WIDE COMPLEX TACHYCARDIA Puja Chopra, PGY-1 Emergency Medicine May 19, 2011

Objectives Differential Diagnosis of wide complex tachycardia Approach to wide complex tachcardia Examples of wide complex tachycardia Adenosine/ACLS

DDx: Ventricular tachycardia SVT with a preexisting bundle branch block or a functional rate related bundle branch block SVT with antegrade conduction via an accessory pathway Drug induced – TCA, Class one antiarryhtmic Electrolyte - hyperkalemia

Wellen’s Criteria RBBB PatternLBBB Pattern

Sensitivity: 98.7% Specificity: 96.5%

Brugada Criteria: -Sensitivity: 79 to 91% -Specificity: 43 to 70%

Approach to WCT 1. History 2. Physical Exam 3. ECG Regular: VT, SVT with aberrancy, SVT with accessory pathway, Electrolyte abnormalities, Medications Irregular: a fib + pre-excitation, a fib + BBB, a flutter + BBB, MAT + BBB, polymorphic Vtach (torsades) ?AV dissociation, Fusion beats, capture beats 4. Adenosine (?Diagnostic, ?therapeutic)

70 yo male with palpitations and history of angina

61 yo male with productive cough and fever

65 yo male with syncope, PMHx: DM

30 yo female with palpations

28 yo male, altered and agitated after an unknown overdose

45 yo male, previously healthy, with palpitations

44 year old chronic alcoholic male with persistent vomiting and becomes unresponsive

65 yo female with palpations

48 yo male with palpitations

Adenosine in the Diagnosis of Broad Complex Tachycardia - Griffith et al. The Lancet March 1988 Broad Complex Tachycardia SVT8/9VT1/17 Atrial Fibrillation with WPW 0/6 No change in mean RR 89% Sensitivity, 95% specificity, 92% predictive accuracy for SVT origin

Broad Complex Tachycardia SVT not requiring the AV node 1/10 Significant shortening of RR interval VT1/14 SVT requiring the AV node 7/10 Sensitivity: 70%, Specificity: 92%, PPV: 85% Intravenous Adenosine Triphosphate During Wide QRS Complex Tachycardia: Safety, Therapeutic Efficacy and Diagnostic utility - Sharma et al. The American Journal of Medicine, April 1990

Adenosine for the Management of Patients with Tachycardias – A new Protocol - Domanovits et al. European Heart Journal, 1994 Wide Complex Tachycardia SVT17/22VT0/4 Afib/Aflutter with aberrancy 0/3

Adenosine For Wide Complex Tachycardia: Efficacy and Safety - Marill et al. Critical Care Medicine, 2009 Regular Wide Complex Tachycardia SVT104/116VT2/81 Primary outcome: termination of tachycardia with adenosine, AV block allowing rhythm identification - The odds of SVT increase by a factor of 36 after a positive response to adenosine - Odds of VT increase by factor of 9 after a negative response to adenosine

Thanks! Questions?