Tachycardia Algorithm
Tachycardia and its ACLS Algorithm
Tachycardia/tachyarrhythmia is defined as a rhythm with a heart rate greater than 100 bpm.
An unstable tachycardia exists when cardiac output is reduced to the point of causing serious signs and symptoms.
Serious signs and symptoms commonly seen with unstable tachycardia are: chest pain, signs of shock, SOA, altered mental status, weakness, fatigue, and syncope
One important question you may want to ask is: “Are the symptoms being caused by the tachycardia?” If the symptoms are being caused by the tachycardia treat the tachycardia.
There are many causes of both stable and unstable tachycardia and appropriate treatment within the ACLS framework requires identification of causative factors. Before initiating invasive interventions, reversible causes should be identified and treated.
Causes
The most common causes of tachycardia that should be treated outside of the ACLS tachycardia algorithm are dehydration, hypoxia, fever, and sepsis. There may be other contributing causes and review of the H’s and T’s of ACLS should take place as needed.
Administration of OXYGEN and NORMAL SALINE are of primary importance for the treatment of causative factors of sinus tachycardia and should be considered prior to ACLS intervention.
Once these causative factors have been ruled out or treated, invasive treatment using the ACLS tachycardia algorithm should be implemented.
Associated Rhythms
There are several rhythms that are frequently associated with stable and unstable tachycardia these rhythms include:
- Atrial fibrillation
- Atrial flutter
- Supraventricular tachycardia (SVT)
- Monomorphic VT
- Polymorphic VT
- Wide-complex tachycardia of uncertain type
Visit the links above to learn about each specific rhythm.
ACLS Treatment for Tachycardia
Click below to view the tachycardia algorithm diagram. When done click again to close the diagram. Tachycardia Algorithm Diagram.» or Members Download the Hi-Resolution PDF Here
The fist question that should be asked when initiating the ACLS tachycardia algorithm is: “Is the patient stable or unstable?” The answer to this question will determine which path of the tachycardia algorithm is executed.
Patients with unstable tachycardia should be treated immediately with synchronized cardioversion. If a pulseless tachycardia is present patients should be treated using the pulseless arrest algorithm.
Patients with stable tachycardia are treated based upon whether they have a narrow or wide QRS complex. The following flow diagram shows the treatment regimen for stable tachycardia with narrow and wide QRS complex.
- Stable (narrow QRS complex) → vagal maneuvers → adenosine (if regular) → beta-blocker/calcium channel blocker → get an expert
- Stable (wide/regular/monomorphic) → adenosine → consider antiarrhythmic infusion → get an expert
If a person has a pre-existing LBBB how would you approach management eg. if they came in with a fever and a wide-complex tachycardia could this be simply their version of a sinus tachy ?
It could be their version of sinus tachycardia. The rate will most likely be less than 150 and they will most likely be asymptomatic. However, if they have any symptoms such as chest pain, shortness of air, hypotension the you would work the pt. up to rule out cardiac problems.
Also, obtain a good history and treat the fever.
Kind regards,
Jeff
If you are trying to cardiovert VT(presumed monomorphic) how long should you give the machine to sync before switching to defib mode ?
If the patient is unstable and the defibrillator will not SYNC, the machine should indicate “failed to capture or failed to SYNC.” If you get failure capture in an unstable patient then you should immediately switch to unsynchronized and shock the patient.
Kind regards,
Jeff
It should be SOB NOT SOA right ?
Either on. SOA means “short of air” and SOB means “short of breath.” SOB also has other meanings and this is why I use SOA.
Kind regards,
Jeff
hi so Rvt, or Rvf you would shock then give an anti arythmic ? I feel like I understand then I become confused! hmmm is this normal. thanks for your help Vicki buz
Defibrillation (unsynchronized cardioversion) will be used PULSELESS VT and VF. True VF will always be pulseless. The following is always the sequence for VT and VF assuming that the defibrillator is attached: Shock, CPR, rhythm check, shock, CPR/epinephrine, rhythm check, shock, CPR/amiodarone, rhythm check….
Stable or unstable tachycardia with a pulse is handled in an number of different ways. Download the tachycardia algorithm diagram and take a look. The main intervention for any unstable tachycardia should be synchronized cardioversion.
Kind regards,
Jeff
Thank you Jeff! Your website rocks. I passed ACLS just using your site as a study guide. Now I use it to update my knowledge and skills weekly. Thanks again….God Bless:)
Hi Jeff with admin
Im getting confused on the diagnosing of Tachycardia, unstable pt, wide QRS. Is the VF/VT algorithym used, or the Tachycardia algorithym used. Im thinking it centers around wether you can determine if there is a “P” wave in the EKG, correct? ie a Supraventricular tachycardia by definition has a “P” wave thus means you use the Tachycardia algorithym and non “P” wave means its the ugly VT thus gets treated with the VF/VT algorithym. Correct?
