This file contains presentation on stable and unstable tachycardia

1. Stable & Unstable
Tachycardia
EMS Management
Medic: Shola Date：2023-09-19

2. contents
Overview
01
Heart Electrical Conduction
System
02
Classification of Tachycardia
03
Stable and Unstable Tachycardia
04
Overview EMS Management
05
Case Presentation
06

3. AN OVERVIEW OF TACHYCARDIA
Tachycardia (tak-ih-KAHR-dee-uh) is the medical term for a heart
rate over 100 beats a minute. Many types of irregular heart
rhythms (arrhythmias) can cause tachycardia.
Tachycardia is a heart rate of greater than 100
beats per minute. When the heart beats too
quickly, there is a shortened relaxation phase.
This causes two main problems: the ventricles are
unable to fill completely, causing cardiac output to
decrease; and the coronary arteries receive less
blood, causing supply to the heart to decrease.

4. Electrical Conduction System
Going back to the analogy of the central heating system, the pump,
pipes and radiators are of no use unless connected to a power supply.
The pump needs electricity to work. The human heart has a similar
need for a power source and also uses electricity. Thankfully we don't
need to plug ourselves in to the mains, the heart is able to create it's
own electrical impulses and control the route the impulses take via a
specialised conduction pathway.
This pathway is made up of 5 elements:
The sino-atrial (SA) node
The atrio-ventricular (AV) node
The bundle of His
The left and right bundle branches
The Purkinje fibres

5. A Brief Summary
A Brief Summary
The Electrical Conduction Of The Heart

6. P wave: • Represents Atrial
depolarization
PRI: • Represents the time it takes
the impulse to travel from the SA
Node through the intraatrial
pathways in atria to the AV
junction and the delay at the AV
node.
• Interval from start of P wave to
start of QRS, measures 0.12-0.20
sec
QRS: • Represents conduction of
impulse from Bundle of His
through the ventricular
muscle. Represents ventricular
depolarization.
• Should measure less than 0.12
sec
T wave: • Follows ST segment. Slightly
rounded, positive deflection
• Represents ventricular repolarization,
“resting phase “of cardiac cycle

7. Classification
Normal Sinus Rhythm:- This rhythm represents the normal state with
the SA node functioning as the lead pacer with normal conduction
through the heart. The
intervals should all be consistent and within normal ranges.
Looking at the ECG you'll see that:
• Rhythm - Regular
• Rate - (60-100 bpm)
• QRS Duration - Normal
• P Wave - Visible before each QRS complex
• P-R Interval - Normal (<5 small squares. Anything above and
this would be 1st degree block)
• Indicates that the electrical signal is generated by the sinus node
and travelling in a normal fashion in the heart.

8. Sinus Tachycardia
It is an excessive heart rate above 100 beats per minute (BPM)
which originates from the SA node. Causes include stress, fright, fever,
anxiety, pain, dehydration, and exercise. Not usually a surprise if it is
triggered in response to regulatory changes (e.g. shock).
Looking at the ECG you'll see that:
• Rhythm - Regular
• Rate – Usually between 100 – 150 beats per minute
• QRS Duration - Normal
• P Wave - Visible before each QRS complex
• P-R Interval - Normal
• The impulse generating the heart beats are normal, but they are
occurring at a faster pace than normal. Seen during exercise

9. Atrial Flutter:- A single irritable focus in the atria fires in a rapid
repetitive fashion at a rate of 150 – 350 beats/min. The F waves appear
in a saw toothed pattern such as those in this ECG. The QRS rate is
usually regular and the complexes appear at some multiple of the P-P
interval. Causes includes Heart valve disorders, Heart condition present
at birth, Coronary artery disease, High blood pressure, Overactive
thyroid.
Looking at the ECG you'll see that:
• Rhythm – Usually regular
• Rate – Usually fast 110-150 beats per minute
• QRS Duration - Usually normal
• P Wave - Replaced with multiple F (flutter) waves, usually at a
ratio of 2:1 (2F - 1QRS) but sometimes 3:1
• P Wave rate - 300 beats per minute
• P-R Interval - Not measurable

