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Advanced Cardiac Life Support (ACLS): Tachycardia With Pulse
ACLS: Tachycardia
1. Initial evaluation is as follows �:
- Assess appropriateness for clinical condition (pulse present).
- Heart rate typically ≥150 bpm in tachyarrhythmia
2. Initial intervention is as follows:
- Maintain patent airway and assist breathing, as needed.
- Administer oxygen if hypoxemic.
- Attach monitor/defibrillator.
- Monitor blood pressure and oximetry.
3. Assess for signs of poor perfusion, as follows:
- Hypotension (systolic blood pressure [SBP] < 90 mm Hg)
- Acutely altered mental status
- Signs of shock
- Ischemic chest discomfort
- Acute heart failure
4. Therapeutic intervention is as follows if poor perfusion is present:
- Perform immediate synchronized cardioversion with initial recommended dose (see below).
- Consider sedation; do not delay therapy.
- If regular narrow complex, consider adenosine; do not delay therapy.
- If refractory after initial cardioversion, consider the following:�
- Identification of underlying cause
- Need to increase energy level for next cardioversion
- Addition of anti-arrhythmic drug
- Expert consultation
5. Measures are as follows if adequate perfusion and narrow QRS (< 0.12 seconds):
- Obtain intravenous (IV)/intraosseous (IO) access.
- Perform 12-lead electrocardiography (ECG), if available.
- Perform vagal maneuvers first, if rhythm is regular.�
- Consider adenosine if rhythm is regular and if vagal maneuvers are unsuccessful.
- Consider beta-blocker or calcium channel blocker if adenosine is unsuccessful.
- Consider expert consultation.
6. Measures are as follows if adequate perfusion and wide QRS (≥0.12 seconds):
- Obtain IV/IO access.
- Perform 12-lead ECG; do not delay therapy.
- Administer adenosine only if regular and monomorphic.
- Consider antiarrhythmic infusion.
- Consider expert consultation.
Synchronized Cardioversion
Initial recommended doses are as follows:
- Narrow regular: 50-100 J
- Narrow irregular: 120-200 J biphasic or 200 J monophasic
- Wide regular: 100 J
- Wide irregular: defibrillation (not synchronized)
Adenosine
Administration of adenosine should proceed as follows:
- First dose: 6 mg rapid IV push, follow with NS flush
- Second dose: 12 mg rapid IV push
- Have equipment for transcutaneous pacing available when administering adenosine.
- Half dose (3 mg IV) if using central line, which includes peripherally inserted central catheter (PICC), patient taking dipyridamole or carbamazepine
- May need increased adenosine dose in patients on theophylline, caffeine, or theobromine
- Caution with adenosine in patients with asthma and/or transplanted hearts
Antiarrhythmic Infusions
For stable wide QRS tachycardia, as follows:
Procainamide 20-50 mg/min IV until arrhythmia suppressed, hypotension ensues, QRS duration increases >50%, or maximum dose 17 mg/kg
- Procainamide 1-4 mg/min IV maintenance infusion; avoid if prolonged QT or congestive heart failure (CHF)
Amiodarone 150 mg IV over 10 minutes first dose; repeat as needed if ventricular tachycardia (VT) recurs
- Amiodarone 1 mg/min IV maintenance infusion for first 6 hours
- Sotalol 100 mg (1.5 mg/kg) IV over 5 minutes; avoid in prolonged QT
Most Recent Guideline Changes
Changes from the 2023 guidelines update include the following:�
- Amiodarone or lidocaine may be considered for ventricular fibrillation/pulseless ventricular tachycardia that is unresponsive to defibrillation, class IIb recommendation.�
- Routine administration of calcium, magnesium, or sodium bicarbonate for cardiac arrest is not recommended.�
- Adults not responding to commands after spontaneous circulation post cardiac arrest, regardless of arrest circumstances, should undergo intentional temperature control. The recommended temperature range during postarrest management is 32°C to 37.5°C.
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