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Acute Management of Stable Narrow Complex Tachycardia Mini Lecture 2013.

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Presentation on theme: "Acute Management of Stable Narrow Complex Tachycardia Mini Lecture 2013."— Presentation transcript:

1 Acute Management of Stable Narrow Complex Tachycardia Mini Lecture 2013

2 Objectives Review the initial approach to diagnose and treat narrow complex tachycardia Review examples of AVNRT, AVRT, Atrial Tachycardia This is not a comprehensive review of all the narrow complex tachycardias You are not expected to manage these patients on your own, always ask for back up

3 Case Nurse calls to inform you that bed 10s heart rate just went up to 200s on telemetry. Which of the following information should you obtain asap? A. Blood pressure B. Mental status C. EKG D. Focused Physical Exam E. All of the above

4 Case Nurse calls to inform you that bed 10s heart rate just went up to 200s on telemetry. Which of the following information should you obtain asap? A. Blood pressure B. Mental status C. EKG D. Focused Physical Exam E. All of the above

5 Narrow Complex Tachycardia Rate >100 (often ) QRS <120 msec –Regular Sinus tachycardia (usually <150) AVNRT AVRT Atrial Tachycardia Atrial Flutter with regular block (150, 100, 75) –Irregular Atrial Fibrillation MAT

6 Initial Assessment for Tachycardia Questions Symptomatic? Hypotensive? 12 lead EKG IV access Stable or Unstable? Altered Mental Status Hypotension Chest Pain Acute SOB Hypoxia

7 Unstable? Crash Cart ACLS Call for backup –Senior resident –Cardiology fellow –Nocturnist –Code blue

8 Stable? Initial Assessment Focused H&P –Talk to the patient to assess mental status –Reason for admission (sepsis, ACS) –Cardiac Hx (CAD, HF, Afib, SVT) –Recent electrolytes –Medications (AV nodal agents, digoxin) –Listen to heart and lungs –Volume status –JVD

9 EKG shows..

10 Too fast to interpret rhythm? Vagal Maneuvers and Adenosine – Slow down the rhythm – Terminate certain SVTs which conduct through the AV node – If possible obtain 12 lead EKG recording during intervention

11 Vagal maneuvers –Bearing down –Face in ice cold water –Carotid Massage –Blowing into a folded straw –Cough Adenosine –May avoid if bronchospasm/asthma/COPD? –Caution if history of pre-exitation/ WPW?* –Warn them about the symptoms 6mg IV push followed by NS flush followed by 12mg IV push followed by NS flush

12 AVNRT Cause Dual AV nodal pathways with differing refractory periods Often initiated by a PAC 60% SVT DX Rate Inverted p or psuedo S Tx Vagal Adenosine BB: Metoprolol 5mg q5min x3 CCB: Diltiazem 10mg IV, repeat 10-30mg IV in 5-10 min

13 AVNRT PSUEDO S WAVES

14 AVRT Cause Re-entrant tachycardic circuit with conduction down AV node and back up a bypass tract (i.e. WPW) 30% SVT Dx: Rate Retrograde P inferior leads Tx: Vagal Adenosine BB: Metoprolol 5mg min q5 x 3 CCB: Diltiazem 10mg IV, repeat 10-30mg IV in 5-10 min

15 AVRT

16 Atrial Tachycardia Cause Enhanced Automaticity of atrial tissue or ectopic atrial pacemaker 10% SVT Dx P wave precedes each QRS Unusual p wave axis Adenosine may show continued atrial beats, without AV conduction Tx: BB: metoprolol 5mg q5 x 3 CCB: Diltiazem 10mg IV, repeat 10-30mg IV in 5-10 min

17 ADENOSINE Atrial Tachycardia Unusual p wave axisContinued atrial automaticity

18 General Principles Note the common theme: Vagal Maneuvers, Adenosine, Beta Blockers, Calcium Channel Blockers, caution in WPW Check vitals (BP) frequently during acute setting to make sure a stable situation does not become unstable Again, this is meant to be a review of the initial management of SVT you are not expected to independently manage these patients- Call for backup!

19 Case Follow Up Nurse calls: Bed 10s heart rate just went up to 200s You reply: –What is his blood pressure? –Is his arousable and oriented? –Please get a 12 lead EKG now –Does he have IV access? –Ill be right there..

20 References UpToDate Med Res UCLA FP Notebook Images sited previously


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