Tacharrhythmia

788 Broad complex tachycardia
ECG shows HR >100bpm and QRS complexes >120ms (>3 small squares on ECG at the
standard UK rate of 25mm/s). Identify the underlying rhythm and treat accordingly.3
Differential diagnosis (See p124.)
• Ventricular tachycardia (VT): consider the pre-ECG probability of VT: older age, LV
dysfunction, and known IHD increase the likelihood of VT. >30s = sustained VT.
• Torsades de pointes: a form of VT with a constantly varying axis, often in the set-
ting of long QT.
• SVT with aberrant conduction: SVT with bundle branch block (p790).
19 Emergencies
• Pre-excited tachycardia: atrial arrhythmia conducted down an accessory

pathway, eg pre-excited AF. Consider if irregularly irregular, varying QRS duration,
delta wave (not always seen).
Identifying the underlying rhythm See p124 If in doubt, treat as VT.
General management See fig 19.13. Connect patient to a cardiac monitor and
ensure a defibrillator is available.
• Monitor O2 sats and give supplemental oxygen if <90%.
• Obtain IV access.
• Check for adverse signs: HR >150, SBP <90mmHg, consciousness, chest pain,
breathlessness (pulmonary oedema), oliguria.
• Correct electrolyte abnormalities: K+ and Mg2+.
Haemodynamically unstable VT
Synchronized DC shock (see p878, fig A3).
• Correct K+ <3.5mmol/L: 20mmol/h IV (20mmol/20min if imminent arrest).
• Correct Mg2+ <0.6mmol/L: 4mL 50% magnesium sulfate (=2g=8mmol) IV
over 10min.
• Amiodarone 300mg IV over 10–20min (peripherally in an emergency).
• If refractory, consider lidocaine 1mg/kg IV.
Haemodynamically stable VT
• Correct hypokalaemia and hypomagnesaemia as above.
• Amiodarone 300mg IV over 20–60min via central line/wide-bore cannula.
• Consider synchronized DC shock—a heart may not cope with VT for long.
After correction of VT
• Establish the cause.
• If VT occurs after MI: IV amiodarone infusion for 12–24h.
• A maintenance oral anti-arrhythmic may be required/indicated, eg -blocker in IHD.
• Recurrent VT: electrophysiology study (EPS)-guided ablation of the arrhythmogenic
area.
All patients with VT should be assessed for an implantable cardiac defibrillator (ICD).
Torsade de pointes
ECG, p125, fig 3.36.
Cause Congenital. Acquired is usually secondary to medication, eg antiarrhythmic,
tricyclic, antimalarial, antipsychotic. See p697.
Treatment 4mL 50% magnesium sulfate (=2g=8mmol) IV over 10min. Correct
hypokalaemia. If bradycardia and prolonged QT, an increase in HR can shorten
QT: overdrive pacing (pace at a faster rate, then slowly reduce), or isoprenaline IVI.
Prevent Congenital long-QT syndrome: -blocker. Acquired: stop predisposing drugs.
SVT with aberrant conduction
Manage as SVT, eg adenosine (see p790).
Ventricular extrasystoles (ectopics)
Found in 1–4% of population. Can be frequent, eg up to >60/h. If no underlying heart
disease they are considered benign, with no role for treatment. If IHD, a -blocker is
indicated and effective.
Ventricular fibrillation
ECG, p125, fig 3.34. Manage as cardiac arrest. Use non-synchronized DC shock (there
is no R wave which can trigger fibrillation, p754). See p878, fig A3.
789
19 Emergencies
Fig 19.13 Management of broad complex tachycardia.

