1. Tachycardias or… “slow down, you move too fast”
Susan P. Torrey, M.D., FACEP, FAAEM
Associate Professor of Emergency Medicine
Tufts University School of Medicine
Baystate Medical Center, Springfield, Mass

2. Objectives Review diagnostic criteria of tachycardias
Consider the diagnostic grid
Answer several interesting questions
What’s the scariest atrial fib you’ll ever see?
Let’s use adenosine – it’s safe, isn’t it?
How DO you know if it’s v. tach?
Review more sneaky rhythm strips

3. Rate Rate = 300 ÷ # “big boxes” between R-R
300 – 150 – 100 – 75 – 60 – 50

4. Rate?

5. Rate?
1. Between
x 3 = 225

6. Normal conduction

7. Wolff-Parkinson-Whitex
short PR
delta wave
increase QRS width

8. Sinus tachycardia normal P before every QRS upright P in lead II
Max. heart rate = 220/minute – age in years

9. Sinus tachycardia Common causes: compensation for shock
- dehydration, hemorrhage, sepsis
fever
drugs (cocaine)
acute pulmonary embolism
thyrotoxicosis
anxiety - needs to be dx of exclusion

11. 19 yo male with multi-drug OD

12. Atrial fibrillation no discernible P waves
- atrial activity is fibrillatory waves (f)
- fibrillatory waves – II and V1
ventricular rhythm is irregularly irregular
- untreated ventricular rate 100 – 180/min

13. Atrial fibrillation

14. Atrial flutter atrial activity – regular deflections (F waves)
- F waves usually 300/minute
rate and regularity of QRS variable
- in purest form, multiple of 300

15. Atrial flutter untreated, flutter usually has 2:1 AV block
 regular rhythm at 150/minute

16. Rate of 150… when the rate is 150/minute
 always consider 2:1 atrial flutter

18. Multifocal atrial tachycardia
P waves of varying morphology (≥ 3 foci)
- absence of single dominant P wave
Variable PP, RR, PR intervals
- the other irregularly irregular rhythm
Seen with COPD, elderly, seriously ill

19. Supraventricular tachycardia
Regular, narrow tachycardia 2° re-entry
AV nodal re-entry vs. AV re-entry (bypass)
Onset and termination is abrupt
Heart rate /minute
Differential: sinus tach, 2:1 flutter, ? a fib

20. Reentry mechanism “fast” pathway rapid conduction time “slow” pathway
long refractory period
“slow” pathway
slow conduction
short refractory

21. SVT

22. Pseudo-S waves with AVNRT
Pseudo-S waves disappear
with sinus rhythm

23. another SVT…

24. AV reentry tachycardia?
QRS alternans
Prolonged RP interval

25. AV Reentry Tachycardia (WPW?)

26. after cardioversion!

27. Ventricular tachycardia
Abnormal wide QRS
Regular rhythm – “dead regular”
Rate usually /minute

28. Wide-complex tachycardia
70% of WCT is ventricular tachycardia
differential includes…
SVT with aberrancy
SVT with pre-existing bundle branch block
SVT with bypass tract

29. Diagnostic grid - tachycardias
Regular
Irregular
Narrow
Wide

30. Diagnostic grid - tachycardias
Regular
Irregular
Narrow
Sinus tach
SVT
2:1 flutter
Wide

31. Diagnostic grid - tachycardias
Regular
Irregular
Narrow
Sinus tach
SVT
2:1 flutter
Atrial fib
MAT
Wide

32. Diagnostic grid - tachycardias
Regular
Irregular
Narrow
Sinus tach
SVT
2:1 flutter
Atrial fib
MAT
Wide
V. tach
SVT with…

33. Diagnostic grid - tachycardias
Regular
Irregular
Narrow
Sinus tach
SVT
2:1 flutter
Atrial fib
MAT
Wide
V. tach
SVT with…
Atrial fib with…

34. Question #1

35. What is the scariest atrial fibrillation you will ever see?
38-year-old man with history of palpitations

36. Or this…

37. Scary atrial fib Atrial fib with… - aberrancy
- pre-existing bundle, or…
- bypass tract with Wolff-Parkinson-White !
- changing QRS shape and rapid conduction

38. Atrial fib with WPW most AV node blockers ↑ bypass conduction
must avoid A – B – C – D
A – adenosine
B – beta-blockers
C – calcium-channel blockers
D – digoxin
treat with electricity or procainamide

39. What about amiodarone? 2005 ACLS – rec: amiodarone
2010 ACLS – returns to procainamide
Simonian S Inter Emerg Med 2010
Literature review challenges superiority and safety of amiodarone for atrial fib with WPW
Complex drug with effects on Na+, K+, and Ca++ channels, as well as α- and β-blocking effects

