Tachycardia and its ACLS Algorithm

Tachycardia/tachyarrhythmia is defined as a rhythm with a heart rate greater than

100 bpm.
An unstable tachycardia exists when cardiac output is reduced to the point of
causing serious signs and symptoms.
Serious signs and symptoms commonly seen with unstable tachycardia are: chest
pain, signs of shock, SOA, altered mental status, weakness, fatigue, and syncope
One important question you may want to ask is: Are the symptoms being caused by
the tachycardia? If the symptoms are being caused by the tachycardia treat the
tachycardia.
There are many causes of both stable and unstable tachycardia and appropriate
treatment within the ACLS framework requires identification of causative factors.
Before initiating invasive interventions, reversible causes should be identified and
treated.

Causes
The most common causes of tachycardia that should be treated outside of the ACLS
tachycardia algorithm are dehydration, hypoxia, fever, and sepsis. There may be
other contributing causes and review of the Hs and Ts of ACLS should take place
as needed.
Administration of OXYGEN and NORMAL SALINE are of primary importance for the
treatment of causative factors of sinus tachycardia and should be considered prior to
ACLS intervention.
Once these causative factors have been ruled out or treated, invasive treatment
using the ACLS tachycardia algorithm should be implemented.

Associated Rhythms
There are several rhythms that are frequently associated with stable and unstable
tachycardia these rhythms include:

Atrial fibrillation

Atrial flutter

Supraventricular tachycardia (SVT)

Monomorphic VT

Polymorphic VT

Wide-complex tachycardia of uncertain type

The fist question that should be asked when initiating the ACLS tachycardia
algorithm is: Is the patient stable or unstable? The answer to this question will
determine which path of the tachycardia algorithm is executed.
Patients with unstable tachycardia should be treated immediately
with synchronized cardioversion. If a pulseless tachycardia is present patients
should be treated using the pulseless arrest algorithm.
Patients with stable tachycardia are treated based upon whether they have a
narrow or wide QRS complex. The following flow diagram shows the treatment
regimen for stable tachycardia with narrow and wide QRS complex.

Stable (narrow QRS complex) vagal maneuvers adenosine (if regular)

beta-blocker/calcium channel blocker get an expert

Stable (wide/regular/monomorphic) adenosine consider

antiarrhythmic infusion get an expert

Bradycardia Algorithm Review

(includes 2010 AHA Guideline Update)
The major ECG rhythms classified as bradycardia include:
Sinus Bradycardia
First-degree AV block
Second-degree AV block
Type I Wenckenbach/Mobitz I
Type II Mobitz II
Third-degree AV block complete block
(See the ECG Interpretation section for images and more detailed information on
rhythms)

Bradycardia vs. Symptomatic Bradycardia

Bradycardia is defined as any rhythm disorder with a heart rate less than 60 beats
per minute. (Typically it will be <50/min) This could also be called asymptomatic
bradycardia. Bradycardia can be a normal non-emergent rhythm. For instance, well
trained athletes may have a normal heart rate that is less than 60 bpm.
Symptomatic bradycardia however is defined as a heart rate less than 60/min that
elicits signs and symptoms, but the heart rate will usually be less than 50/min.
Symptomatic bradycardia exists when the following 3 criteria are present: 1.) The
heart rate is slow; 2.) The patient has symptoms; and 3.) The symptoms are due to
the slow heart rate.
Functional or relative bradycardia occurs when a patient may have a heart rate within
normal sinus range, but the heart rate is insufficient for the patients condition. An
example would be a patient with an heart rate of 80 bpm when they are experiencing
septic shock.

Bradycardia Pharmacology
There are 3 medications that are used in the Bradycardia ACLS Algorithm. They are
atropine, dopamine (infusion), and epinephrine (infusion). More detailed ACLS
pharmacology information can be found here.
2010 AHA Update: For symptomatic bradycardia or unstable bradycardia IV infusion
chronotropic agents (dopamine & epinephrine) is now recommended as an equally
effective alternative to external pacing when atropine is ineffective.
Atropine: The first drug of choice for symptomatic bradycardia. Dose in the
Bradycardia ACLS algorithm is 0.5mg IV push and may repeat up to a total dose of
3mg.
Dopamine: Second-line drug for symptomatic bradycardia when atropine is not
effective. Dosage is 2-10 micrograms/kg/min infusion.
Epinephrine: Can be used as an equal alternative to dopamine when atropine is not
effective. Dosage is 2-10 micrograms/min.

Transcutaneous pacing (TCP)

Preparation for TCP should be taking place as atropine is being given. If atropine
fails to alleviate symptomatic bradycardia, TCP should be initiated. Ideally the patient
should receive sedation prior to pacing, but if the patient is deteriorating rapidly, it
may be necessary to start TCP prior to sedation.
For the patient with symptomatic bradycardia with signs of poor perfusion,
transcutaneous pacing is the treatment of choice.
Do not delay TCP for the patient with symptomatic bradycardia with signs of poor
perfusion. TCP rate should use 60/min as a starting rate and adjust up or down

based on the patients clinical response. The dose for pacing should be set at 2mA
(milliamperes) above the dose that produces observed capture.
TCP is contraindicated for the patient with hypothermia and is not a recommended
treatment for asystole.
A carotid pulse should not be used for assessment of circulation as TCP can create
muscular movements that may feel like a carotid pulse. Assess circulation using the
femoral pulse.
Identification of contributing factors for symptomatic bradycardia should be
considered throughout the ACLS protocal since reversing of the cause will likely
return the patient to a state of adequate perfusion.