1. Case 9
Stable Tachycardias
© 2001 American Heart Association 1

2. Stable Tachycardias Overview Step 1: Assess patient
Step 2: Identify and evaluate arrhythmia
Step 3: Treat arrhythmia
The clinical approach to tachycardias involves these 3 steps (see slide).
The learning objectives in this case are
To learn to evaluate and treat patients with stable tachycardias
To learn to assess patients for serious signs and symptoms
To recognize the arrhythmia
To know the appropriate treatment sequence

3. Stable Tachycardia Initial therapy Administer oxygen Start IV
Attach monitor
Obtain 12-lead ECG
Obtain portable chest x-ray in hospital setting
Emphasize the importance of synchronization.
Emphasize the need to resynchronize after each delivered shock if an additional cardioversion attempt is necessary.
Reemphasize the initial step of assessing the patient’s stability.
Reemphasize that the initial management of stable tachycardia is always the same:
Administer oxygen
Start IV
Attach monitor
Order 12-lead ECG
Order portable chest x-ray

4. Step 1 Is patient stable or unstable?
Patient has serious signs or symptoms? Look for
Chest pain (ischemic? possible ACS?)
Shortness of breath (lungs getting ‘wet’? possible CHF?)
Low blood pressure (orthostatic? dizzy? lightheaded?)
Decreased level of consciousness (poor cerebral perfusion?)
Clinical shock (cool and clammy? peripheral vasoconstriction?
Are the signs and symptoms due to the rapid heart rate?
An initial assessment should be done quickly to determine whether the condition is stable.
In the absence of serious signs or symptoms, vagal maneuvers and drug therapy should be tried first.
Patients with serious signs or symptoms related to the tachycardia should be managed according to the algorithm for unstable tachycardia (see Case 8).

5. Step 2
Identify arrhythmia; classify patient into 1 of 4 tachycardia categories:
1. Atrial fibrillation/flutter
2. Narrow-complex tachycardia
3. Stable wide-complex tachycardia, unknown type
4. Stable monomorphic VT and/or stable polymorphic VT
Make sure that everyone in the small groups has in hand the 2000 ECC Handbook or an equivalent source of the 3 tachycardia algorithms and the table on atrial fibrillation/flutter.

6. 1. Atrial Fibrillation/Flutter
Notice this technique of asking a clinical question on one slide and then providing the answer on the next one. 
The questions at the end of most of the slides are not rhetorical: pause long enough before advancing to let the students know you expect an answer from them––not from the next slide.
Your evaluation of atrial fibrillation/flutter should focus on 4 clinical features.
What are they?

7. Atrial Fibrillation: Evaluation Focus
4 Clinical Features
1. Is patient clinically unstable?
2. Is cardiac function impaired?
3. Is WPW present?
4. Is duration of AF <48 or >48 hours?
Direct the attention of the group to Figure 7: The Tachycardias: Overview Algorithm (page 15). Point out the box in the algorithm where these 4 clinical features are listed.

8. Atrial Fibrillation: Treatment Focus
4 Treatment Considerations
1. Treat unstable patients urgently
2. Control rate
3. Convert rhythm
4. Provide anticoagulation if indicated
Direct the attention of the group to Figure 7: The Tachycardias: Overview Algorithm (page 15).
Point out the box in the algorithm where these 4 clinical features are listed. 
Also direct their attention to the Atrial Fibrillation/Flutter table on pages 16 and 17 in the 2000 ECC Handbook.

9. Atrial Flutter Point out the following: Rate Regularity
P waves: present or absent?
“Flutter waves”
Sawy tooth pattern 
Emphasize the differences between PSVT and atrial flutter.

