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:

 

• Oxygen

• 12-Lead EKG

• Initiate IV of Normal Saline (INT is not acceptable)

• Attempt valsalva maneuver

 

Stable Tachycardia (QRS < 0.12) ?

 

• No

 

See V-Tach Protocol

 

• Yes

 

Regular ?

 

• Yes

 

• • Adenosine (Adenocard) 12 mg rapid IV; may repeat once in 5 min.

 

Improving ?

 

• Yes

 

• • Notify receiving facility or contact Medical Control

 

• No

 

• • Diltiazem (Cardizem) 20 mg IV if SBP > 90

 

• • After 15 min of uncontrolled A-fib or SVT administer Diltiazem (Cardizem) 25 mg IV; be prepared to provide fluids if BP drops

 

• • 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 ?

 

• Yes

 

• • Diltiazem (Cardizem) 20 mg IV if SBP > 90

 

• • After 15 min of uncontrolled A-fib or SVT administer Diltiazem (Cardizem) 25 mg IV; be prepared to provide fluids if BP drops

 

• • 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) ?

 

• Yes

 

• • Consider conscious sedation

 

• Synchronized Cardioversion

 

• • Cardiovert (synchronized) 100 joules
  • Cardiovert (synchronized) 200 joules
  • Cardiovert (synchronized) 300 joules
  • Cardiovert (synchronized) 360 joules

 

• • Consider Diltiazem (Cardizem) 20 mg IV over 2 min if SBP > 90

 

• • 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.