Notes – Tachycardia with a Pulse

Tachycardia with a Pulse

Notes/Educational Pearls

Key Considerations

  1. Causes:
    1. Hypovolemia
    2. Hypoxia
    3. Hydrogen (acidosis)
    4. Myocardial infarction
    5. Hypokalemia/hyperkalemia
    6. Hypoglycemia
    7. Hypothermia
    8. Toxins/Overdose
    9. Tamponade
    10. Tension pneumothorax
    11. Thrombus – central or peripheral
    12. Trauma
    13. Hyperthyroidism
  2. Atrial fibrillation rarely requires cardioversion in the field. As it is difficult to ascertain onset of rhythm, risk of stroke needs to be considered prior to cardioversion
  3. A wide-complex irregular rhythm should be considered pre-excited atrial fibrillation; extreme care must be taken in these patients
    1. Characteristic EKG findings include a short PR interval and, in some cases, a delta wave
    2. Avoid AV nodal blocking agents such as adenosine, calcium channel blockers, digoxin, and possibly beta-blockers in patients with pre-excitation atrial fibrillation (e.g. Wolff-Parkinson-White Syndrome, Lown-Ganong-Levine Syndrome) because these drugs may cause a paradoxical increase in the ventricular response
    3. Blocking the AV node in some of these patients may lead to impulses that are transmitted exclusively down the accessory pathway, which can result in ventricular fibrillation
  4. Biphasic waveforms have been proven to convert atrial fibrillation at lower energies and higher rates of success than monophasic waveforms
    1. Strategies include dose escalation (70, 120, 150, 170 J for biphasic or 100, 200, 300, 360 J for monophasic) versus beginning with single high energy/highest success rate for single shock delivered
  5. Studies in infants and children have demonstrated the effectiveness of adenosine for the treatment of hemodynamically stable or unstable SVT
  6. Adenosine should be considered the preferred medication for stable SVT
    1. Verapamil may be considered as alternative therapy in older children but should not be routinely used in infants
    2. Procainamide or amiodarone given by a slow IV infusion with careful hemodynamic monitoring may be considered for refractory SVT

Pertinent Assessment Findings

No recommendations

Patient Safety Considerations

  1. Only use one antidysrhythmic at a time
  2. If using cardioversion, consider sedation and pain control
  3. With irregular wide complex tachycardia (atrial fibrillation with aberrancy such as Wolff-Parkinson-White and Lown-Ganong Levine), avoid use of AV nodal blocking agents (e.g. adenosine, calcium channel blockers, beta blockers)

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914199 – Medical-Tachycardia
  • 9914151 – Medical-Ventricular Tachycardia (With Pulse)
  • 9914147 – Medical-Supraventricular Tachycardia (Including Atrial Fibrillation)

Key Documentation Elements

  • Initial rhythm and all rhythm changes
  • Time, dose and response to medications given
  • Cardioversion times, synchronization, attempts, joules and response
  • Obtain monitor strips after each intervention
  • Patient weight
  • Pediatric length-based tape color (for pediatrics who fit on tape)
  • History of event supporting treatment of underlying causes

Performance Measures

  • Time to clinical improvement from patient contact
  • Blood sugar obtained
  • Correct medication(s) and dose given for patient condition, age and weight
  • Correct cardioversion joules delivered given patient weight and/or condition
  • Use of sedation for responsive patient
  • EMS Compass® Measures (for additional information, see http://www.emscompass.org)
    • PEDS-03: Documentation of estimated weight in kilograms. Frequency that weight or length-based estimate are documented in kilograms
    • Hypoglycemia-01: Treatment administered for hypoglycemia. Measure of patients who received treatment to correct their hypoglycemia

References

  1. DeSouza IS, Martindale JL, Sinert R. Antidysrhythmic drug therapy for the termination of stable, monomorphic ventricular tachycardia: a systematic review. Emerg Med J. 2015;32(2):161-7.
  2. Fengler BT, Brady WJ, Plautz CU. Atrial fibrillation in the Wolff-Parkinson-White Syndrome: EKG recognition and treatment in the ED. Am J Emerg Med. 2007;25(5):576-83.
  3. Fuster V, Rydén LE, Cannom DS, et al. [ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation – executive summary]. Rev Port Cardiol. Apr;26(4):383-446.
  4. Link MS, Berkow LC, Kudenchuk HR, et al. Part 7: adult advanced cardiovascular life support. Circulation. 2015;132(18 Suppl 2):S444-64.
  5. Long B, Koyfman A. Best clinical practice: emergency medicine management of stable monomorphic ventricular tachycardia. J Emerg Med. Epub 2016 Oct 15.
  6. McNamara RL, Tamariz LJ, Segal JB, Bass EB. Management of atrial fibrillation: review of the evidence for the role of pharmacologic therapy, electrical cardioversion, and echocardiography. Ann Intern Med. 2003;139(12):1018-33.
  7. Ortiz M, Martin A, Arribas F, et al. Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. Eur Hear J. 2017;38(17):1329-35.
  8. Somberg JC, Bailin SJ, Haffajee CI, et al. Intravenous lidocaine versus intravenous amiodarone (in a new aqueous formulation) for incessant ventricular tachycardia. Am J Cardiol. 2002;90(8):853-9.
  9. Wann LS, Curtis AB, January CT, et al. 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (updating the 2006 guideline): a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. Circulation. 2011;123:104-23.
  10. Zimetbaum P, Reynolds MR, Ho KK, et al. Impact of a practice guideline for patients with atrial fibrillation on medical resource utilization and costs. Am J Cardiol, 2003;92(6):677-81.