Tachycardia and its ACLS algorithm | ACLS-Algorithms.com


  1. Lisa Chan says

    Hello, may I ask at most doses of adenosine can we give for SVT, since some sources mention give 6mg adenosine for first dose, followed by 12mg adenosine for second dose if needed; whereas some sources mention can even consider giving another second dose 12mg for one more time (i.e. 3 doses in total). So, for your expert opinion, at most should we give 2 or 3 doses of adenosine before considering other medications (e.g. BB, CCB)? Thank you very much!

    • ACLS says

      American heart association has two doses of adenosine listed, 6 mg and then 12 mg. In previous guidelines prior to 2015, there were three doses of adenosine listed in the algorithm 6mg, 12mg, 12mg. This third dose would be up to the physicians discretion and it can be done. The AHA provides guidelines for providers, and then the providers are ultimately responsible to strictly follow the guidelines or use their best clinical judgments to deviate when needed. I think that there may be times where a third dose of 12 mg is clinically indicated.

      Kind regards,

  2. Cathy says

    What to do with a stable patient with wide complex tachycardia with whom cardioversion with adenosine (6mg, then 12mg) has failed?

    • ACLS says

      Some providers based upon their own clinical judgment, may attempt another 12 mg of adenosine. Expert consultation with a cardiologist would be the next step. There are a number of things that need to be considered, when addressing wide complex tachycardia and since the patient is stable, expert consultation would be advised.
      Kind regards, Jeff

  3. Sophia says

    Hello Jeff,

    I am reviewing the Tachycardia with a pulse algorithm and would like clarification.

    Specifically, Unstable Tachycardia. When the patient is showing signs of instability with Tachycardia, we will cardiovert.

    A. However, in Unstable, irregular and wide, we will Defibrillate if its Torsades, no dig,ccb or BB because that can block AV node pathway causing increase in ventricular response.

    B. In Unstable, regular and wide, we will sync & cardiovert. If Refractory, we Increase energy level, look at underlying cause and get Expert consultation ( no antiarrythmics recommended as it may cause more harm)

    C. if Unstable, irreg and narrow- 1. Do we cardiovert despite risk of clots? 2. There’s a contraindication with CCB and BB – how do we manage rate control with this group?

    • ACLS says

      Hi Sophia,

      Unstable tachycardia with an irregular rate and narrow QRS may be due to atrial fibrillation, which carries a risk of forming blood clots in the atria.

      Therefore, before performing cardioversion, it is important to assess the patient’s risk of thromboembolism.

      The risk of thromboembolism can be estimated using various scoring systems, such as the CHADS2 or CHA2DS2-VASc score. These scores take into account factors such as age, gender, history of stroke or transient ischemic attack, hypertension, diabetes, and congestive heart failure.

      If the patient has a high risk of thromboembolism, anticoagulation therapy should be initiated before cardioversion.

      In some cases, such as in unstable tachycardia with hemodynamic compromise, immediate cardioversion may be necessary even without anticoagulation therapy. In such cases, the benefits of cardioversion may outweigh the risks of thromboembolism.

      Ultimately, the decision to perform cardioversion should be based on a careful assessment of the patient’s individual risk-benefit profile, taking into account the potential risks and benefits of the procedure, as well as the patient’s overall clinical condition and comorbidities. This decision should be made in consultation with a qualified healthcare provider.

      Kind regards,

  4. Abbie says

    If a patient had a syncopal episode in the community and then was seen in the emergency department and found to be in SVT, would this be classed as stable or unstable?
    If the patient was conscious and had no evidence of cerebral hypoperfusion at the time of assessment, but had a history of a syncopal episode, how should this be managed?

    Many thanks,

    • ACLS says

      The question of whether the patient is stable or unstable would be determined at the time of the assessment and based upon the patient’s condition at the time of the assessment. In the emergency room if they had no evidence of cerebral hypo perfusion and no signs or symptoms of instability then they would be considered stable.

      Kind regards,

  5. Khine Khine says

    Hi, a case of a patient with DDD(R) pacemaker underlying tachy-brady arrhythmia who developed fast atrial fibrillation. ECG generated HR of 157bpm and a patient is hypotensive and BP machine cannot capture the actual reading. Patient remains conscious and asymptomatic (No signs of cerebral hypo perfusion and shock).
    Is it considered stable AF or unstable AF?
    What would be the treatment to intervene fast AF? IV anti-arrhythmic or DC synchronised cardioversion?

    • ACLS says

      That would be a borderline stable/unstable issue. If the patient is conscious and asymptomatic then the best thing would be to determine what that blood pressure is. Also, is there a palpable pulse? Sometimes a pulse pressure tells you a lot about perfusion.

      I think most physicians in this case would go with a IV anti-arrhythmic. Would begin anticoagulant therapy if not already going and perform a transesophageal echocardiogram in order to prepare for synchronized cardioversion.

      Kind regards,

  6. Rose says

    If you do one dose of adenosine, can you then deem them unstable and cardiovert? Or do you need to do both doses?

    • ACLS says

      And unstable condition would be identified based upon the patient’s vital signs and also the assessment. If the patient is unstable then different interventions other than adenosine should be used. Kind regards, Jeff

  7. Robbie D says

    If after the first initial shock during Cardio version at 50j you do not cardiovert, when time frame do you initiate the next 100j….150j…..200j?

  8. Shaz says

    Hi, if patient have normal blood pressure (130/89mmHg) and pulse rate of 180, but have cool and clammy peripheries, is it stable or unstable tachycardia?

    • ACLS says

      If these are the only symptoms that the patient is experiencing then this would be considered stable tachycardia.

      Kind regards,

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