Objectives
- Identify the basic electrophysiology of the four causes of wide complex tachycardia.
- Develop a simple framework for acute management of wide complex tachycardia.
- Practice three cases with ECGs to differentiate ventricular tachycardia from other causes and determine the correct initial management.
Teaching Instructions
Plan to spend at least 30-60 minutes preparing for this talk. It is designed to be delivered on a chalkboard/whiteboard or using the website as a display. The chalk talk takes roughly 15 minutes and the cases are another 15 minutes.
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:
- Unstable -> SHOCK (synchronized cardioversion)
- Stable ->
- Place defibrillation pads
- If regular and monomorphic, attempt vagal maneuvers or adenosine
- If it is irregular and suspicious for atrial fibrillation with aberrancy, attempt rate control
- If it doesn’t work, consciously sedate and cardiovert.
- If conscious sedation is not a safe option, try procainamide.
Using a chalkboard – Print out the WCT Teacher Guide for your reference. Draw the “Board Set-up” along with abridged learning objectives before starting the presentation. Also print out the WCT Learners Handout with Cases on double-sided sheets for each of the learners, or at least enough for them to share. Ask them not to look at the back. The front of each page is a case stem and ECG. Go through the cases one at a time. Case 1 teaches an approach to identify ventricular tachycardia, which is useful in subsequent cases. The back of each page has the answers and diagnostic framework or post-intervention ECG. The last image is the final chalkboard for their reference.
Printouts
Interactive Boards
While we work on the interactive boards you can use the “Teacher Guide” under “Printouts” to prepare your talk.
For Learning
Use for self-directed learning and for preparing to present
Coming soon…
For Teaching
Use for Presenting – there is less text and fewer pop-ups
For Self-Directed Learning and Preparing to Present
For Presenting (Less Text and Fewer Pop-ups)
Practice Cases
Take Home Points
- Place defibrillation pads once you identify a wide complex tachycardia.
- Adenosine will reveal the underlying rhythm in SVT with aberrancy, resolve AVRT or AVnRT and not impact VT.
- Extreme right axis deviation (positive in aVR) is a quick and reliable way to diagnosis VT.
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.
