Pdf definition, diagnosis and management of tachycardia. Recognition and management in the emergency room ib ray abstract cardiac arrhythmias often present as urgent medical conditions requiring immediate care. A new approach to the differential diagnosis of a regular tachycardia with a wide qrs complex. Wide complex tachycardiadiagnostic approachalgorithms sen. We were taught common sense back in the day, what i see coming out of school today is a lot of dangerous people with tunnel vision leading their way. The details of this patients complaints and presentation are lost, but we know he was a 66yearold man who was being treated in the emergency department. June 5, 2009 page 1 of 3 wide complex tachycardia presumed ventricular tachycardia a guideline for patients with wide complex tachycardia of cardiac origin with qrs 0. The purpose of this case is to prepare residents and students to care for patients in stable and unstable wide complex tachycardia. Wide complex tachycardia wide complex tachycardia is a cardiac rhythm with more than 100 ventricular beats per minute and a qrs complex of 120 ms or greater. Supraventricular tachycardia svt is a heterogeneous group of arrhythmias used to describe tachycardias that involve cardiac tissue at the level of the bundle of his or above.
When atrial fibrillation occurs with aberrant conduction and a rapid ventricular response, a totally irregular broad complex tachycardia is produced. The drug of choice for a narrowcomplex irregular tachycardia is a calcium channel blocker. Wide complex tachycardia, hyperkalemia, ventricular tachycardia introduction wide complex tachycardias present diagnostic challenges for emergency physicians delbridge and yealy, 1995. Started in 1995, this collection now contains 6769 interlinked topic pages divided into a tree of 31 specialty books and 732 chapters. Broad complex tachycardias are potentially lifethreatening.
Tachycardias are broadly categorized algorithm 1 based upon the width of the qrs complex on the electrocardiogram ecg. Were in the er, and today youre the ecrn in charge. An arrhythmia with a sustained rate of more than 100 bpm in which the surface electrocardiogram reveals qrs complexes lasting at least 120 msec. Lets get into our widecomplex tachycardia arrest today. Confirm wide complex tachycardia versus svt with abberancy do not use calcium channel blocker for wide complex unless absolutely certain of svt. Broad complex tachycardiapart ii pubmed central pmc. Focal atrial tachycardia p wave morphology changes. The ecg differential diagnosis includes ventricular tachycardia vt vs. However, sometimes you can accurately identify wide complex tachycardia as svt in the field and im using the broadest possible definition of wide complex tachycardia. Tachycardia terminates with a qrs complex right atrial origin p wave inverted in v1. Wide complex tachycardia definition of wide complex. Widecomplex tachycardia posted in cardiology on april 24, 2018 by editor several algorithms exist for the electrocardigraphic evaluation of regular, widecomplex tachycardias with the objective of distinguishing ventricular tachycardia vt from a supraventricular tachycardia svt with aberrant conduction. In this video, you will learn the essential basics.
Classification of tachycardias with a broad qrs complex. Mental status, skin, neck, lung, heart, abdomen, back, extremities, neuro most important goal is to differentiate the type of tachycardia and if stable or unstable. Broad qrs complex tachycardia bct still presents a diagnostic challenge when confronted with a 12lead electrocardiogram ecg. Patient presenting with a tachyarrhythmia is a common finding in the emergency room.
Supraventricular tachycardia a report of the american college of cardiologyamerican heart association task force on clinical practice guidelines and the heart rhythm society writing committee members richard l. Wide complex tachycardia ecg guru instructor resources. A supraventricular tachycardia is a rapid heart rate that originates from above or within the av node. The bundle branch block may predate the tachycardia, or it may be a rate related functional block, occurring when atrial impulses arrive too rapidly for a bundle branch to conduct normally. However, an arrhythmia arising from the atria or the atrioventricular junction will produce a broad complex if associated with ventricular preexcitation or bundle branch block. The qrs morphology in postmyocardial infarction ventricular tachycardia. In the emergency setting most broad complex tachycardias have a ventricular origin. A study of 100 tracings compared with 70 cases of idiopathic ventricular tachycardia. Supraventricular tachycardia svt is an abnormally fast heart rhythm arising from improper electrical activity in the upper part of the heart. The major clinical problem that arises when dealing with someone exhibiting a wide complex tachycardia is that it is not always immediately clear if the rhythm. To divide up this myriad of possibilities, a bit of basic electrophysiology terminology needs to.
From the division of cardiology, department of internal medicine, university of michigan health system, ann arbor,fmichigan case presentation an 80yearold man underwent an electrophysiologic procedure because of recurrent ep. The qrs complex in ventricular tachycardia often has a right or left bundle branch morphology. Ward, md, frcp from the department of electrophysiology, the heart hospital, university college london hospitals and institute of. It is a blanket term that includes a lot of different rhythms and is simply a starting point on the road to diagnosis. Symptoms may include palpitations, feeling faint, sweating, shortness of breath, or chest pain. Adenosine should be pushed rapidly via proximal iv site followed by 20 ml normal saline rapid flush. Some literature says over 2 minutes, but 5 over 5 is how i remember it. Diagnostic criteria of broad qrs complex tachycardia. As shown in fig 1, broad qrs tachycardia can be divided in three groups svt with bundle branch blockbundle branch block bbb may be preexisting or can occur when the refractory period of one of the bundle branches is reached because of the heart rate of the svt so called tachycardia related or phase 3 block. This case was created as part of our emergency medicine resident simulation curriculum and is based on an actual patient seen in the authors emergency department and highlights specific teaching points and potential pitfalls in treatment algorithms. If at any point patient becomes unstable move to unstable arm in algorithm.
Most importantly, the treatment of a broad complex tachycardia depends on the origin of the tachycardia. Broad complex tachycardia bct is defined as a heart rate 100 bpm with a qrs complex 0. Wct is usually caused by ventricular tachycardia, although it may occasionally result from a supraventricular tachycardia whose conduction through the ventricles produces an abnormally wide qrs complex. Typical sinus tachycardia is in the range of 100 to 200 patient s age beats per minute. Youre working the er when you get a call coming in for a cardiac arrest.
His rhythm went from sinus tachycardia with nonrespiratory sinus arrhythmia to multifocal atrial tachycardia mat to. The causes of ventricular and supraventricular tachycardias are generally quite different, with widely differing prognoses. This article continues the discussion, started last week, on ventricular tachycardias and also examines how to determine whether a broad complex tachycardia is ventricular or supraventricular in origin. Department of cardiology, royal prince alfred hospital, sydney, australia. Narrow complex tachycardia supraventricular tachycardia. For example, two abnormalities that go handinhand with heart failure are atrial fibrillation and bundle branch block. A narrow qrs complex tachycardia university of michigan.
Barrett, md division of cardiology, massachusetts general. Wide complex tachycardia ho wever can be supraventricular in origin if there is preexisting bundle bran ch block in either of bundles or if t h er e i s ac t i va t i on o f t he. Broad complex tachycardias occur by various mechanisms and may be ventricular or supraventricular in origin. Every clinician taking care of cardiac patients should be able to diagnose them.
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