# Tachycardia Management

## Overview

This module describes the emergent management of tachycardia, where the patient has a palpable pulse.

## Indications

1. Patients with tachycardia (heart rate more than 150 beats/min for adults) with a palpable pulse

2. ​​Pediatric patients with:

   1. Narrow complex (QRS < 0.08 sec) : > 180 child; > 220 infant
   2. Wide complex (QRS > 0.08 sec): > 200

## Contraindications

1. Pulseless patients regardless of electrical activity on the monitor—treat according to cardiac arrest algorithms

## Patient information & consent

The management of tachycardia requires monitoring, administration of medication, and possibly synchronised cardioversion. Ensure that you explain your findings and decisions to the patient as you go along. Some patients may be haemodynamically unstable and unable to understand; communicate with family members if present. See Synchronised Cardioversion for specific patient information.

## Preparation

Tachycardia management management may be an emergency procedure. Always:

1. Know where defibrillators, transcutaneous pads, and red trolleys are kept. Know the relevant staff and keep your seniors’ contact details close at hand.

2. Familiarise yourself with the defibrillators in your work area. Check that they are maintained regularly and have pads and the correct connections.

3. Keep unstable patients in resuscitation bays with continuous monitoring.

## Site & Positioning

The patient should be lying flat on their back on a firm surface. There should be space behind the head of the bed for staff to stand to give rescue breaths if the patient deteriorates.

## Procedure

Follow medical asepsis with non-sterile gloves.

1. Hazards:

   look for hazards
   look for hazards

   any body fluid spills, trip hazards, or others which may be more likely in the out-of-hospital scenario

   and put on gloves. Follow Transmission-Based Precautions as required.

2. Hello:

   1. If patient is not awake, tap the patient’s shoulder and call hello. Look for a response.
   2. If unresponsive, feel and listen for breathing with your ear close to the patient’s mouth. Look for chest rise. Don’t take more than 10 seconds.
   3. Feel for a pulse on the neck. Don’t take more than 10 seconds. Identify tachycardia.

3. Help: Call for

   assistance and equipment
   assistance and equipment

   Call for assistance from other healthcare workers. Get someone to bring a defibrillator. Get someone more senior than yourself involved.

   .

4. Airway: open and maintain if necessary

5. Breathing: administer oxygen/ventilation if necessary

6. Circulation: attach BP cuff and cardiac monitoring. Confirm whether the patient is stable or

   unstable
   unstable

   Signs of instability are ischaemic chest pain, acute heart failure, hypotension, signs of shock, or acutely altered mental state.

   . Obtain a 12-lead ECG as soon as possible.

7. Unstable patient: proceed with synchronised cardioversion starting at 100 J.

8. Establish large bore IV access. Consider and correct

   contributing causes
   contributing causes
   - Sepsis
   - Pain / anxiety
   - Hypovolaemia
   - Anaemia
   - Street drugs
   - Hyperthyroidism

   .

9. Stable patient: Identify and manage narrow complex tachycardia:

10. OR wide complex tachycardia:

11. Refer early to cardiology.

## Troubleshooting

I am unsure about the ECG diagnosis and how to manage this patient.

The exact ECG diagnosis of the rhythm is less important or urgent in unstable patients, who require emergency management as soon as tachycardia is confirmed. Stable patients require workup and ECG identification, and should preferably be referred early to cardiology for management.

## Risks

1. Conversion to pulseless rhythm; death

2. Hypoxic injury

3. Drug reactions

## References

1. Resuscitation Council of Southern Africa. Tachycardia Management Algorithm. 2021.

2. Goyal A, Sciammarella JC, Chhabra L, et al. Synchronized Electrical Cardioversion. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482173/