Tachycardia and its ACLS algorithm | ACLS-Algorithms.com

Comments

  1. Mustafa says

    Hi
    my question
    1- How long will press bottom ( Pad ) when perform cardioversion ..??
    2- when administered amidrone 150 mg over 10 mit ( 1 amp = 150 mg ) how will dilute it and which by saline or Dextrose .??

    • ACLS says

      1. I do not understand your first question. I do not understand what you mean when you say “how long will press bottom?”

      2. Amiodarone is diluted with D5W. 150ml of amiodarone in 100 ml of D5W.

      Kind regards,
      Jeff

  2. Richard Kerio says

    if we have a patient with old AFib and end stage ckd presents with a pulmonary edema..is it recommended to do an electric sync schock?? and why??

    • ACLS says

      There are a number of variables within your scenario. If the patient is stable this scenario would require prior consultation with a cardiologist and a nephrologist prior to any intervention.

      If the patient is unstable and the instability is clearly related to the atrial fibrillation then a cardioversion may be necessary. Other causes would need to be ruled out prior to any emergency intervention. There are other interventions that can be performed for chronic or new onset atrial fibrillation with a rapid ventricular rate.

      This scenario is definitely beyond the scope of basic advanced cardiovascular life support and there would not be a clear-cut answer.

      Kind regards,
      Jeff

  3. SUDHIR DEY says

    Dear Sir : I completed my ACLS. But your site for cardiology is excellent . I want to practice it through out the year. I want more megacode series and case history. How to get it. In tachycardia,pt is stable ,pulse palpable but monitor shows HR 110 to 140 ,varying time to time. At this stage is it justified to use adenosine? I will renew my membership. pl reduce the cost if possible. Thanks.

    Dr. Dey.

    • ACLS says

      Adenosine would not be justified in this situation. A sustained heart rate of 110 to 140 would not be considered SVT. A 12-lead ECG would also need to be obtained. Other causes of the tachycardia should be ruled out, and as long as the patient is stable they should be evaluated by a cardiologist.

      Typically, SVT will have a rate much higher than 110-140 per minute.

      Kind regards,
      Jeff

  4. Norma Chesney says

    I know no questions are stupid, but I have a hard time with “synchronized cardioversion, and unsynchronized”. Could you explain this in simple terms?
    Thanks…by the way…love your site!!

  5. Anthony Price says

    Let’s say an unstable A-fib patient was cardioverted at 50 J, then 100 J. If he/she still did not convert, should I continue cardioverting and higher and higher joules?

    • Jeff with admin. says

      I have had this discussion with several cardiologists and they tell me that if the lowest dose fails then they go straight to the maximum dose that the machine will deliver. They say that this gives them the best results.

      AHA does not have a specific recommendation, and I think the above recommendation is good.

      Kind regards,
      Jeff

  6. Enrique Luis Nuguid says

    Hi
    Just to clarify the initial dose of shocking, does This mean we can increase the initial dose if the rhythm is not converted?

  7. lawal2022 says

    Hi Jeff

    Thanks for an amazing website.
    How long should you do vagal maneuvers whilst preparing Adenosine?

    Regards and thanks
    Alice

    • Jeff with admin. says

      Two or three attempts with vagal maneuver’s should be sufficient. This should not take longer than 5-10 minutes. If conversion has not occurred after the third attempt with vagal maneuver’s then it’s unlikely that it will work.

      You have to realize that these patients are stable. The timeframe is not as critical. Once you have established that vagal maneuvers are not likely to succeed then move on to adenosine.

      Kind regards,
      Jeff

      • kran says

        best way to use a the vagal maneuver is combining carotid massage with valsalva maneuver. That gives you a very high conversion rate, its amazing to see how a patient not responding to carotid massage , suddenly responds to addition on valsalva.
        thank you for your amazing effort on this site
        regards

    • Jeff with admin. says

      It depends upon the patient’s condition. It is a shockable rhythm. It’s very unlikely that synchronized cardioversion will be possible because of the variation in the QRS complexes. If the patient is unstable or pulseless with torsades then defibrillation is indicated.

      In the unlikely chance that the patient is in torsades and is stable then antiarrhythmics and or magnesium can be used. Preparation for defibrillation should be made because this rhythm can quickly become unstable.

      Kind regards,
      Jeff

  8. Abe says

    I’ve read conflicting recommendations about treatment of unstable (impaired perfusion but with a pulse) polymorphic VT / torsades. Polymorphic VT is a subset of irregular VT. Are there situations in which the treatment of polymorphic VT differs from other irregular VT?

    If not, the recommendations above are clear enough- defibrillation not synchronized cardioversion. Are there any situations in which synchronized cardioversion is used for irregular VT?

    Thanks!

    • Jeff with admin. says

      Defibrillation is recommended for all polymorphic ventricular tachycardia. The reason for this is that the defibrillator will not synchronize with the irregular rhythm and therefore shock delivery will not be able to occur.

      Defibrillation allows the defibrillator operator to manually provide shock and therefore bypasses synchronization.

      Kind regards,
      Jeff

  9. Mackenzie Corrigan says

    Hello,
    What is the specific dosing for the antiarrthymthic infusion for the following tachy situation : (wide/regular/monomorphic) → adenosine → consider antiarrhythmic infusion → get an expert consultation

    Also, is only one dose of Adenosine (6 mg IV rapid infusion) considered the correct dosing for the first line of treatment of this tachy?

