Narrow Complex Tachcardia (QRS < 0.12)
History:
-
Medications
- Aminophylline
- Diet pills
- Thyroid supplements
- Decongestants
- Digoxin
- Diet (caffeine/chocolate)
- Drugs (nicotine/cocaine)
- Past medical history
- History of palpitation/heart racing
- Syncope/near syncope
Significant findings:
- Heart rate >150
- Chest pain
- Systolic BP < 90
- CHF
- Dizziness
- SOB
- Diaphoresis
- AMS
- If QRS >0.12 or history of WPW, go to Sustained V-Tach Protocol
-
Potential presenting rhythm:
- Atrial/sinus tachycardia
- Atrial fibrillation/flutter
- Multifocal atrial tachycardia
Differential:
- Hypoxia
- Fever
- Sepsis
- Dehydration
- Sick sinus syndrome
- Myocardial infarction
- Electrolyte imbalance
- Exertion/pain/emotional stress
- Hypovolemia/anemia
- Drugs/medications (see History)
- Hyperthyroidism
- Pulmonary embolus
- Heart disease (WPW, valvular)
Treatment:
- Initiate IV of Normal Saline (INT is not acceptable)
- Attempt valsalva maneuver
Stable Tachycardia (QRS < 0.12) ?
See V-Tach Protocol
Regular ?
Improving ?
-
- Notify receiving facility or contact Medical Control
-
- if Diltiazem is unavailable consider Metoproplol 5 mg IV/IO slow push; may repeat a 2nd dose of 5 mg; max total dose 10 mg.
Stable Irregular Tachycardia ?
-
- if Diltiazem is unavailable consider Metoproplol 5 mg IV/IO slow push; may repeat a 2nd dose of 5 mg; max total dose 10 mg.
-
- Notify receiving facility or contact Medical Control
Unstable Tachycardia (QRS <0.12) ?
- Synchronized Cardioversion
-
- Cardiovert (synchronized) 100 joules
- Cardiovert (synchronized) 200 joules
- Cardiovert (synchronized) 300 joules
- Cardiovert (synchronized) 360 joules
-
- Notify receiving facility or contact Medical Control
PEARLS:
- Symptomatic tachycardia usually occurs at rates of 120-150 and are typically greater than or equal to 150 beats per minute. Symptomatic patients with heart rates less than 150 likely have impaired cardiac function such as CHF.
- Typical sinus tachycardia is in the range of 100 to (220 minus patient's age) beats per minute.
-
Serious signs/symptoms:
- hypotension,
- acutely altered mental status,
- signs of shock/poor perfusion,
- chest pain with evidence of STEMI or
- T- wave inversions or depressions,
- acute CHF.
- If the patient has a history of WPW or 12-Lead EKG reveals WPW, DO NOT administer a calcium channel blocker (e.g., Diltiazem (Cardizem)) or a beta blocker.
- Avoid carotid sinus massage in patients over 50 years old or with a history of prior neurological event.
- For A-fib/A-flutter, consider administering Diltiazem (Cardizem) prior to administration of Adenosine (Adenocard).
- For conscious sedation, see Sedation/Anxiety protocol. Dose should be titrated to provide comfort without causing respiratory failure. Be sure to monitor patient's breathing/ventilations, blood pressure and O2 saturation.
- Document all rhythm changes and therapeutic interventions with monitor strips.