wide complex tachycardia puja chopra, pgy-1 emergency medicine may 19, 2011

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 Pattern LBBB 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. ECGRegular: 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

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

89% Sensitivity, 95% specificity, 92% predictive accuracy for SVT origin

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

Adenosine For Wide Complex Tachycardia: Efficacy and Safety

- Marill et al. Critical Care Medicine, 2009

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?