Adult Tachycardia (With Pulse)

Step 1:
Assess appropriateness for clinical condition. Heart rate typically ≥ 150/min if tachyarrhythmia.

Step 2:
Identify and treat underlying cause
     •Maintain patent airway; assist breathing as necessary
     •Oxygen (if hypoxemic)
     •Cardiac monitor to identify rhythm; monitor blood pressure and oximetry

Step 3:
Persistent tachyarrhythmia causing:
     •Hypotension?
     •Acutely altered mental status?
     •Signs of shock?
     •Ischemic chest discomfort?
     •Acute heart failure?

Step 4:
Synchronized cardioversion
     •Consider sedation
     •If regular narrow complex, consider adenosine
Step 5:
Wide QRS? ≥ 0.12 second

Step 6:
     •IV access and 12-lead ECG if available
     •Consider adenosine only if regular and monomorphic
     •Consider antiarrhythmic infusion
     •Consider expert consultation

Step 7:
     •IV access and 12-lead ECG if available
     •Vagal maneuvers
     •Adenosine (if regular)
     •β-Blocker or calcium channel blocker
     •Consider expert consultation

Doses/Details
Synchronized Cardioversion
Initial recommended doses:
     •Narrow regular: 50-100 J
     •Narrow irregular: 120-200J biphasic or 200 J monophasic
     •Wide regular: 100J
     •Wide irregular: defibrillation dose (NOT synchronized)

Adenosine IV Dose:
First dose: 6 mg rapid IV push; follow with NS flush.
Second dose: 12 mg if required.
Antiarrhythmic Infusions for Stable Wide-QRS Tachycardia

Procainamide IV Dose:
20-50 mg/min until arrhythmia suppressed, hypotension ensues, QRS duration increases >50%, or maximum dose 17 mg/kg given. Maintenance infusion: 1-4 mg/min. Avoid if prolonged QT or CHF.

Amiodarone IV Dose:
First dose: 150 mg over 10 minutes. Repeat as needed if VT recurs. Follow by maintenance infusion of 1 mg/min for first 6 hours.

Sotalol IV Dose:
100mg (1.5 mg/kg) over 5 minutes. Avoid if prolonged QT.

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