The site of origin may be in the sinus node, the atria, the atrioventricular av node, the his bundle. Wolffparkinsonwhite syndrome pacemakertracked or pacemakermediated tachycardia. It is speculated that these relatively rare cases of narrowcomplex ventricular tachycardia utilize the hispurkinje system as part of the tachycardia circuit. Qrs complex tachycardia is best deduced by first assessing the relationship of atrial activity p waves to the qrs com. A narrow qrs complex tachycardia qrs duration 100 bpm indicates a supraventricular origin with ventricular activation occurring via the fastconducting hispurkinje system. Some patients may have cardiovascular instability with tachycardia at heart rate less than 150 bpm. It is a blanket term that includes a lot of different rhythms and is simply a starting point on the road to diagnosis. If response or condition changes see appropriate protocol.
Adenosine should be pushed rapidly via proximal iv. Atrial fibrillation, multifocal atrial tachycardia, and wandering atrial pacemaker do not constitute regular narrow qrs complex tachycardias and will not be. In the emergency setting most broad complex tachycardias have a ventricular origin. Current algorithms for the diagnosis of wide qrs complex. Treat as for regular narrowcomplex tachycardia synchronised dc shock up to 3 attempts amiodarone 300 mg iv over 1020 min repeat shock.
Next one should determine if the rhythm is irregular or irregular, as this will help narrow down your differential diagnosis of possible causes. Regular narrowcomplex tachycardia sinus tachycardia. Flow of protocol presumes that narrow complex tachycardia is continuing. Most narrow complex tachycardias originate from a pacemaker above the ventricles and are therefore supraventricular tachycardias.
Narrow complex when evaluating a tachyarrhythmia one should first evaluate whether the qrs is a narrow complex or a wide complex. Acls tachycardia algorithm the acls tachycardia algorithm is used for patients who have marked tachycardia, usually greater than 150 beats per minute, and a palpable pulse. In this article we present a differential diagnostic and treatment approach to irregular. P waves are buried in the qrs complexes simultaneous activation of atria and ventricles most common presentation of avnrt 66%. Acls tachycardia algorithm for managing stable tachycardia. Supraventricular tachycardia svt is an abnormally fast heart rhythm arising from improper electrical activity in the upper part of the heart. Programmed atrial extrastimulation elicited dual atrioventricular av nodal physiology and ventricular pacing showed no ventriculoatrial conduction despite isoproterenol. Adenosine should be pushed rapidly via proximal iv site followed by. Narrow complex tachycardia supraventricular tachycardia. June 5, 2009 page 2 of 2 a guideline for the care of patients with narrow complex ta irregular may repeat 12 mg dose once fentanyl 1 mcgkg ivio chycardia of cardiac origin with a ventricular rate greater than 150minute qrs complex tachycardia 3. Pediatric narrow complex tachycardia electrical and medication treatments in this protocol are not intended to treat tachycardia that is secondary to underlying conditions i.
Pdf chapter08 narrow complex tachycardia researchgate. Management and treatment for a stable tachycardia with a wide qrs complex and either a regular or irregular rhythm should be done in the hospital setting with expert consultation available. The authors present the case of a 9monthold infant with wolffparkinsonwhite syndrome admitted with both wide and narrow qrs complex. If the tachycardia has a wide complex qrs and is stable, consult with an expert. To divide up this myriad of possibilities, a bit of basic electrophysiology terminology needs to. Supraventricular tachycardia is defined as pulse rate 220 in infants 180 in children. Tachycardia this protocol is used for the care of patients with persistent tachycardia ventricular rate greater than 150minute where the tachycardia is believed to be the primary cause of the patients symptoms. It is not intended to treat tachycardia that is secondary to underlying conditions i. A narrow complex tachycardia with an accessory conduction pathway, often termed supraventricular tachycardia with preexcitation e. The acute management of a regular narrow qrs complex tachycardia will depend on the hemodynamic state of the patient. If at any point patient becomes unstable move to unstable arm in algorithm. A narrow complex tachycardia with atrioventricular. It can be due to sinus tachycardia, where the sinus node fires at a rate of over 100 beats per minute.