10. 2. Narrow-Complex Tachycardias
Attempt to establish a specific diagnosis:
Obtain 12-lead ECG
Gather clinical information
Perform vagal maneuvers
Give adenosine as a therapeutic agent, but it also serves as a diagnostic test
Make sure everyone is following this section along in the handbook, with Figure 8: Narrow-complex tachycardia (page 18).
Emphasize the following points: (1) Avoid carotid massage in older patients. (2) Never perform bilateral carotid massage. (3) Listen for bruits before carotid massage (massage is contraindicated if bruits are present). (4) Avoid ice-water immersion of patients with ischemic heart disease.
Show technique on a manikin or volunteer (do not perform massage on a volunteer!):
Turn the head to the left.
Apply firm, momentary pressure over the right carotid bifurcation near the angle of jaw.
If unsuccessful repeat with a 5- to 10-second rotary “massage motion.”
If unsuccessful turn the head to the right side and perform left carotid massage.
Emphasize these characteristics of adenosine: depresses AV and sinus nodes; terminates AV nodal reentrant tachycardia; clarifies diagnosis of atrial fibrillation, atrial flutter, and atrial and ventricular tachycardias by producing transient AV or VA block; may be used with wide-complex tachycardia of uncertain type when lidocaine has failed; short half-life (5 seconds); PSVT may recur; few hemodynamic effects.
Emphasize the following points about adenosine administration:
Give each bolus over 1 to 3 seconds.
Follow each bolus with a saline flush.
The 12-mg bolus may be repeated once after 1 to 2 minutes if necessary.

11. 2. Narrow-Complex Tachycardias (cont’d)
Diagnostic efforts yield
Ectopic atrial tachycardia
Multifocal atrial tachycardia
Paroxsymal supraventricular tachycardia (PSVT)
Make sure everyone is following this section along in the handbook, with Figure 8: Narrow-complex tachycardia (page 18).

12. 2. Narrow-Complex Tachycardias (cont’d)
Treatment considerations
Attempt therapeutic diagnostic maneuver:
Vagal stimulation
Adenosine
Patient: impaired heart vs normal cardiac function?
Junctional tachycardia:
Automatic focus tachycardias respond better to blocking agents
Make sure everyone is following this section along in the handbook, with Figure 8: Narrow-complex tachycardia (page 18).

13. 2. Narrow-Complex Tachycardias (cont’d)
Treatment considerations (cont’d)
PSVT:
Re-entry tachycardia responds better to cardioversion
Ectopic or multifocal atrial tachycardia:
Automatic focus tachycardias respond better to blocking agents
Make sure everyone is following this section along in the handbook, with one of the algorhythms.

14. Paroxysmal Supraventricular Tachycardia
Review the key characteristics of PSVT.

15. Sinus Tachycardia
Emphasize the differences between PSVT and sinus tachycardia.
It always makes for an interesting discussion with valuable teaching points to present a patient who is suffering from every possible sign of instability: SOB, low BP, poor mentation, chest pain, syncope on standing, rales heard in the chest. Tell the students that the above sinus tachycardia is the rhythm of the “unstable” patient. See how many people would elect to perform cardioversion for an “unstable tachycardia.” If you continue to increase the rate and continue to have the patient deteriorate, more and more students will raise their hand to indicate they would cardiovert.
Of course, cardioversion is wrong—your goal with cardioversion is to convert the patient to a sinus rhythm. Cardioversion cannot make sinus tachycardia any better than it already is.

16. 3. Stable Wide-Complex Tachycardia, Unknown Type
Attempt to establish a specific diagnosis:
12-lead ECG
Esophageal leads
Clinical information
Follow column 3. Stable wide-complex tachycardia: unknown type (Figure 7, page 15).

17. 3. Stable Wide-Complex Tachycardia, Unknown Type
Attempt to establish a specific diagnosis:
Confirmed as an SVT
Wide-complex tachycardia of unknown type
Confirmed as stable VT
Follow column 3. Stable wide-complex tachycardia: unknown type (Figure 7, page 15).

18. Wide-Complex Tachycardia
Ventricular or
Supraventricular with aberrant conduction?
Note the obvious distinguishing feature of the tracing (ie, wide QRS complexes) and ask the participants for a diagnosis. Mention the possibilities of either ventricular tachycardia or supraventricular tachycardia with aberrant conduction.

19. 4. Stable Monomorphic/ Polymorphic VT
Monomorphic VT: is cardiac function impaired?
Preserved: procainamide
Impaired: amiodarone OR lidocaine OR synchronized cardioversion
Polymorphic VT: QT interval (baseline) prolonged?
Normal: treat ischemia, correct electrolytes (amiodarone or lidocaine if heart impaired)
Prolonged: correct electrolytes
Magnesium, overdrive pacing, isoproterenol, dilantin, lidocaine
Turn to Figure 9: the Stable Ventricular Tachycardia: Monomorphic and Polymorphic Algorithm (page 19 in the 2000 ECC Handbook). Review the critical steps in management of stable tachycardia.

