachycardias

EMERGENCY MEDICINE 2
Recognising ECG
Narrow complex tachycardia
A tachycardia is defined as a heart rate greater than 100 beats
per minute (bpm). In narrow complex tachycardias the QRS
complex is shorter than 120 ms (three small squares on the
ECG).
Wide complex tachycardia
The QRS-complex needs to be wide. >120ms (or >3 small
squares).
The patient needs to be tachycardic, >100/min
TO DIFFERENTIATE NARROW AND BROAD COMPLEX TACHYCARDIA
SINUS TACHYCARDIA
PATHOPHYSIOLOGY NONE. SYMPTOM NOT ARRHYTHMIA
NORMAL IMPULSE CONDUCTION AND
FORMATION
ECG CHARACTERISTICS RATE:>100/MIN
RHYTHM: SINUS
PR<0.02sec
P FOR ALL QRS, QRS<0.10 SEC
CLINICAL FEATURES SYMPTOM OF UNDERLYING DISEASE
CAUSES FEVER, HYPOXIA, ANEMIA,
HYPERTHYROIDISM
WORD OF CAUTION OF FOLLOWING ACLS PROTOCOL IN
SINUS TACHYCARDIA

Sinus tachycardia is caused by external influences on the

heart, such as fever, anemia, hypotension, blood loss, or
exercise. These are systemic conditions, not cardiac
conditions. Sinus tachycardia is a regular rhythm, although the
rate may be slowed by vagal maneuvers. Cardioversion is
contraindicated.

The fact of the matter is that sinus tach at rates between 150-
200 not only exists, but is not uncommon. We need to be
better at assessing for sinus tachycardia, because it is the most
common SVT.
Atrial flutter & Fibrillation

PATHOPHYSIOLOGY FIB: MULTIPLE, CHAOTIC PATHWAYS

FLUT:CIRCULAR PATHWAYS CREATING
THE FLUTTER
RATE FIB: 300-400/MIN WITH WIDE RANGE
VENTRICLE RESPONSE. RATE NORMAL
OR SLOW
FLUT: 220-350/MIN. VENTRICULAR
RESPONSE 150-180/MIN
RHYTHM FIB: IRREGULARLY IRREGULAR
FLUT: REGULAR 2:1 OR 4:1
P WAVES FIB: IRREGUALR, NO CLEAR PICTURE
FLUT: NO TRUE P, SAW TOOTH
PATTERN
PR CANNOT BE MEASURED
QRS < 0.12 SEC UNLESS DISTORTED
SYMPTOMS DEPENDS ON VENTRICULAR
RESPONSE. VARIES FROM NO
SYMPTOMS TO PALPITATIONS, DOE,
SOB, PULMONARY ODEMA
 CAD,MI,ACS
HYPOXIA: PULMONARY EMBOLISM
DRUGS: DIGOXIN, QUINIDINE, BETA AGONIST
HYPERTENSION
HYPERTHYROIDISM
HEART FAILURE
SVT- AVNRT
PATHOPHYSIOLOGY ORIGIN ABOVE BUNDLE OF HIS
WITHIN ATRIA OR A-V NODE.
RE-ENTRY
ECG 150-250/MIN, REGULAR, P DIFFICULT
TO DETECT, QRS NORMAL & NARROW
CLINICAL FEATURES PALPITATIONS, DISCOMFORT IF STABLE
CAUSES
CAFFEINE, CIGARETTES
HYPOXIA
CAD
STREES, ANXIETY, SLEEP DEPRIVATION
COPD
CCF
The distinction between ST and SVT can be difficult at very rapid rates. Here
are a few clues that may help in this distinction:

