Adult Tachycardia - Narrow Complex Admin Guideline (Age ≥ 14)

Question 1

Narrow tachycardia with serious signs or symptoms (generally HR >150):

Answer 1

dyspnea, chest pain, syncope/near-syncope, hemodynamic compromise, altered mental status or other signs of end organ hypoperfusion

Question 2

Are they asymptomatic?

Answer 2

For ASYMPTOMATIC PATIENTS (or those with only minimal symptoms, such as palpitations) and any tachycardia with rate approximately 100-120 and a normal blood pressure, consider CLOSE OBSERVATION and/or fluid bolus rather than immediate treatment with an anti arrythmic medication.

Question 3

SBP < 90 with

poor perfusion/ALOC

Answer 3

Cardioversion: 120J
(Attempt to synchronize, if no sync and
unstable - defibrillate)
May repeat if needed at 200J check pulse
and evaluate for cardiac arrest if no conversion)

Administer 500mL NS/LR fluid bolus

Consider Sedation Prior to Cardioversion:
Midazolam 2.5 mg IV/IO or 5mg IM
May repeat as needed; Max 10 mg

Question 4

SBP < 90 with normal mentation

Answer 4

Administer O2, VS assessment (inc. temp when available)

IV/IO access, O2, Cardiac monitor
Administer 500 mL NS/LR fluid bolus.
May repeat as needed.

Question 5

Regular rhythm? (SVT)

Answer 5

Vagal maneuvers!!!!

Administer adenosine 6 mg adenosine IV (proximal) followed by 20 mL saline flush
May repeat x 1 at 12 mg IV

If no conversion, consider administration of
diltiazem 20 mg IV/IO.
May repeat x 1 as blood pressure allows

Give 1/2 dose slowly over 2 minutes. Administer
remainder of dose as blood pressure allows.
Patients over age 65, max initial dose of 10 mg.

Repeat 12 lead EKG, repeat vital signs, monitor

Question 6

Irregular Rhythm (Afib/Aflutter)

Answer 6

Vagal maneuvers!!!

Administer diltiazem 20 mg IV/IO.
May repeat x 1 as blood pressure allows
Give 1/2 dose slowly over 2 minutes. Administer remainder of dose as blood pressure allows.
Patients over age 65, max initial dose of 10 mg.

Repeat 12 lead EKG, repeat vital signs, monitor

Question 7

Sinus tach facts

Answer 7

Typically ranges from 100 to (220 - patient?s age) beats per minute. It may be caused by dehydration, fever, substance use, etc.

• Symptomatic tachycardia usually occurs at rates of 120 -150 and typically ? 150 beats per minute.
• Patients symptomatic with heart rates < 150 often have impaired cardiac function, such as CHF
• Search for underlying cause of tachycardia such as fever, sepsis, dyspnea, etc.

Question 8

Wolf-Parkinson-White facts

Answer 8

• A rare syndrome, WPW is diagnosed by a short PR interval and upsloping QRS complex (delta wave).
  The rhythm can degenerate to appear similar to atrial fibrillation with rapid ventricular response. A 12-lead ECG or the patient’s history may reveal WPW
• DO NOT administer any Ca Channel Blocker (e.g. Diltiazem), Beta Blockers, or Adenosine
• Unstable patients with WPW require electrical cardioversion.

Question 9

SVT facts

Answer 9

• Vagal maneuvers and adenosine may be administered. Vagal maneuvers may convert up to 25 % of SVT.
• Adenosine should be pushed rapidly via proximal IV site followed by 20 mL Normal Saline rapid flush.
• Diltiazem may be considered alternatively or if rhythm does not convert with adenosine.

Question 10

Facts about Afib and Aflutter

Answer 10

• First line agents for rate control are calcium channel blockers.
• Adenosine may be considered to assist with diagnosis or if patient has history of Adenosine conversion, but Adenosine is NOT mandated.
• Adenosine may not be effective in atrial fibrillation / flutter, yet is not harmful and may help identify rhythm.

Question 11

What should you do during all rhythm changes and therapeutic interventions?

Answer 11

Print a strip.

Question 12

Can you use Amiodarone in narrow complex tachycardia?

Answer 12

Yes
- Amiodarone may also be used to treat narrow complex tachycardia, either regular or irregular, as a second line agent if there is an allergy or contraindication to adenosine or diltiazem or other primary agent

Question 13

You’ve just given a calcium channel blocker. You should ____

Answer 13

Monitor for hypotension

Question 14

You’re about to cardiovert and you give midazolam for sedation. What do you need to watch out for?

Answer 14

respiratory depression and hypotension