10. Atrial Fibrillation
Atrial fibrillation is the chaotic firing of numerous atrial pacemaker cells in
a totally haphazard fashion. The result is that there are no
discernible P waves. And the QRS complexes are innervated
haphazardly in an irregularly irregular pattern. The ventricular rate is
guided by occasional activation from one of the pacemaking sources.
Because the ventricles are not paced by anyone site, the intervals are
completely random.
Looking at the ECG you'll see that:
• Rhythm - Irregularly irregular
• Rate - usually 100-160 beats per minute but slower if on medication
• QRS Duration - Usually normal
• P Wave - Not distinguishable as the atria are firing off all over
• P-R Interval - Not measurable
• The atria fire electrical impulses in an irregular fashion causing
irregular heart rhythm

11. Supraventricular Tachycardia (Narrow complex
Tachycardia) (SVT)
SVT is a narrow complex tachycardia originating above the ventricles.
SVT can occur in all age groups.
Looking at the ECG you'll see that:
• Rhythm - Regular
• Rate - > 150 beats per minute
• QRS Duration - Usually normal
• P Wave - Often buried in preceding T wave
• P-R Interval - Depends on site of supraventricular pacemaker

12. Wide Complex Tachycardia (usually monomorphic
ventricular
tachycardia) Abnormal
Ventricular tachycardia is simply the presence of three or more ectopic
ventricular complexes in a row with a rate above 100. Originates from
one irritable focus of the ventricles so the rhythm is regular. Poor cardiac
output is usually associated with this rhythm
Looking at the ECG you'll see that:
• Rhythm - Regular
• Rate – Fast usually 180-190 Beats per minute
• QRS Duration - Prolonged
• P Wave - Not seen
• Results from abnormal tissues in the ventricles generating a
rapid and irregular heart rhythm.

13. Polymorphic V-Tach (Torsades de Pointes)
Similar to ventricular tachycardia
Morphology of QRS complexes shows variations in width and
shape
Resembles a turning about or twisting motion along base line
May result from hypokalemia, hypomagnesemia, tricyclic
antidepressant drug overdose, the use of antidysrhythmic drugs,
or combination of these
Seen in alcoholics, eating disorders and the debilitated patients

14. Ventricular Fibrillation (VF)
Disorganized electrical signals cause the ventricles to quiver instead of
contract in a rhythmic fashion. A patient will be unconscious as there is
no cardiac output and blood is not pumped to the brain. Immediate
treatment by defibrillation is indicated. This condition may occur
during or after a myocardial infarct.
Looking at the ECG you'll see that:
• Rhythm - Irregular
• Rate - 300+, disorganized
• QRS Duration - Not recognizable
• P Wave - Not seen
• This patient needs to be defibrillated!! QUICKLY

15. Stable and Unstable Tachycardia
An unstable tachycardia exists when cardiac output is reduced to the
point of causing serious signs and symptoms.
Serious signs and symptoms commonly seen with unstable
tachycardia are: chest pain, signs of shock, SOA (short of air), altered
mental status, weakness, fatigue, and syncope.
Tachycardia is classified as stable or unstable.
Heart rates greater than or equal to 150 beats per minute usually
cause symptoms.
Unstable tachycardia always requires prompt attention.
Stable tachycardia can become unstable.

16. EMS Management

17. SYMPTOMATIC TACHYCARDIA WITH HEART RATE
> 150 BPM
1. If the individual is unstable, provide immediate synchronized
cardioversion.
Is the individual’s tachycardia producing hemodynamic instability and
serious symptoms?
Are the symptoms (i.e., pain and distress of acute myocardial infarction
(AMI)) producing the tachycardia?
2. Assess the individual’s hemodynamic status and begin treatment by
establishing IV, giving supplementary oxygen, and monitoring the heart.
Heart rate of 100 to 130 bpm is usually the result of an underlying
process and often represents sinus tachycardia. In sinus tachycardia, the
goal is to identify and treat the underlying systemic cause.
Heart rate greater than 150 bpm may be symptomatic; the higher the

18. the more likely the symptoms are due to the tachycardia.
3. Assess the QRS Complex
 REGULAR NARROW COMPLEX TACHYCARDIA (PROBABLE
SVT)
Attempt vagal maneuvers.
Obtain 12-lead ECG; consider expert consultation.
Adenosine 6 mg rapid IVP; if no conversion, give 12 mg IVP (second
dose); may attempt 12 mg once.
 IRREGULAR NARROW COMPLEX TACHYCARDIA (PROBABLE A-
FIB)
Obtain 12-lead ECG; consider expert consultation.
Control rate with diltiazem 15 to 20 mg (0.25 mg/kg) IV over two
minutes or beta-blockers.
 REGULAR WIDE COMPLEX TACHYCARDIA (PROBABLE VT)
Obtain 12-lead ECG; consider expert consultation.

