1. Assessing and treating tachyarrhythmias Workshop
Version: Jun 2016

2. Learning outcomes This workshop should enable you to:
define a tachycardia by its regularity and QRS width
explain the principles of treatment
list the indications for electrical and chemical cardioversion
describe how to perform synchronised cardioversion

3. Conducting system

4. QRS Complex

5. How to read a rhythm strip1.
Is there any electrical activity with a pulse?

6. How to read a rhythm strip1.
Is there any electrical activity with a pulse? 2.
What is the ventricular (QRS) rate? 3. 4.
Is the QRS width normal (narrow) or broad?
Describe the rhythm on this basis.
Continue further only if you are sure that you can see atrial activity.

7. How to read a rhythm strip1.
Is there any electrical activity with a pulse? 2.
What is the ventricular (QRS) rate? 3. 4.
Is the QRS width normal (narrow) or broad? 5.
Is atrial activity present?
(If so, what is it: P waves? Other atrial activity?) 6.
How is atrial activity related to ventricular activity?

8. Tachycardia algorithm (with pulse)

9. Tachycardia algorithm

10. Stable broad-complex tachycardia

11. Stable narrow-complex tachycardia

12. What action will you take?
Case study 1
Clinical setting and history
65-year-old woman
in CCU bed 36 h after PPCI for anterior STEMI
complains to nurse of feeling unwell
Clinical course
ABCDE
A : clear
B : spontaneous breathing, rate 26 min-1
C : pale, HR 180 min-1, BP 70/42 mmHg, CRT 3 s, ECG monitoring in place
What is the rhythm?
D : alert, glucose 5.0 mmol L-1
E : nil of note
What action will you take?

13. What is the initial rhythm? What action will you take?
Case study 2
Clinical setting and history
48-year-old woman admitted to ED
history of rapid palpitation for 12 h
Clinical course
ABCDE
A : clear
B : spontaneous breathing, rate 16 min-1
C : P 180 min-1, BP 110/90 mmHg, CRT < 2 s, ECG monitoring in place
What is the initial rhythm?
D : alert, glucose 4.5 mmol L-1
E : nil of note
What action will you take? 13

14. Case study 2 (continued)
Clinical course
no response to vagal manoeuvres
vital signs unchanged
What action will you take now?

15. Case study 2 (continued)
Adenosine
Indications
narrow-complex tachycardia
broad-complex tachycardia if previously confirmed SVT with bundle branch block
diagnosis in regular broad-complex tachycardia of uncertain nature
Contraindications
asthma
Dose
6 mg bolus by rapid IV injection into a large vein
up to 2 further doses, each of 12 mg, if needed
Action
blocks conduction through AV node

16. Case study 2 (continued)
Amiodarone
Indications
broad-complex and narrow-complex tachycardia
Dose
300 mg over min IV
900 mg infusion over 24 h
preferably via central venous catheter
Actions
lengthens duration of action potential
prolongs QT interval
may cause hypotension 16

17. What is the initial rhythm? What action will you take?
Case study 3
Clinical setting and history
76-year-old man
history of hypertension treated with a diuretic
in the recovery area after an uncomplicated hernia repair
nurses report the sudden onset of tachycardia
Clinical course
ABCDE
A : clear
B : spontaneous breathing, rate 18 min-1
C : P 170 min-1, BP 100/60 mmHg, CRT < 2 s, ECG monitoring in place
What is the initial rhythm?
D : alert, glucose 3.6 mmol L-1
E : nil of note
What action will you take? 17

18. Case study 3 (continued)
Clinical course
patient is given IV metoprolol
30 min later, he complains of chest discomfort
ABCDE
A : clear
B : spontaneous breathing, rate 24 min-1
C : HR 170 min-1, BP 85/50 mmHg, CRT 4 s
What is the rhythm?
What action will you take?

19. Case study 3 (continued)
Clinical course
cardioversion restores sinus rhythm
patient is asymptomatic
vital signs are normal
patient is transferred back to the day-case unit
What actions should you consider
as part of discharge planning?

20. Any questions?

21. Summary
assess any tachycardia according to its regularity and QRS width
the principles of treatment
indications for electrical and chemical cardioversion
perform synchronised cardioversion

22. Advanced Life Support Course Slide set
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© Australian Resuscitation Council (June 2016)