790 Narrow complex tachycardia
ECG shows rate of >100bpm and QRS complex duration of <120ms (<3 small squares
on ECG done at the standard UK rate of 25mm/s).
Differential diagnosis (See p122.)
• Sinus tachycardia Normal P wave followed by normal QRS. This is not an ar-
rhythmia. Look for and treat the underlying cause, eg hypovolaemia, PE, sepsis,
hyperthyroidism.
• Atrial tachyarrhythmias
• Atrial fibrillation (AF): absent P wave, irregular QRS complexes. If rhythm is
19 Emergencies
irregular, AF is likely.
• Atrial flutter: atrial rate ~260–340bpm. Saw-tooth baseline, due to a re-entrant
circuit usually in the right atrium. Ventricular rate often ~150bpm (ie 2:1 block).
• Atrial tachycardia: abnormally shaped P waves, which may outnumber QRS.
• Supraventricular tachycardia AV node is part of the arrhythmogenic pathway. P
wave may be either buried in QRS complex or occur after QRS complex.
• AV nodal re-entry tachycardia.
• AV re-entry tachycardia via an accessory pathway. Can occur with pre-excitation,
eg WPW (p129), or without pre-excitation if only retrograde conduction.
Management Be guided by patient status. See fig 19.14.
Identify the underlying rhythm and treat accordingly.
Prepare for DC cardioversion if patient is compromised due to arrhythmia.
Supraventricular tachycardia
1 Vagal manoeuvres: carotid sinus massage, modified Valsalva manoeuvre (see
p126). Transient increase in AV block may unmask underlying atrial arrhythmia.
2 Adenosine: short half-life (10–15s).
• Give 6mg IV bolus into a large vein, followed by 0.9% saline flush, while re-
cording a rhythm strip (or 12-lead ECG if possible).
• If unsuccessful after 2min, give 12mg IV.
• If unsuccessful after 2min, give 18mg IV bolus.
Warn about SE: chest tightness, dyspnoea, headache, flushing. Do not use in
pre-excited AF as can precipitate VT, see p788. Will not work in cardiac trans-
plant as heart is denervated. Caution in asthma (but remember adenosine is
short-acting and effective).
3 Review rhythm strip after adenosine. If adenosine does not cardiovert, AV
block may reveal an alternative atrial arrhythmia.
4 Recurrent SVT: -blocker, eg metoprolol 5mg IV or atenolol 2.5mg IV; verapamil
5mg IV.
5 DC cardioversion if other measures fail or if compromised.
6 Refer for specialist electrophysiology review.
Atrial fibrillation/flutter See BOX: irregular narrow complex tachycardia. Seek
help if resistant (p126).
Atrial tachycardia Rare. Manage with rate control. Seek expert help.
Wolff–Parkinson–White (WPW) syndrome (ECG, p129, fig 3.42.)
Congenital accessory conduction pathway between atria and ventricles. Resting
ECG shows short PR interval, widened QRS complex due to slurred upstroke (= ‘delta
wave’). Presents with SVT which may be:
• AVRT (p122).
• pre-excited AF/atrial flutter with risk of degeneration to VF and sudden death.
Consider if irregularly irregular, varying QRS duration, delta wave, variable rate up
to 300bpm (ie too high to be conducted via AV node). Do not use medications which
block the AV node as this increases the risk of VF via the accessory pathway. Treat
with cardioversion or flecainide.
791
19 Emergencies
Fig 19.14 Management of narrow complex tachycardia.
 Irregular narrow complex tachycardia

• AF is the most likely diagnosis.
• The need for emergency rate control is uncommon. Treat precipitants, eg
hypovolaemia, sepsis. Consider:
• -blocker: eg metoprolol 5mg IV if rapid rate control needed. Otherwise oral
-blocker. Caution if LVF.
• Rate limiting calcium-channel blocker: eg diltiazem, verapamil.
• Digoxin. Load (eg 500mcg PO every 8h for 3 doses), then maintenance
(eg 125–250mcg PO daily).
• LMWH or DOAC based on persistence beyond 48h, and stroke/bleeding risk.
• Rhythm control. Cardioversion. Risk of thromboembolism unless clear onset
<48h, or effectively anticoagulated for >3wk.
• Electrical cardioversion: synchronized DC cardioversion under sedation.
• Chemical cardioversion: flecainide (normal heart structure and no IHD),
amiodarone.

Tacharrhythmia

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788 Broad complex tachycardia

• Pre-excited tachycardia: atrial arrhythmia conducted down an accessory

Fig 19.13 Management of broad complex tachycardia.

Fig 19.14 Management of narrow complex tachycardia.

 Irregular narrow complex tachycardia

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