Tachycardia (Peri-Arrest)
Resuscitation Council UK Adult Advanced Life Support Guidelines. Published: May 2021.
Background Information
This article covers the algorithm for peri-arrest tachycardia, meaning in the presence of a pulse.
If there is no pulse, that is cardiac arrest, the Advanced life support algorithm should be used.
If there is no pulse, that is cardiac arrest, the Advanced life support algorithm should be used.
Any tachycardia could be approached with the following method. This is not an exhaustive list, instead the author included the important ones.
| QRS duration | Rhythm | Common causes |
|---|---|---|
| Narrow QRS (<120 ms) | Regular |
|
| Irregular |
|
|
| Broad QRS (>120 ms) | Regular |
|
| Irregular |
|
Guidelines
The first step is to check ANY of the life-threatening features or not:
Note this is the same as adult peri-arrest bradycardia algorithm.
- Shock – hypotension (SBP < 90 mmHg) and/or features
- Syncope – due to ↓ cerebral blood flow
- Myocardial ischaemia – chest pain and/or 12-ECG findings
- Heart failure – pulmonary oedema (LV failure) and/or raised JVP (RV failure)
Note this is the same as adult peri-arrest bradycardia algorithm.
Regardless of the arrhythmia → immediate up to 3 attempts (under sedation or anaesthesia)
If DC shock is unsuccessful and patient remains unstable:
If DC shock is unsuccessful and patient remains unstable:
- Amiodarone 300mg IV over 10-20 min (alternative: procainamide)
- Re-attempt synchronised DC shock
Management depends on the likely rhythm. Approach systemically according to QRS duration and rhythm regularity.
In the context of regular narrow complex tachycardia: Supraventricular tachycardia or atrial flutter is most likely
- 1st line:
- If ineffective → adenosine IV bolus (6mg →12mg → 18mg)
- If ineffective → beta blocker or verapamil
- If ineffective → synchronised DC shock up to 3 attempts
In the context of irregular narrow complex tachycardia: atrial fibrillation is most likely
For detailed management of atrial fibrillation, see this article.
- 1st line: rate control with beta blocker
- If evidence of heart failure → consider amiodarone or digoxin
For detailed management of atrial fibrillation, see this article.
Regular broad complex tachycardia is ventricular tachycardia until proven otherwise
Unless there is previous certain diagnosis of Supraventricular tachycardia with aberrancy → treat as regular narrow complex tachycardia
- 1st line: amiodarone 300mg IV over 10-60 min
- If ineffective → synchronised DC shock up to 3 attempts
Unless there is previous certain diagnosis of Supraventricular tachycardia with aberrancy → treat as regular narrow complex tachycardia
In the context of irregular broad complex tachycardia: polymorphic ventricular tachycardia or atrial fibrillation with aberrancy is most likely
- Polymorphic ventricular tachycardia (e.g. torsades de pointes) → magnesium IV 2g over 10 min
- If atrial fibrillation with aberrancy → treat as irregular narrow complex tachycardia
