Narrow complex tachycardia supraventricular tachycardia. Monomorphic vt will have qrs complexes of the same shape and amplitude pediatric cardiac wide complex tachycardia monomorphic b abcs and establish patent airway maintain o2 sats of 90% vital signs apply cardiac monitor reassess vital signs and perfusion status frequently if stable. Unstable means that either important organ functions are affected or cardiac arrest is about to occur. Several algorithms have been developed to aid in this differentiation below. Heart rates above the resting rate may be normal such as with exercise or abnormal such as. As shown in fig 1, broad qrs tachycardia can be divided in three groups svt with bundle branch blockbundle branch block bbb may be preexisting or can occur when the refractory period of one of the bundle branches is reached because of the heart rate of the svt so called tachycardia related or phase 3 block. Recognition and management in the emergency room ib ray abstract cardiac arrhythmias often present as urgent medical conditions requiring immediate care. Wide complex tachycardia cardiac electrophysiology clinics. A broad qrs complex is either caused by the ventricular conducting system not working bundle branch block or the electrical circuit not involving the atrioventricular av node correctly.
A break in the rhythm is caused by a right ventricular premature complex, followed by a. The evaluation and treatment of wide qrscomplex tachycardia remains a challenge, and mismanagement is quite common. An overview of the acute management of tachyarrhythmias, along with detailed discussions of specific narrow complex tachycardias eg, avnrt, avrt, and at and a broad discussion of wide complex. We present a case of a 54yearoldfemale who recently underwent placement of an implantable cardioverter. Adenosine may elicit hidden atrial activity, and it is particularly safe as the pacemaker should respond if prolonged av block or a brief period of asystole occurs. These four criteria can be used as simple rules in determining the origin of a broad complex tachycardia. Wide complex tachycardia is a cardiac rhythm of more than 100 beats per minute with a qrs duration of 120 milliseconds or more. The rhythm is regular or almost regular complex tachycardia. Thus, the first consideration should be atrial fibrillation with wpw preexcited af, and this was my first impression. Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate.
This is a very broad and inclusive definition of regular wide complex tachycardia. Jan 01, 2009 when this criteria is met, and the the rhythm is regular no variability in the rr interval then itas a regular wide complex tachycardia. Supraventricular origin 058 sinus tachycardia with raterelated left bundle branch block. Wct, fast and wide, wide and fast, widecomplex tachycardia, wide complex rhythm, svt with aberrancy, svt with aberrant conduction, supraventricular tachycardia with aberrancy, vt versus svt, broad complex tachycardia overview causes differentiating vt from svt as a cause of wide complex. Figure 1 the 12lead surface electrocardiogram of clinical tachycardia showing broad complex tachycardia at 220 beatsmin with right bundle branch block, right inferior axis, and precordial qrs complex concordance. Broad complex tachycardias occur by various mechanisms and may be ventricular or supraventricular in origin. Morphology of the widecomplex tachycardia the morphology of the tachycardia also give hints concerning the origin. Comparison of five electrocardiographic methods for. If at any point patient becomes unstable move to unstable arm in algorithm. Supraventricular tachycardia svt is an abnormally fast heart rhythm arising from improper electrical activity in the upper part of the heart. Symptom onset occurred while he was taking his daily walk about 15 minutes prior to ems arrival.
The underlying cause of wide complex tachycardia tends to be ventricular tachycardia in patients 35 years of age sensitivity of 92% and a positive predictive value of 85% for vt and supraventricular tachycardia with aberrancy in patients broad complex tachycardia bct is defined as a heart rate 100 bpm with a qrs complex 0. A regular broadcomplex tachycardia is likely to be ventricular tachycardia vt or a regular supraventricular rhythm with bundle branch block. Wide complex tachycardiadiagnostic approachalgorithms sen. If a widecomplex tachycardia is monomorphic, its origin can be ventricular tachycardia in a structurally abnormal heart, most commonly scar reentry in coronary artery disease or cardiomyopathies such as hypertrophic or dilated cardiomyopathy, or arrhythmogenic right. Every clinician taking care of cardiac patients should be able to diagnose them. Pdf broad qrs complex tachycardia still presents a diagnostic challenge when confronted with a 12lead electrocardiogram ecg. The pharmacologic and nonpharmacologic antiarrhythmic approaches discussed may, therefore, include some accahaesc guildelines 1859. Wide qrscomplex tachycardia wct may be a ventricular tachycardia vt or a supraventricular tachycardia svt with intraventricular conduction disturbance or with a preexcitation. In ventricular tachycardia the rate is normally 120300 beatsminute. In the emergency setting most broad complex tachycardias have a ventricular origin. The differential diagnosis of a regular, monomorphic wide qrs complex tachycardia wct mechanism represents a great diagnostic dilemma commonly. Wide complex rhythms have a qrs duration greater than 0. Because the previous sinus rhythm ecg was not available, the ecg diagnosis of this wide complex tachycardia was very difficult. But there are sections of wide complex regular monomorphic rhythm within the tracing.