If a patient is pulseless you will use the pulseless arrest algorithm. If the patient has VF or VT and is pulseless use the left branch of the pulseless arrest algorithm. Any other rhythm that is pulseless, you will use the right branch of the pulseless arrest algorithm.
If you have a pulse, then you will determine which algorithm to use based upon the rate of the pulse (bradycardia or tachycardia). If bradycardia use the bradycardia algorithm. If tachycardia use the tachycardia algorithm.
Kind regards, Jeff
Regarding vagal maneuvers: only MD is to do carotid massage. What maneuvers should RN try first?
Great site, by the way. Format makes it so much easier to understand and remember.
You can have the patient bear down as if having a bowel movement.
You can also have the patient blow forcefully through a thin straw.
You can have the patient try and blow the plunger out of a 5-10 mL syringe
All of the above actions as well as any other vagal maneuver will increase intraabdominal and intrathoracic pressure and stimulate the vagus nerve which will elicit a parasympathetic response.
Kind regards,
Jeff
in children, or uncooperative patients, try putting an ice pack of the forehead…it would help…
How do you tell the difference between Sinus Tachycardia and SVT or RSVT? thanks.
The major difference you will notice between SVT and sinus tachycardia is the rate. Usually, the rate of SVT will be greater than 150. The rate for sinus tachycardia will usually be less than 150.
RSVT is a type of SVT. SVT is a general term for several types of tachycardia rhythms that originate above the ventricles. When someone says they have SVT, usually they are referring to the most common type of SVT which is PSVT. PSVT is Paroxysmal supraventricular tachycardia.
Kind regards,
Jeff
Could you please explain the difference between polymorphic and monomorphic. I have an idea but have not encountered these terms before.
Kim, this page on the site will explain the difference.
Kind regards,
Jeff
Hey Jeff, need clarity on if it’s stable tachycardia wide QRS irregular polymorphic do I get expert consult and do nothing!. If its narrow complex irregular like atrial fib do I give vagal massage and get expert consult and not give adenosine! It’s not on algorithm!
If the tachycardia is Stable then you would not do anything without consulting an expert.
If the narrow complex irregular is unstable the it would be treated with cardioversion. If the narrow complex irregular is stable its treatment would be outside the scope of ACLS and would be treated in an intensive care unit.
Page 128 AHA ACLS Manual (bottom of the page): “Stable Irregular tachycardias both narrow and wide complex are advanced rhythms requiring additional expertise or expert consultation.” They are not discussed because they are beyond the scope of ACLS.
Page 129 AHA Manual States: “Aviod AV nodal blocking agens such as adenosine, calcium cannel blockers, digoxin, and possibly b-Blockers in patients with pre-excitation atrial fibrillation, because these drugs may cause a paradoxical increase in the ventricular response.”
Page 130 AHA Manual States: “AV nodal blocking drugs should not be used for pre-excited atrial fibrillation or flutter. Treatment with an AV nodal blocking agent is unlikely to slow the ventricular rate and in some instances may accelerate the ventricular response.”
Kind regards,
Jeff
hypotension (<90 SBP), ongoing chest pain, changes in LOC, are the parameters used to judge instability in tachycardia..correct??
That is correct.
Kind regards,
Jeff
Adenosine is new to the algorithm. Is this to unmask an underlying SVT that may have slow conduction causing the monomorphic wide / narrow ventricular tachycardia? What is the rational?
In one study of 40 patients with narrow complex tachycardia, administration of adenosine restored sinus rhythm in 25 patients with junctional tachycardias and produced AV block to reveal atrial or sinus node origination of the tachycardia in 15 patients. The response of the narrow tachycardia to adenosine-induced AV block allowed correct localization of the source of SVT in 100% of cases. In that same study, 24 patients with regular wide complex tachycardia were given intravenous adenosine. The wide complex tachycardia terminated in six patients, and atrial or sinus tachycardias were revealed in another four patients. In the 14 patients with persistent wide complex tachycardia (despite up to 20 mg of adenosine), two patients had transient ventriculoatrial dissociation, allowing a confident diagnosis of ventricular tachycardia. Overall, diagnosis based on adenosine-induced AV block allowed a correct diagnosis in 92% of the 24 patients with wide complex tachycardia. Side effects (dyspnea, chest pain,flushing, headache) were reported in 63% of patients and were severe in 36% of patients, but they were self-limited in all cases.67 While four studies totaling approximately170 patients suggest that diagnostic administration of adenosine to patients with narrow or wide complex tachycardia is safe, there are several reports of hemodynamic deterioration after intravenous adenosine,primarily when given to patients with pre-excited atrial fibrillation. It is therefore suggested that physicians using adenosine as a diagnostic aid in patients with wide complex tachycardia be absolutely certain that the wide complex rhythm is regular before giving adenosine.
