Volume I:
First Thirty Minutes
- Section 1
  Acute Care Algorithm/ Treatment Plans/ Acronyms
- Section 2
  Universal Approach
  - CALS Universal Approach To Emergency Advanced Life Support
- Section 3
  Steps 1-6
- Section 4
  Preliminary Impression/Focused Clinical Pathways
Volume II:
Resuscitation Procedures
Volume III:
Definitive Care

Acute Care 16: Tachycardia Algorithm

AC16a

AC16b

AC16c

AC16d

AC16e

Regular narrow complex tachycardias	Regular wide complex tachycardias
Vagal (Valsalva) maneuvers If ineffective in converting rhythm: adenosine 6 mg IV rapid push and flush. PEDS: 0.1 mg/kg. If ineffective, may double dose and repeat x 2 Calcium channel blockers and beta blockers may also be considered Consider synchronized electrical cardioversion	Amiodarone 150 mg IV over 10 to 20 min; repeat if needed. PEDS: 5 mg/kg over 20 to 60 min; may repeat to 15 mg/kg max/24 hours Procainamide 20 mg/min to 17 mg/kg IV PEDS: 15 mg/kg IV over 30 to 60 min Lidocaine 1 to 1.5 mg/kg IV push; total loading dose 3 mg/kg PEDS: same Consider synchronized electrical cardioversion

Defibrillator Energy Delivery for Cardioversion¹
Synchronized
Rhythm	Monophasic Defibrillator	Biphasic Defibrillator
Atrial fibrillation	200 J	120 J - 200 J
Atrial flutter	50 J - 100 J	NA*
PSVT (narrow complex, regular)	50 J - 100 J	NA*
VT-monomorphic (wide complex, regular)	100 J - 360 J	NA*
Unsynchronized
VT-polymorphic (wide complex irregular)	360 J (unsynchronized)	Device specific (or 200 J (unsynchronized)
NA*=insufficient data to recommend energy levels; use the same or less than monophasic.

Reference

Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, et al. Part 8. Adult Advanced Cardiovascular Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S729-S768.

Paroxysmal Supraventricular Tachycardia (PSVT) Algorithm

Vagal Maneuvers:

Valsalva Maneuver
Ice Water Immersion (Don’t use on a patient with ischemic heart disease.)

Adenosine: 6 mg rapid IV push over 1 to 3 seconds followed by 20 mL fluid flush

longarrowdown PEDS: 0.1 mg/kg

If fails to convert in 1 to 2 minutes, give:

Adenosine: 12 mg rapid IV push. May repeat the 12 mg dose once after 1 to 2 minutes.
PEDS: 0.2 mg/kg

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If rhythm fails to convert or recurs, consider other treatments.

Assess Blood Pressure

longarrowdown arrow right Low or Unstable BP Synchronized Cardioversion (50 J to 100 J)

Normal or Elevated BP

Calcium Channel Blockers and Beta Blockers:

Verapamil: 2.5 to 5.0 mg IV over 2 minutes. If rhythm does not convert in 15 to 30 minutes, a second dose of 5 to 10 mg IV over 2 minutes may be given. (Do not give to patients with impaired hearts.)
Diltiazem: 15 to 20 mg (0.25 mg/kg) IV over 2 minutes. If rhythm does not convert in 15 minutes, give a 2nd dose of 20 to 25 mg (0.33 mg/kg) IV over 2 minutes.
If hypotension occurs with these agents, place patient in Trendelenburg position or slowly infuse calcium chloride 0.5 to 1.0 g IV.

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Digoxin (Lanoxin) or Beta Blockers (Propanolol or Esmolol) may be tried. (Use extreme caution with use of beta blockers after use of calcium channel blockers.)

Synchronized Cardioversion

Acute Care 16: Tachycardia Algorithm

Reference

Edition 13-October 2011