Tachycardia with a Pulse

Table of Contents

Aliases

Supraventricular tachycardia (SVT), ventricular tachycardia (VT), multifocal atrial tachycardia (MAT), torsades, atrial fibrillation (A-FIB), atrial flutter

Patient Care Goals

  1. Maintain adequate oxygenation, ventilation, and perfusion
  2. Control ventricular rate
  3. Restore regular sinus rhythm in unstable patient
  4. Search for underlying cause:
    1. Medications (caffeine, diet pills, thyroid, decongestants)
    2. Drugs (cocaine, amphetamines)
    3. History of dysrhythmia
    4. CHF

Patient Presentation

Patients will manifest elevated heart rate for age and may or may not also present with associated symptoms such as palpitations, dyspnea, chest pain, syncope/near-syncope, hemodynamic compromise, altered mental status, or other signs of end organ malperfusion.

Inclusion Criteria

Heart rate greater than 100 bpm in adults or relative tachycardia in pediatric patients

Exclusion Criteria

Sinus tachycardia

Patient Management

Assessment, Treatments, and Interventions

  1. Generic Management
    1. Manage airway as necessary
    2. Administer oxygen as appropriate with a target of achieving 94-98% saturation.
    3. Initiate cardiac monitoring and perform 12-lead EKG
    4. Establish IV access
    5. IV Fluid bolus of 10 cc/kg , max of 500 cc, may repeat every 5 minutes, up to 30 cc/kg (peds) or 2 L if pulmonary edema not present
    6. Check blood glucose and treat hypoglycemia per the Hypoglycemia guideline

Adult Management

Consider the following additional therapies if tachycardia and symptoms or hemodynamic instability continue:

  1. Unstable Tachycardia – Any Rhythm
    1. Place Combo Pads on patient
    2. Deliver a synchronized shock at maximum monitor settings and repeat, as needed every minute
      1. If unable to do synchronized shock, switch to unsynchronized shock (defibrillation) at maximal monitor settings and repeat, as needed every minute.
    3. For responsive patients, choose one of the following:
      1. Etomidate 0.1 mg/kg IV/IO (Preferred)
      2. Fentanyl 2 mcg/kg IN/IM; max of 100 mcg
      3. Fentanyl 1 mcg/kg IV/IO; max of 100 mcg
  2. Regular Narrow Complex Tachycardia – Stable (SVT)
    1. Perform vagal maneuvers
    2. Adenosine 6 mg IV (proximal site) followed by 10 mL fluid bolus
      1. If tachycardia continues, give adenosine 12 mg IV
      2. A third dose of adenosine, 12 mg IV, can be given
      3. It is acceptable to mix adenosine and fluid bolus into same syringe to ensure rapid IV bolus each time
  3. Irregular Narrow Complex Tachycardia – Stable (atrial fibrillation, atrial flutter, multifocal atrial tachycardia)
    1. IV Fluid Bolus as above
  4. Regular Wide Complex Tachycardia – Stable (ventricular tachycardia, supraventricular tachycardia, atrial fibrillation/flutter with aberrancy, accelerated idioventricular rhythms, pre-excited tachycardias with accessory pathways,)
    1. Place Combo Pads on patient
    2. For known or strongly suspected hyperkalemia,
      1. Calcium chloride 1 gm slow IV push
      2. Albuterol 10 mg via small volume nebulizer
    3. Lidocaine 1 mg/kg IV
      1. May be repeated at 0.5 mg/kg at 5-minute intervals for a maximum dose of 3 mg/kg IV
  5. Irregular Wide Complex Tachycardia – Stable (atrial fibrillation with aberrancy, pre-excited atrial fibrillation (i.e. atrial fibrillation using an accessory pathway), MAT or polymorphic VT/torsades de pointes.
      1. Place defibrillation pads on patient.
      2. If torsades de pointes, give magnesium sulfate, 2 grams IVPB. Add to 100 cc NS bag and infuse over 15 minutes.

Pediatric Management

Consider the following additional therapies if tachycardia and symptoms or hemodynamic instability continue:

  1. Unstable Tachycardia – Any Rhythm
    1. Place Combo pads on patient.
    2. Deliver a synchronized shock:
      1. 1st shock – 0.5 J/kg
      2. 2nd shock – 1 J/kg
      3. 3rd shock and beyond – 2 J/kg
      4. If unable to do synchronized shock, switch to unsynchronized shock (defibrillation) at the above monitor settings and repeat, as needed every minute.
    3. For responsive patients, choose one of the following:
      1. Etomidate 0.1 mg/kg IV/IO (Preferred)
      2. Fentanyl 2 mcg/kg IN/IM; max of 100 mcg
      3. Fentanyl 1 mcg/kg IV/IO; max of 100 mcg
  2. Regular Narrow Complex Tachycardia – Stable (SVT)
    1. Perform vagal maneuvers
    2. Adenosine 0.1 mg/kg, max of 6 mg; if unsuccessful, may repeat twice with 0.2 mg/kg, max of 12 mg each time
      1. It is acceptable to mix adenosine and fluid bolus into same syringe to ensure rapid IV bolus
  3. Irregular Narrow Complex Tachycardia – Stable (Afib/Aflutter)
    1. IV Fluid boluses as above.
  4. Regular/Irregular, Wide Complex Tachycardia – Stable
    1. Place defibrillation pads on patient.
    2. Contact Pediatric Medical Control
    3. For known or strongly suspected hyperkalemia,
      1. Calcium chloride 20 mg/kg (0.2 mL/kg) slow IV push, max of 1 g.
      2. Albuterol 10 mg via small volume nebulizer
    4. For Torsades de Pointes, magnesium sulfate 25 mg/kg IVPB, max of 2 g. Add to 100 cc NS bag and infuse over 15 minutes.

Notes – Tachycardia with a Pulse