ACLS - Tachycardia

Question 1

When tachycardia is the cause of signs/symptoms, the heart rate is generally
greater than _____

Answer 1

150 bpm

Question 2

If a symptomatic tachycardia exists clinically we see this triad:

Answer 2

○ Rapid heart rate is present
○ The patient has symptoms
○ The symptoms are due to the rapid heart rate (more likely at >150 bpm)

Question 3

Tachycardia symptoms

Answer 3

● Chest discomfort or pain, ischemic
● Shortness of breath
● Altered mental status
● Weakness/Fatigue
● Lightheadedness/Dizziness
● Presyncope

Question 4

Tachycardia Signs

Answer 4

● Hypotension
● Orthostatic hypotension
● Pulmonary congestion (on PE or CXR)
● Frank congestive heart failure
● Syncope
● Signs of shock

Question 5

An important component in the management of a patient with any
tachycardia is to determine _____

Answer 5

whether a pulse is present or not.
If not, we move to cardiac arrest protocol

Question 6

After determining whether a patient with a tachyarrhythmia has a pulse, we then need to determine ____

Answer 6

whether the patient is stable or unstable

Question 7

ABCD approach to perform an initial assessment of bradycardia/tachycardia

Answer 7

○ Airway
○ Breathing
○ Circulation
Differential

Question 8

Signs/symptoms that would signal an unstable tachycardia

Answer 8

○ Hypotension
○ Acutely altered mental status
○ Signs of shock
○ Ischemic chest discomfort
○ Acute heart failure

Question 9

Synchronized Cardioversion

Answer 9

a form of shock therapy (like defibrillation)
where the delivery of a low-level energy dose is administered at the peak of the QRS complex (avoiding the T wave, or repolarization).

Question 10

Unstable patients with tachycardia require ____

Answer 10

immediate cardioversion

Question 11

Even if delivered as a synchronized shock, there is still a very small risk of
triggering VF; if this occurs, _____

Answer 11

immediately Defibrillate.

Question 12

Synchronized shocks are recommended for patients with:

Answer 12

○ Unstable SVT
○ Unstable Atrial Fibrillation
○ Unstable Atrial Flutter
○ Unstable regular monomorphic VT

Question 13

If the patient has regular narrow-complex SVT or a monomorphic wide-complex tachycardia and is NOT hypotensive, you may administer
______

Answer 13

adenosine while preparing for synchronized cardioversion.

Question 14

If there is no response to the first shock for synchronized cardioversion, you can _____

Answer 14

Increase the dose in a
stepwise fashion and try again.

Question 15

Treatment of stable narrow-complex tachycardias involves

Answer 15

○ Vagal Maneuvers (valsalva and/or carotid massage)
○ Adenosine

Question 16

Cardioversion is contraindicated with a _____

Answer 16

sinus rhythm

Question 17

Treating sinus tachycardia involves

Answer 17

Identifying and correcting the underlying problem causing the tachycardia (such as fever, anemia, hypovolemia, etc.)

Question 18

The first-line treatment for stable narrow-complex tachycardia is generally
_____

Answer 18

attempting vagal maneuvers
○ These terminate supraventricular tachycardias about 25% of the time

Question 19

Valsalva Maneuver

Answer 19

○ The idea is that increasing the intrathoracic pressure triggers changes in
the preload and afterload that result in initial tachycardia, followed by
increase in cardiac output, then an increased vagal response

Question 20

Carotid Massage-

Answer 20

○ Massaging over the carotid bifurcation can also simulate a sudden
increase in cardiac output and BP, triggering increased vagal tone.

Question 21

How to perform the carotid massage maneuver:

Answer 21

■ Auscultate for carotid bruits with the bell. If bruits are present, abort!
■ With the Pt lying flat, extend the neck and rotate the head slightly away from you.
■ Palpate the carotid artery at the angle of the jaw and apply gentle pressure for
10-15 seconds, right over carotid bifurcation.
■ Never compress both carotid arteries simultaneously.
■ Try the right carotid first (better success rate), but try left if right fails.
■ Have a rhythm strip running during the entire procedure so you can see what is
happening.

Question 22

Adenosine indications

Answer 22

● If the narrow-complex tachycardia does not respond to vagal maneuvers, IV
administration of Adenosine is indicated

Question 23

Adenosine is contraindicated in

Answer 23

2nd or 3rd degree AV block,
sinus node dysfunction, and signs/symptoms of acute myocardial ischemia.

Question 24

Potential adverse effects of Adenosine include _____

Answer 24

cardiac arrest and myocardial infarction

Question 25

After vagal maneuvers and adenosine, provide the patient with ______

Answer 25

Beta-Blocker or Calcium Channel Blocker can help to slow the rate and stabilize the ventricular conduction.

Question 26

If the tachycardic patient was deemed as
Stable, assess ____

Answer 26

the width of the QRS

Question 27

The common forms of stable, wide-complex tachycardias include:

Answer 27

○ Monomorphic VT
○ Polymorphic VT
○ SVT with Aberrancy

Question 28

SVT with Aberrancy

Answer 28

○ Sometimes supraventricular beats can produce wide QRS complexes,
making it difficult to decide if it’s VT or SVT.
○ This occurs when a supraventricular beat is conducted “aberrantly”
through the ventricles (essentially abnormal purkinje conduction).
■ Produces wide, bizarre-looking QRS complexes

Question 29

A few Clinical Clues for SVT with Aberrancy:

Answer 29

■ VT is more commonly seen in diseased hearts, while PSVT is more
commonly a concern in otherwise normal hearts.
■ Carotid massage has no effect on VT, but can terminate PSVT.
■ Cannon A Waves are sometimes seen with VT, but not PSVT.
● Visualization of forceful pulses in the neck (see next slide)

Question 30

Cannon A Waves in VT

Answer 30

Produced when there is a sudden back-flooding of blood out of the heart,
into the jugular veins.
● Can occur sometimes in VT; does not occur in supraventricular tachycardia.

Question 31

Some EKG Clues for SVT with Aberrancy:

Answer 31

■ If P waves are seen in PSVT, they march along with the QRS,
although they are usually inverted. Uncommonly, P waves are seen
with VT, and if so, they are completely dissociated

Question 32

IV antiarrhythmic medications for Stable wide-complex tachy

Answer 32

Procainamide, Amiodarone, and Sotalol

Question 33

Treatment of these stable, wide-complex tachycardias is centered on a few
different medication options and expert consultation, what are some of the options?

Answer 33

● IV Adenosine can be attempted for both treatment and diagnosis of regular, wide-complex monomorphic tachycardias.
● IV antiarrhythmic medications can be tried as well.
● Otherwise, in stable wide tachycardias, you have time to monitor the Pt and wait for expert consultation