The value of the electrocardiogram in the differential diagnosis of a tachycardia with a widened qrs complex. Describe pitfalls in the diagnosis and treatment of wpwrelated tachydysrhythmias. Human subjects and data safety monitoring plan for details. Tissue and animal models of sudden cardiac death europe pmc. Narrow complex tachycardia, regular, 150min, two p waves to every qrs complex at 300min. This is because a wct caused by svt with aberrancy and right ventricular outflow tract ventricular tachycardia are responsive to adenosine. Atrioventricular reentrant tachycardia avrt refers to a form of paroxysmal svt caused by an anatomically defined reentrant circuit involving one or more accessory pathways. Pvc beats and pvc features such as location, qrs duration and coupling interval or prematurity. Brugada p, brugada j, mont l, smeets j, andries ew. Differential diagnosis of wide complex tachycardias ems 12 lead. Mar 30, 2002 age is a useful factor in determining the origin of a broad complex tachycardia. Patient presenting with a tachyarrhythmia is a common finding in the emergency room. A nonsustained tachycardia is a rhythm disturbance lasting for 3 or more qrs complexes at a rate exceeding 100 and lasting less than 30 seconds.
Heart rates above the resting rate may be normal such as with exercise or abnormal such as. Narrow complex tachycardia schoolcraft memorial hospital. Jun 17, 2016 broad complex tachycardias are potentially lifethreatening. To divide up this myriad of possibilities, a bit of basic electrophysiology terminology needs to be applied. The baseline sinus 1st beat has a normal qrs morphology and normal intracardiac conduction intervals. Acls tachycardia algorithm for managing stable tachycardia. Supraventricular tachycardia svt is an abnormally fast heart rhythm arising from improper electrical activity in the upper part of the heart. June 5, 2009 page 1 of 3 wide complex tachycardia presumed ventricular tachycardia a guideline for patients with wide complex tachycardia of cardiac origin with qrs 0. Broad complex tachycardia in a patient with a dualchamber. Broad complex tachycardiapart ii pubmed central pmc. Symptoms may include palpitations, feeling faint, sweating, shortness of breath, or chest pain.
We present a case of a 54yearoldfemale who recently underwent placement of an implantable cardioverter. A 67yearold patient noted some lightheadedness on the morning of admission and was not able to feel his pulse. This is a very broad and inclusive definition of regular wide complex tachycardia. Arriving at the correct diagnosis in cases of wide complex tachycardia remains problematic for many clinicians. Wide qrs complex tachycardia wct is a rhythm with a rate of more than 100 beatsmin and a qrs duration of more than 120 milliseconds. Panel a shows the response to atrial overdrive pacing. Sudden narrowing of a qrs complex during vt may also be the result of a premature ventricular depolarisation arising in the ventricle in which the tachycardia originates, or it may occur when retrograde conduction during vt produces a ventricular echo beat leading to fusion with the vt qrs complex.
Presentation a ventricular origin for a broad complex tachycardia is suggested if the patient is aged over 35 years and has a history of ischaemic heart disease or. Unstable means that either important organ functions are affected or cardiac arrest is about to occur. Review article approach to the evaluation and management. Svt with bbb or aberrancy includes sinus tachycardia and atrial flutter ventricular. Mediastinal lymphoma presenting in cardiogenic shock with. Typical sinus tachycardia is in the range of 100 to 200 patient s age beats per minute. Catecholaminergic polymorphic ventricular tachycardia patient. It may occur in av junctional tachycardia with bbb after cardiac surgery or during digitalis intoxication. K verma, raj kishore, 3500 n broad st mebr983, philadelphia, pa. Methylene blue counteracts h2sinduced cardiac ion channel. From the division of cardiology, department of internal medicine, university of michigan health system, ann arbor,fmichigan case presentation an 80yearold man underwent an electrophysiologic procedure because of recurrent ep. Approach to wide qrs complex tachycardias clinical gate. List the shortcomings associated with the use of amiodarone in managing patients with wide complex tachycardias. An external file that holds a picture, illustration, etc.
Synchronized cardioversion is the preferred treatment for unstable wct. Dec 28, 2008 however, sometimes you can accurately identify wide complex tachycardia as svt in the field and im using the broadest possible definition of wide complex tachycardia. The differentiation of wide qrs complex tachycardias presents a challenging diagnostic dilemma to many physicians despite multiple published algorithms and approaches. Atrial fibrillation and flutter with rapid vr with possible tachycardia.
If its the same then its a monomorphic widecomplex tachycardia. Ward, md, frcp from the department of electrophysiology, the heart hospital, university college london hospitals and institute of. Pdf definition, diagnosis and management of tachycardia. Consultation with online medical control should be considered for complex patients in whom the cause of the arrhythmia is not obvious. Simple and noninvasive diagnostics of a broad complex. It is a blanket term that includes a lot of different rhythms and is simply a starting point on the road to diagnosis. Mental status, skin, neck, lung, heart, abdomen, back, extremities, neuro most important goal is to differentiate the type of tachycardia and if stable or unstable. Started in 1995, this collection now contains 6769 interlinked topic pages divided into a tree of 31 specialty books and 732 chapters. San mateo county emergency medical services wide complex tachycardia pearls most important goal is to differentiate the type of tachycardia and if stable or unstable.