20. Ventricular Tachycardia
Pose the question in the header with a brief case: a 55 year-old-male with substernal chest pain, some nausea, mild SOB, improved with nitroglycerin x 3; nondiagnostic changes on 12-lead ECG.
The setting (ie, a patient with ischemic pain and an acute coronary syndrome) makes VT more likely than PSVT with aberrant conduction.
Briefly review the drug sequence for VT (Figure 9, page 19). Remind the students who were tempted to diagnose PSVT with aberrancy that adenosine is not part of the VT algorithm. Discuss the possibilities of harm that could occur if VT is treated with adenosine and a calcium channel blocker (eg, verapamil; see page 18, Narrow-Complex Tachycardia).
Continue the scenario, assuming correct identification of the arrhythmia as VT; include a deterioration in clinical status, and initiate a discussion of the appropriate next step in management.
Emphasize the need for immediate cardioversion (without further pharmacologic interventions) when the tachycardia becomes unstable.
Emphasize that the participant must
Proceed to synchronized cardioversion if vagal maneuvers and drug therapy fail or the patient becomes unstable
Synchronize before each attempt at cardioversion
Know the appropriate drug sequences and doses for each arrhythmia
Know the appropriate energy levels for cardioversion of each arrhythmia

21. Stable Tachycardia Initial therapy Administer oxygen Start IV
Attach monitor
Obtain 12-lead ECG
Obtain portable chest x-ray
Emphasize that these actions should be performed during the initial history and assessment of stability. (Figure 9, page 19).

22. Sinus Rhythm and PACs With Aberrant Conduction
12-lead ECG preceding the wide-complex tachycardia may demonstrate
the same aberrant conduction, indicating that the tachycardia is
supraventricular.
Emphasize the following points about pharmacologic therapy for wide-complex tachycardias of uncertain type:
Known VT should be treated as such.
Wide-complex tachycardia known to be PSVT, MAT or junctional should be treated as such (see algorithm for narrow-complex tachycardia, page 18).
Emphasize the following points about pharmacologic therapy for wide-complex tachycardias:
Wide-complex tachycardia of uncertain type should be treated with cardioversion, amiodarone, or procainamide, depending on the chronic heart condition.
If drug therapy is unsuccessful or the rhythm becomes unstable, cardioversion should be performed.
Briefly review the sequence of doses and the appropriate rapid method of administering adenosine. See Tachycardia Overview Algorithm (Figure 7, page 15). Initial management is lidocaine. Briefly review the sequence of doses and the appropriate rapid method of administering adenosine.

23. Wide-Complex Tachycardia Followed by Second-Degree AV Block
Use this rhythm as a summary and review of the important elements of caring for tachycardias. See how many students would shout out a treatment just after seeing only this rhythm. Several pieces of information are critical to managing this rhythm. Plan on a brief history to present along with this rhythm as the students begin to ask clinical questions. They should ask:
1. Is this patient stable or unstable? (Hint: make the rhythm unstable in that it keeps reverting to the wide-complex tachycardia. Each time the patient stays in the wide-complex tachycardia for longer periods and begins to clinically deteriorate.
2. Does this patient have a normal cardiac function or is the function impaired? Look at the algorithms and state what differences the heart condition would make in treatment.
3. What medications are already on board? (Either chronically or given within the last hour or so.)
4. Play out the scenario where this rhythm is occurring (going back and forth between wide-complex tachycardia and second-degree heart block.) See how many students will notice that between the tachycardia episodes the patient has type II second-degree heart block, which if symptomatic is an indication for other drugs as well as pacing. Direct them to the Bradycardia Algorithm (page 14) and state the drugs that could possibly be used there (atropine, epinephrine, isoproteronol). What would be the effect if one of those agents was started to treat the heart block and the patient returned to the tachycardia?
5. Should further therapy be guided by the Narrow-Complex Tachycardia Algorithm on page 18; the algorithm for wide-complex tachycardia of unknown type on page 15; or the Stable Ventricular Tachycardia Algorithm on page 19?