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Tachycardia (Adult) (Peri-arrest)

Adult Advanced Life Support Guidelines (2021)

Background Information

This article covers the algorithm for peri-arrest tachycardia, meaning in the presence of a pulse.

If there is no pulse, that is cardiac arrest, the ALSAdvanced life support algorithm should be used.

Any tachycardia could be approached with the following method. This is not an exhaustive list, instead we included the important ones.

Flow chart to be added
 

Simplified flowchart

Adult tachycardia algorithm

The first step is to determine whether the patient has ANY of the life-threatening features or not:
  • Shock – hypotension (SBP < 90 mmHg) and/or features of sympathetic compensation
  • Syncope – due to ↓ cerebral blood flow
  • Myocardial ischaemia – chest pain and/or 12-ECG findings
  • Heart failure – pulmonary oedema (LV failure) and/or raised JVP (RV failure)

Note this is the same as adult tachycardia algorithm.

Regardless of the arrhythmia → synchronised DC shock up to 3 attempts (under sedation or anaesthesia)

If unsuccessful and remains unstable:
  • Amiodarone 300mg IV over 10-20 min (alternative: procainamide)
  • Re-attempt synchronised DC shock

First attempt pharmacological treatment. Management depends on the likely rhythm. Approach systemically according to QRS width and rhythm regularity.

pSVT and atrial flutter likely.
  • 1st line: vagal manoeuvres 
  • If ineffective → adenosine IV bolus (6mg →12mg → 18mg)
  • If ineffective → beta blocker or verapamil
  • If effective → synchronised DC shock up to 3 attempts
 

Atrial fibrillation likely →
  • 1st line: rate control with beta blocker
  • If evidence of heart failure → consider amiodarone or digoxin
For detailed management of atrial fibrillation, see separate article.

Ventricular tachycardia until proven otherwise.
  • 1st line: amiodarone 300mg IV over 10-60 min
  • If ineffective → synchronised DC shock up to 3 attempts
If previous certain diagnosis of SVT with aberrancy → treat as regular narrow complex tachycardia

Polymorphic VT or atrial fibrillation with aberrancy
  • Polymorphic VT → magnesium IV 2g over 10 min
  • If atrial fibrillation with aberrancy → treat as irregular narrow complex tachycardia

References

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