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 (short of air), 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.
Causes
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.
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 a review of the H’s and T’s of ACLS should take place as needed.
Click below to view the H and T’s table. When done click again to close the diagram.
H’s and T’s Table
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:
- Supraventricular tachycardia (SVT)
- Atrial fibrillation
- Atrial flutter
- Monomorphic VT
- Polymorphic VT
- Wide-complex tachycardia of uncertain type
ACLS Treatment for Tachycardia
Click below to view the tachycardia algorithm diagram. When done click again to close the diagram.
Tachycardia Diagram
or Members Download the Hi-Resolution PDF Here(This will open in another window.)
The first 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.
Unstable Tachycardia
Patients with unstable tachycardia should be treated immediately with synchronized cardioversion. If a pulseless tachycardia is present patients should be treated using the cardiac arrest algorithm.
The AHA no longer provides specific shock dose recommendations for synchronized cardioversion. Instead, they instruct to refer to your specific device’s recommended energy level to maximize first shock success.
For the purposes of a basic understanding of cardioversion, the information about general shock dosages and recommendations will remain in the content on this website.
The initial recommended synchronized cardioversion voltage doses are as follows:
- narrow regular: 50-100 J; i.e., SVT and atrial flutter
- Narrow irregular: 120-200 J biphasic or 200 J monophasic; i.e., atrial fibrillation
- Wide regular: 100 J; i.e., monomorphic VT
- Wide irregular: defibrillation dose (not synchronized)
Stable Tachycardia
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
kathy says
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.
Jeff with admin. says
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
Mylee Belle says
in children, or uncooperative patients, try putting an ice pack of the forehead…it would help…
akdewart says
How do you tell the difference between Sinus Tachycardia and SVT or RSVT? thanks.
Jeff with admin. says
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
kim says
Could you please explain the difference between polymorphic and monomorphic. I have an idea but have not encountered these terms before.
Jeff with admin. says
Kim, this page on the site will explain the difference.
Kind regards,
Jeff
DrSikwambane says
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!
Jeff with admin. says
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
Mylee says
hypotension (<90 SBP), ongoing chest pain, changes in LOC, are the parameters used to judge instability in tachycardia..correct??
Jeff with admin. says
That is correct.
Kind regards,
Jeff
Sean McPhillips says
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?
Jeff with admin. says
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)
Jeff with admin. says
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
Bogeyzombie says
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)?
Jeff with admin. says
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
ellen_xii2004 says
CAN YOU TELL ME WHICH ASSOCIATED RHYTHMS HAVE NARROW QRS COMPLEX AND WHICH HAVE WIDE QRS COMPLEX?
Jeff with admin. says
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
tgeer1 says
What is SOA?
Jeff with admin. says
Short of air.
Tamra Kruyswyk says
Why do you really treat wide vs narrow complex tachycardias different? Esp. in regards to vagal maneuvers
Chris says
“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
Darlene Wigley says
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
Jeff with admin. says
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
Diego Carta says
What is SOA?
Jeff with admin. says
SOA means “shortness of air.” It means that the patient cannot breathe well.—Jeff
Cathie says
I love you and thank you with all my heart!
Marva A. Hanson says
EXCELLENT!
THANK YOU.
CAN WE MAKE THE MONITOR GET LARGER? THANKS AGAIN.
Elizabeth Risner says
What medication would you give if your patient has refractory ventricular tachycardia? And what does refractory mean?
Chris with admin says
Refractory Ventricular Tachycardia is rare and hard to treat. Refractory implies that drugs aren’t working, so in the ACLS situation, synchronized cardioversion or defibrillation depending on if there is a pulse, is the method of treatment. Expert consultation is necessary. Some options outside the scope of ACLS is Catheter Ablation, Implanted ICD. I haven’t had any patients that had refractory VT, but from cursory reading, it is seen in patients with chronic cardiac disease processes.
Michelle Hilsabeck says
What is SOA?
Jeff with admin. says
Short of air
Jeff
h says
SOB (breath) in other parts of the world!!
Jeff with admin. says
Health care is trying to move away from the use of SOB as an acronym. As the acronym can have various meanings. As far as I konw SOA is now the appropriate term for describing someone who is having difficulty breathing.
Kind regards,
Jeff