19. IRREGULAR WIDE COMPLEX TACHYCARDIA
Obtain 12-lead ECG; consider expert consultation.
Consider anti-arrhythmic.
If Torsades de Pointes, give magnesium sulfate 1 to 2 gm IV; may
follow with 0.5 to 1 gm over 60 minutes.

20. Cardioversion
Synchronized cardioversion is used
during unstable tachycardia, but there
may be times when unsynchronized
cardioversion will need to be used.
Synchronized cardioversion needs to
be used with:
 Unstable SVT
 Unstable atrial fibrillation
 Unstable atrial flutter
 Unstable regular monomorphic
tachycardia with a pulse
Unsynchronized
cardioversion needs to be
used with:
 No pulse
 Critical issues – patient going
into cardiac arrest
 Patient in monomorphic or
polymorphic VT
 Patient at risk of going into
arrest

21. Energy in Joules used
during cardioversion:
Rhythm First Dose
(Monophasic
Defibrillator
Unstable atrial
fibrillation
200 J
Unstable
Monomorphic VT
100 J
Other unstable SVT,
Atrial Flutter
200 J
Unstable polymorphic
VT (irregular form &
rate)
Use like VF with high-
energy shock (360J)
 Put the leads on the patient and ensure
the rhythm is on the monitor. Put on the
adhesive electrode pads on the patient
 Push the SYNC button to get to the
synchronized mode
 Ensure the markers are on the R wave –
this shows that the sync mode is on
 Pick the correct energy level
 Ensure everyone is clear – “Stand clear,
charging defibrillator!”
 Push the charge button
 Again clear patient – “Everyone Clear!”
 Push the shock button
 Check rhythm to see if tachycardia is still
present. If tachycardia is persistent,
increase energy level slowly
 Press SYNC button again to activate the
sync mode
How to Give Synchronized Cardioversion
Anesthetize patient unless they are crashing or
unstable
 Turn on the defibrillator

22. If a patient shows stable tachycardia they
will not present with hypotension, shock,
ischemic chest pain, AMS or heart failure.
In a case when the patient is stable and
has regular rhythm, consider administering
adenosine and attempting to do vagal
maneuvers.
Vagal maneuvers and administration of
adenosine is the initial first line intervention
for narrow complex stable tachycardias.
These maneuvers initiate baroreceptors in
the aortic arch and the internal carotid
arteries, which then cause stimulation of
the Vagus nerve which releases
acetylcholine. The acetylcholine reduces
AV node conduction and that eventually
slows down the heart rate.
Types of Vagal Maneuvers
 Constant and forceful coughing
 Holding the breath
 Gagging
 Immersing face in ice-cold water
 Carotid sinus pressure – putting
slight pressure on the carotid
sinus for about 5 seconds
 Valsalva maneuver – this is a
forceful exhalation against a
closed airway. For example
bearing down like during bowel
movement for up to 10 seconds
or closing the mouth/pinching the
nose and blowing as if blowing up
a balloon.
Vagus
Maneuvers

23. 1. Scenario: A 45 year old patient arrives to the hospital with
chest pain and palpitations. As the nurse was obtaining
medical history and checking vital signs the patient faints for a
few minutes. She was connected to a monitor, Upon
assessment BP-87/68mmHg, P- I80bpm, Spo2- 91%, Temp.-
36.4°C & R- 20cpm. The doctor on duty order an ECG
examination. See result below.
a. Identify rythm
b. State your management
Case
Presentation

24. 2. Scenario: You are the night Inhospital Paramedic on duty and a
40-year-old woman is complaining of palpitations. She mentions that
she has a history of recurrent increased heart rates, and she feels
she’s having a heart attack. Upon assessment Heart rate was
132bpm, BP- Unobtainable, R- 18, Temp.- 36.9°C.
a. Upon obtaining ECG, a regular narrow QRS complex tachycardia
was found. Identify the class of Tachycardia
b. State your management? Put in mind that she is Asthmatic.

25. Thank You