ACLS Cases – Tachycardia Stable and Unstable

• Tachycardia is a heart rate greater than 100 bpm
• Symptoms usually start to emerge at heart rates > 150 bpm
• The first goal is to determine whether tachycardiais stable or unstable
  • Stable tachycardia is tachycardia that does not cause symptoms
  • Unstable tachycardia is tachycardia that causes symptoms

• Symptomatic (unstable) tachycardia includes:
  • Altered mental status
  • Chest discomfort
  • Signs of shock
  • Hypotension
  • Acute heart failure

• Synchronized cardioversion
  • Atrial fibrillation: 120 J to 200 J biphasic or 200 J monophasic
  • Unstable supraventricular tachycardia: 50 J to 100 Jmonophasic
  • Unstable atrial flutter: 50 J to 100 J monophasic
  • Monomorphic VTach: 100 J monophasic
  • Unstable VTach: 200 J monophasic
  • Narrow regular: 50 J to 100 J
  • Narrow irregular: 120 J to 200 J biphasic or 200 J monophasic
  • Wide regular: 100 J monophasic
  • Polymorphic irregular: Defibrillation dose (unsynchronized)
  • Wide irregular: Defibrillation dose (unsynchronized)

Be prepared to move to VTach/VFib pathway if patient enters cardiac arrest!

Stable Tachycardia Management

• Get 12-lead ECG
  • Is the QRS complex narrow or wide?
  • Is the rhythm regular or irregular?
  • Is the rhythm sinus tachycardia?

• Narrow complex, stable tachycardia
  • Vagal maneuvers
  • Adenosine
    • 6 mg IV first dose
    • 12 mg IV second dose

• Wide QRS complex, regular and monomorphic, stable tachycardia
  • Consider adenosine or anti-arrhythmic infusion
  • Consider anti-arrhythmic infusion
    • Amiodarone
      • first dose: 150 mg over 10 minutes
      • Repeat if VTach recurs
      • Maintenance infusion: 1 mg/min for 6 hours
    • Procainamide
      • 20-50 mg/min
      • Maintenance infusion: 1-4 mg/min
      • Do not use if QT prolongation or CHF present
    • Sotalol
      • 100 mg (1.5 mg/kg) over 5 min
      • Do not use in people with prolonged QT

• Consider expert consultation

• Wide complex, polymorphic tachycardia
  • Consider anti-arrhythmic infusion
  • Expert consultation

If any stable tachycardia deteriorates to unstable tachycardia or is resistant to other treatments, administer synchronized cardioversion