Tachycardia in which the duration of the qrs complex is less than 0. Narrow qrs complex tachycardias mayo clinic proceedings. Narrow complex tachycardia nct is defined as a heart rate. Narrow and wide complex tachycardia interventional cardiology. It is important to consider the clinical context when treating adult tachycardia. Tachycardias are broadly categorized based upon the width of the qrs complex on the electrocardiogram ecg. Treatment of symptoms close observation consider placing the pads on the patient and prep medications for decompensation p narrow irregular unstable. Baseline atriohis and hisventricular intervals measured 75 ms and 50 ms, respectively. Ecg showed an irregular narrow complex tachycardia. Pdf on jan 1, 2005, indranill ray and others published chapter08 narrow complex tachycardia find, read and cite all the research you. The operative word narrow maintains that regardless of the arrhythmia mechanism or atrial activity, ventricular depolarisation is rapid via engagement of the hispurkinje. P waves are retrograde and are inverted in leads ii,iii,avf. The supraventricular tachycardias journal of cardiology.
The pharmacologic and nonpharmacologic antiarrhythmic approaches discussed may, therefore, include some accahaesc guildelines 1859. Differential diagnoses include atrial fibrillation, atrial flutter with variable block, sinus rhythm with premature supraventricular complexes, atrioventricular nodal reentry tachycardia with upper common pathway block, multifocal atrial tachycardia, and dual atrioventricular nodal nonreentrant tachycardia davnnt. Consultation with online medical control should be considered for complex patients in whom the cause of the arrhythmia is not obvious. What makes a narrowcomplex tachycardia a narrowcomplex tachycardia. 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. 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. Recognition and management in the emergency room ib ray abstract cardiac arrhythmias often present as urgent medical conditions requiring immediate care. Broad complex tachycardias occur by various mechanisms and may be ventricular or supraventricular in origin. Amiodarone 300 mg iv over 2060 min then 900 mg over 24 h if known to be svt with bundle branch block. Symptoms may include palpitations, feeling faint, sweating, shortness of breath, or chest pain. Narrow complex tachycardia definition of narrow complex. Overall, this is a consensus document that includes evidence and expert opinions from several countries. Avnrt presence of a narrow complex tachycardia with regular rr intervals and no visible p waves.
P waves consistent with retrograde atrial activation are seen labeled with arrow, along with a short rp interval 85 ms and intermittent 2. The narrow complex tachycardias ncts are defined by the presence in a 12 lead electrocardiogram. If the patient remains stable and rhythm does not convert, transport to appropriate hospital. A supraventricular tachycardia is a rapid heart rate that originates from above or within the av node. Accahaesc guidelines for the management of patients with. A narrow qrs complex pdf available in singapore medical journal 523.
Irregular narrowcomplex tachycardia is most likely to be af or sometimes atrial flutter with variable av conduction variable block. Foundations ekg i approach to tachyarrhythmias narrow. Patient presenting with a tachyarrhythmia is a common finding in the emergency room. Atrial fibrillation af is the most common cause of an irregular, narrowcomplex tachycardia, affecting approximately 33 million people worldwide. A 74yearold woman underwent diagnostic electrophysiologic study because of recurrent, symptomatic supraventricular tachycardia. Arises almost always as a physiologic response or compensation to an underlying trigger, and this must be identified. Differential diagnosis of regular, narrowqrs tachycardias. Supraventricular tachycardia svt refers to any tach.
Treat as for regular narrow complex tachycardia synchronised dc shock up to 3 attempts amiodarone 300 mg iv over 1020 min repeat shock. The differential diagnosis of a regular, monomorphic wide qrs complex tachycardia wct mechanism represents a great diagnostic dilemma commonly encountered by the practicing physician, which has important implications for acute arrhythmia management, further workup, prognosis and chronic management as well. Avnrt presence of a narrow complex tachycardia with regular rr intervals. Narrow complex tachycardia schoolcraft memorial hospital. Narrow complex tachycardias are supraventricular tachycardias, meaning only that they originate above the ventricles. This is a common physiological response to stimuli such as exercise or anxiety. Pdf definition, diagnosis and management of tachycardia. The correct differentiation of an irregular, narrowcomplex tachycardia has crucial implications for the therapeutic management of these conditions. A 30yearold man with palpitations and heart rate 241min had a temperature of 38. The narrow complex tachycardias ncts are defined by the presence in a 12lead electrocardiogram ecg of a qrs complex duration less than 120 ms and a heart rate greater than 100 beats per minute. The ecg reveals a narrow complex tachycardia with a ventricular rate of 108 beatsmin and nonspecific stt wave changes. Tachycardias may be classified as either narrow complex tachycardias supraventricular tachycardias or wide complex. Typical sinus tachycardia is in the range of 100 to 200 patient s age beats per minute.
21 1502 101 1352 891 270 1591 797 1569 1322 1540 879 199 862 10 1373 1494 757 407 1465 86 369 874 170 326 1000 976 527 314 1345