40. rapid atrial fib with wide complex
after cardioversion
after ablation of bypass tract

41. Question #2

42. Let’s use adenosine…it’s safe isn’t it?
Adenosine (Adenocard®)
an α1 receptor agonist
rapid onset and brief duration
frequent side-effects:
facial flushing, chest pressure, dyspnea

43. SVT conversion with adenosine

44. Adenosine

45. Beware proarrhythmias !
Torsade de pointe
Precipitates atrial fib and flutter
Protracted bradycardia and asystole
2:1 flutter  1:1 conduction
Mallet Emerg Med J 2004

46. SVT at 140 ?
Adenosine 6 mg IV
1:1 atrial flutter at 280/minute

47. Adenosine as diagnostic tool
SVT
Atrial flutter
Sinus tach
Ventricular tach
converts to sinus
reveals flutter waves
reveals P waves
nothing !

48. pediatric tachycardia
8-month-ago child with hx cardiac surgery as infant;
parents say child is “fussy” HR 300/minute
Adenosine…

49. Pre-hospital tachycardia

50. Question #3

51. How do you know if it’s V. tach?

52. How do you know if it’s V. tach?
EKG criteria favoring V. Tach
AV dissociation

53. AV dissociation

54. How do you know if it’s V. tach?
EKG criteria favoring V. Tach
AV dissociation
QRS concordance
all chest leads (V1-6) predominantly negative

55. QRS concordance

56. How do you know if it’s V. tach?
algorithms
Brugada’s four-step algorithm
 98% sens / 96% spec
Circ 1991
Vereckei’s new “simplified” algorithm
Euro Heart J 2007

57. How do you know if it’s V. tach?
clinical predictors
association with heart disease or MI
 98% positive predictive value
Aktar Ann Intern Med 1988

58. It’s v. tach!

61. sneaky rhythms

62. 1. 68-year-old woman with COPD complains of palpitations and nausea.
Irregularly irregular  a. fib vs. MAT

63. 2. 38-year-old woman complains of palpitations and weight loss.
Regular, narrow  SVT vs sinus tach

64. 3. 70-year-old woman with weakness. PMH: Parkinson’s Disease
Regular…but fibrillatory waves?

65. 4. 72-year-old man with palpitations, weakness, and chest discomfort.

66. after adenosine… F

67. 5. 65-year-old man with palpitations and shortness of breath.

68. wide-complex, irregularly irregular  yikes
after Amiodarone…
then spontaneously converted to sinus

69. 6. 56-year-old man with lung cancer from oncology clinic with SOB.

70. Irregularly irregular at 185/min
Now 145/minute, and…

71. 7. 75-year-old man from nursing home with altered mental status.

72. Appropriate DDD pacer function
– essentially sinus tach

73. 8. 65-year-old woman with dyspnea and chest pain.

74. Emergency Department EKG

75. After diltiazem…

76. 9. 70-year-old man with palpitations and SOB

77. Close-up of III and aVF

78. After adenosine…oops!

79. 10. 65-year-old woman after syncope.

80. After spontaneous conversion

81. Pseudo-S waves of AVNRT

82. 11. 70-year-old man with chest pain 90/60, 200, 28, 92%

83. After electrical cardioversion…

84. 12. 72-year-old woman “heart racing” EMS gave Amiodarone

85. ED 12-lead – 15 minutes later

86. 15 min later…spontaneous conversion

87. In conclusion… Remember, tachycardias are easy…
Narrow or wide complex?
Regular or irregular?

88. Diagnostic grid - tachycardias
Regular
Irregular
Narrow
Sinus tach
SVT
2:1 flutter
Atrial fib
MAT
Wide
V. tach
SVT with…
Atrial fib with…

89. In conclusion… Remember, tachycardias are easy…
Narrow or wide complex?
Regular or irregular?
If the rate is around 150 think 2:1 flutter.

90. In conclusion… Remember, tachycardias are easy…
Narrow or wide complex?
Regular or irregular?
If the rate is around 150  think 2:1 flutter.
Use Adenosine, but respect it.

91. In conclusion… Remember, tachycardias are easy…
Narrow or wide complex?
Regular or irregular?
If the rate is around 150  think 2:1 flutter.
Use Adenosine, but respect it.
Rapid wide-complex atrial fib  think WPW…
Avoid A – B – C – D (and amiodarone)

92. In conclusion… Remember, tachycardias are easy…
Narrow or wide complex?
Regular or irregular?
If the rate is around 150  think 2:1 flutter.
Use Adenosine, but respect it.
Rapid wide-complex atrial fib  think WPW…
Treat wide-complex tachycardia per ACLS