1. Generally the maximal sinus rate that a patient produces will be

220-age. That means that a 20 year old can possibly have a ST up to
200 beats/min, but a 70 year old can only have a ST has fast as 150
beats/min. Rates that exceed that simple formula are extremely
unlikely to be ST.
2. If the rate varies with respiration, with positional changes, with
relaxation, or with fluid administration, these all favor ST.
3. If the rate reduces slowly, it favors ST. SVT, on the other hand,
tends to "break" suddenly.
4. SVT generally will either have no P-waves visible or there may be
P-waves just after the QRS complexes. These are referred to as
retrograde Ps.
5. History, history, history. Is there a reason for tachycardia, for
example a history consistent with dehydration or anxiety? That
favors ST. If the patient reports palpitations or other symptoms that
were of abrupt onset, that favors SVT.
6. Valsalva maneuvers may gently slow down ST but will either not
affect SVT or will abruptly break the SVT....SVT shouldn't gently slow
down.
VAGAL MANEUVER- for narrow complex tachycardia with
symptoms
The Valsalva maneuver should be the first vagal maneuver
tried and works by increasing intra-thoracic pressure and
affecting baroreceptors (pressure sensors) within the arch of
the aorta.
Other vagal maneuvers including: holding one's breath for a
few seconds, coughing, drinking a glass of ice cold water.
Carotid sinus massage, carried out by firmly pressing the bulb
at the top of one of the carotid arteries in the neck, is
effective but is often not recommended in the elderly due to
the potential risk of stroke in those with atherosclerotic
plaque in the carotid arteries.
Reducing coffee, alcohol, or tobacco use or increasing the
amount of rest may help to alleviate symptoms.
 VENTRICULAR TACHYCARDIAS- MONOMORPHIC

MONOMORPHIC
PATHOPHYSIOLOGY ORIGIN IS VENTRICLE AND SINGLE FOCUS
USUALLY AREA OF INFARCT, ISCHAEMIA,
INJURY
ECG V.RATE 150-250/MIN,
NO P WAVE, PR ABSENT
QRS IS WIDE & BIZARRE BUT REGULAR,
>0.12 SEC, T waves of opposite polarity to
QRS. Same morphology for all QRS

CF HYPOTENSION, DIZZINESS, SYNCOPE,

CHEST PAIN
may deteriorate to unstable VT and then
to VF

ETIOLOGY CHRONIC HEART FAILURE, MI, DRUGS:

LONG TERM ANTIHISTAMINICS, DIGOXIN,
TCA, because they prolong the QT interval
 VENTRICULAR TACHYCARDIAS
POLYMORPHIC

PATHOPHYSIOLOGY ORIGIN IS VENTRICLE AND MULTIPLE FOCUS

USUALLY AREA OF INFARCT, ISCHAEMIA, INJURY

ECG V.RATE 150-250/MIN, REGULAR OR IRREGULAR

NO P WAVE, PR ABSENT
QRS IS WIDE & BIZARRE, >0.12 SEC, T waves of
opposite polarity to QRS, DIFFERENT MORPHOLOGY.

CF SYMPTOMS OF CO, PROGRESS TO PULSELESS VT

AND VF
ETIOLOGY AS FOR PREVIOUS ALONG WITH HEREDITARY QT
SYNDROMES
Unique VT: TORSADES DE POINTES
QT PROLONG AND SPINDLE WAVE PATTERN
Q1. Tachycardia with symptoms?
Q2: Is the patient stable or unstable?
Atrial fibrillation
Atrial flutter
Supraventricular tachycardia (SVT)
Monomorphic VT
Polymorphic VT
Wide-complex tachycardia of uncertain type

ACLS PROTOCOL IS FOR UNSTABLE TACHYCARDIAS

Hypotension, altered mental status, shock, chest pain, acute heart failure
Question yourself for the scenario of
tachycardia
1.. QRS narrow or wide

2.. Rhythm regular or irregular

3.. QRS MONOMORPHIC OR

POLYMORPHIC
ACLS SURVEY
A: Maintain patent airway
B: Assist breathing, O2 for
hypoxaemia, Monitor SPO2
C: Monitor BP, PR, Obtain 12 lead
ECG, IV access
D: Problem focused PE and history,
search for and treat contributing
factors
Stable tachycardia
The patient's QRS is narrow and Try vagal maneuvers. Give adenosine
rhythm is regular. 6 mg rapid IV push. If patient does
not convert, give adenosine 12 mg
rapid IV push. May repeat 12 mg
dose of adenosine once.

The patient's rhythm is irregular. Control patient's rate with diltiazem

or beta-blockers. Use beta-blockers
with caution for patients with
pulmonary disease or congestive
heart failure.
INDICATIONS FOR CARDIOVERSION or
SYNCHRONISED SHOCKS
Unstable SVT
Unstable AFIB
Unstable AFLUT
Unstable MONOMORPHIC VT with
pulse
Situation Assessment and Actions

Patient has significant signs or The tachycardia is unstable.

symptoms of tachycardia AND Immediate cardioversion is
they are being caused by the indicated.
arrhythmia.

Patient has a pulseless Follow the Pulseless Arrest

ventricular tachycardia. Algorithm. Deliver
unsynchronized high-energy
shocks.

Patient has polymorphic Treat the rhythm as ventricular

ventricular tachycardia AND the fibrillation. Deliver
patient is unstable. unsynchronized high-energy
shocks.