Wide Complex Tachycardia

Nathan Cade, MD
Brandon Fainstad, MD
Andrew Prouse, MD


OBJECTIVES
1. Identify the basic electrophysiology of the four causes of wide complex tachycardia.
2. Develop a simple framework for acute management of wide complex tachycardia.
3. Practice three cases with ECGs to differentiate ventricular tachycardia from other causes and determine the correct initial management.


TEACHING INSTRUCTIONS


INTRODUCTION
Wide complex tachycardias are uniquely challenging due to the difficulty in interpreting the ECG and the need for immediate management.  Fortunately, there are only a handful of potential rhythms and a few options for management.   If you remember nothing else, remember this:

  1. Unstable -> SHOCK (synchronized cardioversion)
  2. Stable ->
    1. Place defibrillation pads
    2. If regular and monomorphic, attempt vagal maneuvers or adenosine
    3. If it is irregular and suspicious for atrial fibrillation with aberrancy, attempt rate control
    4. If it doesn’t work, consciously sedate and cardiovert.
    5. If conscious sedation is not a safe option, try procainamide.

CHALK TALK – 15 min
Board Set-up:

Stage 1 – Electrophysiology

Stage 2 – Management

Final Board


PRACTICE CASES – 10-15 min

Case 1
A 65-year-old man with a recent MI presents to the ED complaining of palpitations. He is cognitively intact without lightheadedness and has palpable pulses.

Courtesy of Andrew Prouse, MD

What is the rhythm?
How do you want to manage it?

Case 2
26-year-old male with chest pain and SOB and no history of structural heart disease. Hemodynamically stable.

Adapted with permission of Dr. Smith’s ECG blog, http://hqmeded-ecg.blogspot.com/

What is the rhythm?
How do you want to manage it?

Case 3
A 60-year-old woman presents to the ED with fever, cough, and shortness of breath found to have the following ECG. She is tachycardic but has a normal blood pressure and cognitively intact. There is no prior ECG available for comparison.

Adapted with permission from Dr. Smiths ECG Blog (http://hqmeded-ecg.blogspot.com)

What is the rhythm?
How do you want to manage it?


TAKE HOME POINTS


REFERENCES

Ortiz M et al. Randomized Comparison of Intravenous Procainamide vs. Intravenous Amiodarone for the Acute Treatment of Tolerated Wide QRS Tachycardia: the PROCAMIO Study. Eur Heart J 2016.

Smith, Stephen W. “An Irregularly Irregular Wide Complex Tachycardia.” Dr. Smith’s ECG Blog, Aug. 2017, hqmeded-ecg.blogspot.com/.

Lazoff, Marjorie, et al. “VT versus SVT with Aberrancy.” LITFL • Life in the Fast Lane Medical Blog, 3 Sept. 2018, lifeinthefastlane.com/.

Garner, John B, and John M Miller. “Wide Complex Tachycardia – Ventricular Tachycardia or Not Ventricular Tachycardia, That Remains the Question.” Arrhythmia & Electrophysiology Review, vol. 2, no. 1, 2013, p. 23., doi:10.15420/aer.2013.2.1.23.