Tachycardia Algorithm

AHA 2015 ACLS Algorithm for the treatment of tachycardia

In general Tachycardia is a heart rate that exceeds 100 beats per minute. Tachycardia can be caused by a wide range of factors that often are benign. However depending on the rate and type of rhythm, tachycardia can be detrimental and even life threatening.

There are numerous causes and types of tachycardia. This wide range makes it important to identify where the rhythm is originating and the underlying causes. Before moving to invasive techniques, reversible causes should be identified and corrected when applicable. Common causes of tachycardia outside of the tachycardia ACLS algorithm can include; fever, pain, hypoxia, anxiety, dehydration, & hypovolemia.

After determining that the tachycardia is the cause of symptoms we must first establish if the patient is stable or unstable and then where the tachycardia is originating to determine appropriate treatment.

Narrow QRS

Tachycardia rhythms that present with a narrow QRS complex originate in the atrium and include rhythms such as Supraventricular Tachycardia, Atrial Fibrillation & Atrial Flutter. Supraventricular Tachycardia is a regular narrow complex tachycardia at a rate of over 160.

Wide QRS

Tachycardic rhythms that present with a wide QRS traditionally originate in the Ventricles and include Monomorphic VT and Polymorphic VT although BBB's and WPW are common causes of a tachycardic rhythms that originate in the atrium but present with a wide complex.

Supraventricular Tachycardia (SVT)

Ventricular Tachycardia (VT or V-Tach) 

Assess C-A-B

Maintain airway, Administer Oxygen and assist breathing as needed, Monitor Vitals, acquire 12-Lead ECG, Start IV/IO
Consider underlying causes of the tachycardia and treat (H’s and T’s)

If patient is UNSTABLE:

Immediate Synchronized Cardioversion
(Consider sedation or for narrow QRS Adenosine administration but do not delay cardioversion)
Initial Biphasic Energy Dose (If unsuccsessful increase joules in a "stepwise fashion")
Narrow QRS, Regular: 50-100J
Narrow QRS, Irregular: 120-200J
Wide QRS, Regular: 100J
Wide QRS, Irregular: 120-200J

If patient is STABLE

Stable Patient, Wide QRS
Acquire 12-lead ECG and initiate IV
Consider Adenosine 6mg for regular monomorphic rhythm that is not V-Tach, may repeat at 12mg
Amiodarone 150 mg/10min
(Consider maintenance drip or Procainamide as an alternative)
Consult with expert

Stable Patient, Narrow QRS
Acquire 12-lead ECG and initiate IV
Vagal maneuvers
Adenosine 6mg Rapid IVP, may repeat at 12mg
For irregular rhythms or suspected a-fib/a-flutter with RVR (choose one)
Calcium Channel Blocker: Diltiazem, Verapamil Beta Blocker:Metoprolol, Atenolol, Propanol
(not a complete list)
Consult with expert

Reversible Causes

Consider and treat potential reversible causes throughout an arrest or dysrhythmias 

Hypovolemia: S/S - Rapid heart rate and narrow QRS on ECG; other symptoms of low volume TX - Infusion of normal saline or Ringer’s lactate

Hypoxia: S/S -Slow heart rate TX - Airway management and effective oxygenation

Hydrogen Ion Excess (Acidosis): S/S - Low amplitude QRS on the ECGHyperventilation TX - consider sodium bicarbonate bolus

Hypoglycemia: S/S - Bedside glucose testing TX IV bolus of dextrose

HypokalemiaS/S - Flat T waves and appearance of a U wave on the ECG TX - IV Magnesium infusion

HyperkalemiaS/S - Peaked T waves and wide QRS complex TX - Consider calcium chloride, sodium bicarbonate, or an insulin and glucose protocol

Hypothermia: S/S - Typically preceded by exposure to a cold environment; TX - Gradual rewarming

Tension Pneumothorax: S/S -Slow heart rate and narrow QRS complexes on the ECG; difficulty breathing TX -Thoracostomy or needle decompression

Tamponade – CardiacS/S - Rapid heart rate and narrow QRS complexes on the ECG TX Pericardiocentesis

Toxins: S/S - Typically will be seen as a prolonged QT interval on the ECG; may see neurological symptoms TX Based on the specific toxin

Thrombosis (PE)S/S - Rapid heart rate with narrow QRS complexes on the ECG TX Surgical embolectomy or administration of fibrinolytics

Thrombosis (MI): S/S - ECG will be abnormal based on the location of the infarction TX Dependent on extent and age of MI

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