Wolffparkinsonwhite wpw syndrome, a preexcitation syndrome which can often lead to avrt, is characterised by a short pr interval and delta waves on ecg. It is difficult to assess for the presence of p waves because of the rate and the baseline artifact. Call for als intercept as soon as possible if the patient becomes pulseless at any time, refer to the appropriate smo vfib or pulseless vtach, asystole, pea. The differential diagnosis for regular wide complex tachycardia includes. A history that includes ischaemic heart disease or congestive cardiac failure is 90% predictive of ventricular tachycardia.
Though, these arrhythmias are potentially fatal, they need to recognized first and treated appropriately. Mar 23, 2002 broad complex tachycardias occur by various mechanisms and may be ventricular or supraventricular in origin. Pdf approach to wide complex tachycardias in patients. Wide complex tachycardia wct refers to a cardiac rhythm of more than 100 beats per minute with a qrs duration of 120 ms or more on the surface electrocardiogram ecg. Several arrhythmias can manifest as wcts table 211. Clinical treatment of sepsis is complex with a high mortality of 2050 % requiring. Does this widecomplex rhythm look the same throughout the run of the rhythm.
Pediatric narrow complex tachycardia electrical and medication treatments in this protocol are not intended to treat tachycardia that is secondary to underlying conditions i. Adenosine can be used initially for stable regular wide complex tachycardia. Abc of clinical electrocardiography broad complex tachycardia. The presenting ecg of this patient shows wide complex tachycardia at a rate of 214 bpm. Approach to the evaluation and management of wide complex. With newer pacemakers, this condition is less common.
Clinical research arrhythmiaelectrophysiology application of a new algorithm in the differential diagnosis of wide qrs complex tachycardia andra. Pacemakermediated tachycardia pmt versus an atrial tachycardia with ventricular tracking was considered in the initial differential diagnosis. Evidence for the presence of an ap can be manifest of the surface electrocardiogram ecg. Although there is no clear av dissociation, the presence of negative concordance in precordial leads, qrs duration longer than 160 milliseconds, and onset to nadir of s wave in lead v 1 longer than 100 milliseconds, all point toward ventricular tachycardia vt. For example, two abnormalities that go handinhand with heart failure are atrial fibrillation and bundle branch block. Miller5 1third department of medicine, semmelweis university, school of medicine, budapest, ku. His blood pressure is 596 mm hg, and his pulse oximetry is 94%. P wave are buried in the qrs complex so cannot be seen on a surface ecg.
Wide complex is defined as a qrs complex equal to or greater than 120 msec. Oct 05, 2012 wide complex tachycardiadiagnostic approachalgorithms sen. Regular narrow complex tachycardia, 140min, short rp, retrograde p wave. However, an arrhythmia arising from the atria or the atrioventricular junction will produce a broad complex if associated with ventricular preexcitation or bundle branch block. Wide complex tachycardia in a patient with a history of. In this video, you will learn the essential basics. Apr 24, 2018 wide complex tachycardia posted in cardiology on april 24, 2018 by editor several algorithms exist for the electrocardigraphic evaluation of regular, wide complex tachycardias with the objective of distinguishing ventricular tachycardia vt from a supraventricular tachycardia svt with aberrant conduction. The management of tachycardia depends on its type wide complex versus narrow complex, whether or not the person is stable or unstable, and whether the instability is due to the tachycardia.
A supraventricular tachycardia is a rapid heart rate that originates from above or within the av node. During wide complex tachycardia heart rate 100min, qrs 0. Adenosine should be pushed rapidly via proximal iv. The major clinical problem that arises when dealing with someone exhibiting a wide complex tachycardia is that it is not always immediately clear if the rhythm represents.
Application of a new algorithm in the differential. Wide complex tachycardia ventricular tachycardia or not. Using the acls tachycardia algorithm for managing stable tachycardia. As you watch his ecg print out, you think, im not sure thats ventricular tachycardia, but its possibly supraventricular tachycardia with aberrancy. Atrial or avnodal reentry tachycardia with preexcitation rare much more commonly in em, if qrs 200ms or rate is tachycardia algorithm for managing stable tachycardia. Beclin1 is a component of the pi3 kinase complex that initiates autophagy in cells. Adenosine may elicit hidden atrial activity, and it is particularly safe as the pacemaker should respond if prolonged av block or a brief period of asystole occurs. The precordial qrs complexes are consistent with a right bundle branch block morphology, with a positive, notched r waveqrs. In the emergency setting most broad complex tachycardias have a ventricular origin. Every clinician taking care of cardiac patients should be able to diagnose them. Ventricular tachycardia is classified as nonsustained often defined as lasting less than 30 seconds or sustained.