Sources:
(Resource for above information)
Rankin AC, Oldroyd KG, Chong E, et al. Value and limitations of adenosine in the diagnosis and treatment of narrow and broad
complex tachycardias. Br Heart J 1989 Sep;62(3):195-203.
Domanovits H, Laske H, Stark G, et al. Adenosine for the management of patients with tachycardias—a new protocol. Eur Heart J 1994 May;15(5):589-593.
Griffith MJ, Linker NJ, Ward DE, et al. Adenosine in the diagnosis of broad complex tachycardia. Lancet 1988 Mar 26;1(8587):672-675.
With ventricular rates < 150 beats per minute in the absence of ventricular dysfunction, it is more likely that the tachycardia
is secondary to the underlying condition rather than the cause of the instability. If not hypotensive, the patient with a regular
narrow-complex SVT (likely due to suspected reentry, paroxysmal supraventricular tachycardia) may be treated with adenosine while preparations are made
for synchronized cardioversion (Class IIb, LOE C). (Resource)
In one study of 40 patients with narrow complex tachycardia, administration of adenosine restored sinus rhythm in 25 patients with junctional tachycardias and produced AV block to reveal atrial or sinus node origination of the tachycardia in 15 patients.
The response of the narrow tachycardia to adenosine-induced AV block allowed correct localization of the source of SVT in 100% of cases. In that same study, 24 patients with regular wide complex tachycardia were given intravenous adenosine. The wide complex tachycardia terminated in six patients, and atrial or sinus tachycardias were revealed in another four patients.
In the 14 patients with persistent wide complex tachycardia (despite up to 20 mg of adenosine), two patients had transient ventriculoatrial dissociation, allowing a confident diagnosis of ventricular tachycardia. Overall, diagnosis based on adenosine-induced AV block allowed a correct diagnosis in 92% of the 24 patients with wide complex tachycardia.
Side effects (dyspnea, chest pain,flushing, headache) were reported in 63% of patients and were severe in 36% of patients, but they were self-limited in all cases. While four studies totaling approximately 170 patients suggest that diagnostic administration of adenosine to patients with narrow or wide complex tachycardia is safe, there are several reports of hemodynamic deterioration after intravenous adenosine, primarily when given to patients with pre-excited atrial fibrillation. It is therefore suggested that physicians using adenosine as a diagnostic aid in patients with wide complex tachycardia be absolutely certain that the wide complex rhythm is regular before giving adenosine.
(Information cited)
Rankin AC, Oldroyd KG, Chong E, et al. Value and limitations of adenosine in the diagnosis and treatment of narrow and broad complex tachycardias. Br Heart J1989 Sep;62(3):195-203.
Griffith MJ, Linker NJ, Ward DE, et al. Adenosine in the diagnosis of broad complex tachycardia. Lancet 1988 Mar 26;1(8587):672-675
This AHA article contains information on the use of Adenosine within the tachycardia algorithm.
If you use the Control-F function, you can search the word “adenosine” in the above document and narrow your reading to pertinent content. Regards, Jeff
Thank you so much for this website! Im a paramedic student about to test for my ACLS pretty soon and i was having a hard time remembering the algorithm of Tachycardia. I finally understood the treatment for stable tachycardia, now what i was wondering… For unstable tachycardia, do we also administered an antiarrhythmic? Or do we only do synchronized cardioversion and Adenosine (if regular narrow QRS)?
For an unstable tachycardia you will perform synchronized cardioversion and adenosine (if regular narrow QRS)
Don’t delay cardioversion if unstable and you cannot get the meds rapidly. –Regards, Jeff
CAN YOU TELL ME WHICH ASSOCIATED RHYTHMS HAVE NARROW QRS COMPLEX AND WHICH HAVE WIDE QRS COMPLEX?
The most common narrow QRS complex tachycardia is SVT and the most common wide complex tachycardia is monomorphic VT. There are many variants within these and the are treated based primarily upon whether they are narrow or wide complex.–Kind regards, Jeff
What is SOA?
Short of air.
Why do you really treat wide vs narrow complex tachycardias different? Esp. in regards to vagal maneuvers
“Vagal maneuvers will not work with Vtach, and wide complex tachycardia should always be assumed to be VTach. 90% of the time it is VTach. Vagal Maneuvers only work 25% of the time with narrow complex tachycardia. If the pt. is unstable, the treatment is the same.”—Chris
I did read the comment below on rsvt and the rarity of it but that being said, when looking at a rhythm and diagnosing it how does one tell if it is an rsvt or svt just by looking at the rythym
Refractory simply means that when you attempt to treat the VT it responds to treatment and comes back quickly or it may not respond at all. It will look like VT which and the patient will be symptomatic (probably unconscious) and the HR will most of the time be greater than 150.—Jeff