The major clinical problem that arises when dealing with someone exhibiting a wide complex tachycardia is that it is not always immediately clear if the rhythm represents. Ecgs were categorized as demonstrating sinus rhythm sr, irregular broadcomplex tachycardia ibct, or regular broadcomplex tachycardia bct. Any supraventricular tachycardia can present as a wide qrs complex tachycardia. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults.
Presentation a ventricular origin for a broad complex tachycardia is suggested if the patient is aged over 35 years and has a history of ischaemic heart disease or. V relationship and avrt involving a retrograde concealed accessory pathway, wide qrs complex tachycardia is the result of delayed or blocked conduction. With newer pacemakers, this condition is less common. The management of tachycardia depends on its type wide complex versus narrow complex, whether or not the person is stable or unstable, and whether the instability is due to the tachycardia. Wide complex tachycardia encompasses a range of cardiac dysrhythmias, some. If the morphology changes, if the complex changes its look then wed call that a polymorphic widecomplex tachycardia, and the treatments a little different. Please note that the retrograde p wave is seen slightly after the qrs complex pseudo r wave in lead v1 and the pseudo s wave in leads ii, iii, and avf, which suggest typical. A 12lead electrocardiography ecg performed during tachycardia demonstrated regular broad complex tachycardia with flutter waves marching across the screen, a qrs complex duration of 172 ms, and a right bundle branch block rbbblike morphology of 167 beatsmin fig. This ecg shows a wide complex tachycardia which is overall irregular and has qrs complexes with differing morphology. Definition ventricular tachycardia is a rapid heart beat initiated within the ventricles, characterized by 3 or more consecutive premature ventricular beats causes, incidence, and risk factors. Full text get a printable copy pdf file of the complete article 1.
Wide qrs complex tachycardia wct is a rhythm with a rate of more than 100 beatsmin and a qrs duration of more than 120 milliseconds. In this video, you will learn the essential basics. But in my experience, itas the best way to approach the problem. Patient presenting with a tachyarrhythmia is a common finding in the emergency room. Therefore, physi cians must have a good understanding of the differential diagnosis of wct so that a malignant arrhythmia, such as ventricular tachycardia vt. Diagnostic criteria of broad qrs complex tachycardia. Classification of tachycardias with a broad qrs complex. To divide up this myriad of possibilities, a bit of basic electrophysiology terminology needs to. Multivariate analysis to simplify the differential diagnosis. During wide complex tachycardia heart rate 100min, qrs 0. This article continues the discussion, started last week, on ventricular tachycardias and also examines how to determine whether a broad complex tachycardia is ventricular or supraventricular in origin. Wide complex tachycardia ventricular tachycardia or not ventricular tachycardia, that remains the question. Wide complex tachycardia treated with amiodarone and. Broad complex tachycardias are potentially lifethreatening.
Article pdf available in netherlands heart journal. In 24 patients with broad complex tachycardias qrs greater than or equal to 0. It is important to keep in mind that a good estimate of vt versus svt can be. Ross from the department of cardiology, westmead hospital, wentworthville, sydney, australia introduction a previously fit 53yearold man presented to another hospital complaining of recurrent rapid palpitations. Initial evaluation and management of widecomplex tachycardia. Abc of clinical electrocardiography broad complex tachycardia. Current algorithms for the diagnosis of wide qrs complex ncbi. In broad complex tachycardias the qrs complex is longer than 120 ms three small squares on the ecg. Value and limitations of adenosine in the diagnosis and. Mar 30, 2002 this article continues the discussion, started last week, on ventricular tachycardias and also examines how to determine whether a broad complex tachycardia is ventricular or supraventricular in origin. Jun 17, 2016 broad complex tachycardias are potentially lifethreatening. Approach to wide complex tachycardias in patients without.
Differential diagnosis of wide complex tachycardias ems 12 lead. The ecg differential diagnosis includes ventricular tachycardia vt vs. Pdf diagnostic criteria of broad qrs complex tachycardia. Mar 30, 2002 the bundle branch block may predate the tachycardia, or it may be a rate related functional block, occurring when atrial impulses arrive too rapidly for a bundle branch to conduct normally. An electrocardiograph ecg revealed a broad complex tachycardia fig. Clinical significance potentially lifethreatening sudden death tachycardiainduced cardiomyopathy vt vs svt prognosis management 5.