The key to managing a patient with any tachycardia is to assess if pulses are present, decide if the patient is stable or unstable, and then treat the patient based on the patients condition and rhythm. Broad street, merb951, philadelphia, pa 19140, usa. It often presents a diagnostic dilemma for the physician particularly in determining its site of origin, which can be ventricular or supraventricular. Ventricular tachycardia was less likely since the qrs complex morphology was identical to the paced morphology, and a pacing artifact was visible before every ventricular complex. Wide complex tachycardias are a commonly encountered entity in coronary care units, intensive care units and emergency departments. Misdiagnosis of chronic recurrent ventricular tachycardia. Recognition and management in the emergency room ib ray abstract cardiac arrhythmias often present as urgent medical conditions requiring immediate care. Identify difficulties in distinguishing amongst various types of wide complex tachycardias.
It can occur at any age, but there is an increased likelihood if the atria are diseased hypertension, pulmonary disease, previous cardiac surgery, etc. Pathophysiology of sepsisrelated cardiac dysfunction. Wolffparkinsonwhite syndrome the most important clinical feature when treating patients with bct is their haemodynamic status. Confirm wide complex tachycardia versus svt with abberancy do not use calcium channel blocker for wide complex unless absolutely certain of svt evaluate for secondary causes e. The cardiac ap is a complex process that involves many different ionic currents, all of which are highly regulated. A narrow qrs complex tachycardia university of michigan. Supraventricular tachycardia a report of the american college of cardiologyamerican heart association task force on clinical practice guidelines and the heart rhythm society writing committee members richard l. Electrocardiographic criteria for ventricular tachycardia in wide complex left bundle branch block morphology tachycardias. Narrow complex tachycardia regular, rate of 190 no p waves. Tachycardias are broadly categorized algorithm 1 based upon the width of the qrs complex on the electrocardiogram ecg.
Catecholaminergic polymorphic ventricular tachycardia. If the morphology changes, if the complex changes its look then wed call that a polymorphic widecomplex tachycardia, and the treatments a little different. Several algorithms have been developed to aid in this differentiation below. Ventricular tachycardia occurs in approximately 2 out of 10,000 people. Wide complex tachycardia treated with amiodarone and. Application of a new algorithm in the differential diagnosis. However, sometimes you can accurately identify wide complex tachycardia as svt in the field and im using the broadest possible definition of wide complex tachycardia. San mateo county emergency medical services wide complex. If at any point the patient becomes unstable, move to the unstable arm of the algorithm. Narrow complex tachycardia supraventricular tachycardia. Patrick lam, samir saba, approach to the evaluation and management of 121 wide complex tachycardias preexcited tachycardias are conducted antegradely over an accessory pathway ap. The differentiation of wide qrs complex tachycardias. You calmly ask for a stat ecg and pads to be placed on the patient.
Presentation a ventricular origin for a broad complex tachycardia is suggested if the patient is aged over 35 years and has a history of ischaemic heart disease or congestive cardiac failure. The differential diagnosis of wct includes ventricular tachycardia and supraventricular tachycardia with aberrant conduction, or interventricular. Adenosine should be pushed rapidly via proximal iv site followed by 20 ml normal saline rapid flush. Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. A new approach to the differential diagnosis of a regular tachycardia with a wide qrs complex. Over the next two months, she continued to have a complicated course consisting of postpartum cardiomyopathy, large right middle.
The patient will have a pulse and may present with hypotension sp signs apply cardiac monitor obtain 12 lead ecg. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. May 08, 2019 atrial tachycardia is usually a narrow complex tachyarrhythmia accounting for 515% of supraventricular tachycardias svts. The qrs complex in ventricular tachycardia often has a right or left bundle branch morphology. After cessation of pacing, the last entrained ventricular v is demonstrated by the arrows, and is one beat removed, i.
Clinical practice guideline 2015 accahahrs guideline for. Broad complex tachycardias are potentially lifethreatening. This 12lead electrocardiogram tracing, recorded at 4. Tachycardias are broadly categorized based upon the width of the qrs complex on the electrocardiogram ecg. Adult wide complex tachycardia regular rhythm designation o f condition. Tachycardia is defined as a sustained rhythm in an adult with a rate equal to or exceeding 100 beats per minute. On first look, you will see a wide complex tachycardia wtc with a rate around 240 per minute. If at any point patient becomes unstable move to unstable arm in algorithm. Wide complex tachycardia wide complex tachycardia is a cardiac rhythm with more than 100 ventricular beats per minute and a qrs complex of 120 ms or greater. Broad complex tachycardias occur by various mechanisms and may be ventricular or supraventricular in origin. On first look, you will see a widecomplex tachycardia wtc with a rate around 240 per minute.