    Thank you!
    This site is extremely helpful!

    • Jeff with admin. says

      The dosing for adenosine would be 6 mg and if 6 mg fails then attempt 12 mg.

      If the adenosine fails to convert the rhythm then you would use amiodarone and this is the infusion information:

      Amiodarone 150 mg over 10 minutes → repeat as needed if VT recurs → maintenance infusion of 1mg/min for 6 hours

      This information can be found on page 133 three the AHA ACLS provider manual.

      Kind regards,
      Jeff

      • Jeff with admin. says

        This is the AHA statement regarding the use of adenosine with wide complex tachycardia.

        If the etiology of the rhythm cannot be determined, the rate is regular, and the QRS is monomorphic, recent evidence suggests that IV adenosine is relatively safe for both treatment and diagnosis.

        However, adenosine should not be given for unstable or for irregular or polymorphic wide-complex tachycardias, as it may cause degeneration of the arrhythmia to VF.

        Reference

        Kind regards, Jeff

  10. Rick John says

    Hello, if the patient with very rapid VT (200bpm) with unstable hemodynamic, altered mental status and rapidly deteriorate to LOC, and pulse is not palpable alternated with sometime very very weak pulse, his documented LV function is very altered (LVEF 10%). Should we give immediately defibrillation or cardioversion? What this patient considered to be in pulseless VT?
    Thanks

    • Jeff with admin. says

      You could attempt synchronized cardioversion. There is a good chance that the machine can sync with the patient’s rhythm and synchronized cardioversion can be performed. If the synchronization fails then you can move to defibrillation.

      Pulseless would be would there is not palpable pulse at all. This case would not be considered pulseless.

      Kind regards,
      Jeff

  11. Theresa Broetzmann says

    Jeff,
    Thank you so much for your services and this site! I will use this site for all future ACLS and PALS renewals. I was so impressed with this site that I have shown it to numerous colleagues and our educator for new hires and people needing renewals. Have a great day!

  12. See Thao says

    I know this is maybe a dumb question but can you tell me what does Regular and Irregular mean in the EKG waveform?

    • Jeff with admin. says

      Regular means that the R to R interval is the same throughout the EKG tracing. Each QRS complex falls equidistantly every time.

      Irregular means that the R to R interval is different throughout the EKG tracing. There is variability between when the QRS complexes fall.

      Kind regards,
      Jeff

    • Jeff with admin. says

      I’m assuming that you are referring to the left branch of the cardiac arrest algorithm.

      A shock is given after each round of CPR if the rhythm remains VF or pulseless VT.

      The administration of medications has nothing to do with when shocks are given.

      The only requirement with regard to the administration of medications is that they be given while chest compressions are being performed.

      Kind regards,
      Jeff

  13. sheikh tariq says

    HELLO,IF PATIENT IS UNSTABLE WITH SINU TACHYCARDIA HR >150/MIN IS CARDIO VERSION INDICATED IN THAT CASE.ANY REFRENCE FOR THAT.IN SINUS TACHY PRIORITY IS TO TREAT UNDERLYING CAUSE,AM I CORRECT OR NOT. THANKS N REGARDS

    • Jeff with admin. says

      If you are dealing with Sinus Tachycardia, it is very unlikely that you will see rates greater than 150. Rates greater than 150 with sinus tachycardia do happen and this is where caution is recommended.

      If you are for sure that you are dealing with sinus tachycardia, you would want to find and treat the underlying cause of the increased heart rate. If no underlying cause can be found your probably not dealing with sinus tachycardia and can proceed with synchronized cardioversion or adenosine.

      True sinus tachycardia will not respond to cardioversion and is contraindicated.

      AHA ACLS Provider Manual pg. 140
      “Sinus tachycardia is caused by external influences on the heart, such as fever, anemia, hypotension, blood loss, or exercise. These are systemic conditions, not cardiac conditions. Sinus tachycardia is a regular rhythm, although the rate may be slowed by vagal maneuvers. cardioversion is contraindicated.”

      Kind regards,
      Jeff

      • Nickicia Campbell says

        Hi Jeff,
        Thanks so much for this site. I have learnt alot so far. Regarding the question, I have been taught the same info regarding sinus tachy as u mentioned, but also that Atrial Flutter with 2:1 block, can look like Sinus tachy with an exact rate of 150 bpm, on an ECG….Sometimes slowing the rate on the ECG machine can reveal this rhythm. And if unstable atrial flutter then treat accordingly, if not then look for other causes of instability? I would appreciate your response to this

      • Jeff with admin. says

        Your statement above would be appropriate for the situation as long as the atrial flutter was causing an unstable state in a patient.

        Adenosine maybe used to slow the ventricular rate in order to see any underlying atrial arrhythmias.

        Synchronized cardioversion would be recommended for unstable atrial flutter. However, a transesophageal echocardiogram should be performed prior to treating new onset atrial flutter when the time of onset is not known. This echocardiogram is for ruling out thrombus. There is a potential for thrombus development and thrombus must be ruled out prior to cardioversion.

        If a patient is stable and has new onset atrial flutter, consultation with a cardiologist would be recommended prior to any treatment.

        Kind regards,
        Jeff

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