In a stable patient, if the broadcomplex tachycardia is thought to be vt, treat with amiodarone 300 mg iv over 2060 min, followed by an infusion of 900 mg over 24 h. However, due to its potential lifethreatening nature, emergency clinicians must know how to assess and manage this condition. Sep 06, 2017 this ecg shows a wide complex tachycardia which is overall irregular and has qrs complexes with differing morphology. Summary this chapter focuses on management, causes, and differential diagnosis of patients with regular broad complex tachycardia. Apr 24, 2018 the bayesian approach improves the electrocardiographic diagnosis of broad complex tachycardia. In 40 patients who had narrow complex tachycardias qrs less than 0. However, an arrhythmia arising from the atria or the atrioventricular junction will produce a broad complex if associated with ventricular preexcitation or bundle branch block. Accahaesc guidelines for the management of patients with. The differentiation of wide qrs complex tachycardias. Wide complex tachycardia wide complex tachycardia is a cardiac rhythm with more than 100 ventricular beats per minute and a qrs complex of 120 ms or greater. Pediatric cardiac wide complex tachycardia monomorphic. Dec 21, 2015 wide complex tachycardia treated with amiodarone and synchronized cardioversion a 55 year old male presents to ems with complaint of intermittent shortness of breath. Several arrhythmias can manifest as wcts table 211.
In avnrt, atrial tachyarrhythmias, atrial flutter with a fixed a. Ventricular tachycardia is a potentially lethal disruption of normal heartbeat arrhythmia that may cause the heart to. Regular broad complex tachycardia acute medicine wiley online. Overall, this is a consensus document that includes evidence and expert opinions from several countries. June 5, 2009 page 1 of 3 wide complex tachycardia presumed ventricular tachycardia a guideline for patients with wide complex tachycardia of cardiac origin with qrs 0.
Sinus rhythm was restored by an intravenous injection. When atrial fibrillation occurs with aberrant conduction and a rapid ventricular response, a totally irregular broad complex tachycardia is produced. Mental status, skin, neck, lung, heart, abdomen, back, extremities, neuro most important goal is to differentiate the type of tachycardia and if stable or unstable. Intraventricular conduction delay can result from heart rate changes, as well as from fixed pathological lesions in the conduction system. We present a case of a 54yearoldfemale who recently underwent placement of an implantable. However, an arrhythmia arising from the atria or the atrioventricular junction. The bayesian approach improves the electrocardiographic diagnosis of broad complex tachycardia. Oct 05, 2012 wide complex tachycardiadiagnostic approachalgorithms sen. Mar 23, 2002 broad complex tachycardias occur by various mechanisms and may be ventricular or supraventricular in origin. It is a blanket term that includes a lot of different rhythms and is simply a starting point on the road to diagnosis.
To divide up this myriad of possibilities, a bit of basic electrophysiology terminology needs to be applied. The differentiation of wide qrs complex tachycardias presents a challenging diagnostic dilemma to many physicians despite multiple published algorithms and approaches. Wide complex tachycardias are a commonly encountered entity in coronary care units, intensive care units and emergency departments. Figure 1 episode of a wide complex tachycardia with a right bundle branch block rbbb configuration, which spontaneously changes to a narrow complex svt in the presence of a slight decrease in cycle length.
It is critical to differentiate whether the wide complex tachycardia is of ventricular origin and is ventricular tachycardia, or if it is of supraventricular origin with aberrant conduction svt with aberrancy. Multivariate analysis to simplify the differential. The rate is 125 and the qrs duration is 160 msec, with broad r waves in leads i, avl, and v56 indicating lbbb. Broad qrs complex tachycardia bct still presents a diagnostic challenge when confronted with a 12lead electrocardiogram ecg. The rhythm is regular or almost regular narrow complex. Wide complex tachycardia is a rare disease entity among patients presenting to the emergency department.
This topic will provide a broad overview of the different causes of narrow qrs complex tachycardia and an approach to their evaluation and diagnosis. Though, these arrhythmias are potentially fatal, they need to recognized first and treated appropriately. The value of electrocardiogram in the differential diagnosis of a tachycardia with a widened qrs complex. As shown in fig 1, broad qrs tachycardia can be divided in three. Broad complex tachycardia bct is defined as a heart rate 100 bpm with a qrs complex 0. Approach to wide qrs complex tachycardias clinical gate. Adenosine may be used as a diagnostic or therapeutic agent in patients with undifferentiated wide complex tachycardia. Pdf when confronted with a tachycardia having a broad qrs complex, it is important to be able to differentiate between a supraventricular and a.
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