It is very common to see patients with different Tachycardias in Emergency department. Dealing with tachycardias as a part of ACLS is a must to know for all Emergency Physicians. This presentation covers different types of Tachycardias like Sinus Tachycardia, stable tachycardia, unstable tachycardia, ventricular tachycardia, supraventricular tachycardia, svt with abberancy, AIVR, TCA Toxicity, Ventricular paced rhythm, modified vagal maneuvre, atrial fibrillation and others

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Dealing with Tachycardias in Emergency Department
- Dr Varun Patel

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What is the
Tachycardia?

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Definition - Tachycardia

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Which is the most common type of
Tachycardia encountered in ER?

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Sinus Tachycardia

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Sinus Tachycardia – A Thinking
man’s Rhythm
 Always think about the cause
 Do not treat the rhythm – No Cardioversion or fancy Anti-
arrythmics needed
 In case of Chronic Atrial Fibrillation with Fast Ventricular
response, always think of the causes of Sinus Tachycardia first
and do not jump on rate control directly.

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Most common causes of sinus
tachycardia -

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Approach – Sinus Tachycardia

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Case 1
• A 25-year-old male with a past medical history of Crohn’s disease and
anemia presented with diffuse abdominal pain, vomiting, and diarrhea for 2
days. He had a heart rate of 130 on arrival, but otherwise normal vital signs.
His abdominal exam did not show focal tenderness or peritonitis. A CBC,
CMP, lipase, U&E, and lactate were ordered. He was given 2 L of IVF. His
labs were unremarkable except for a hemoglobin of 9.3 and a platelet count
of 615. He was discharged with iron supplementation and instructed to keep
his upcoming appointment with his gastroenterologist in 10 days.
• He returned 16 hours later with persistent pain. At that point, it was noted that
his heart rate at the time of discharge was 115. Repeat blood work showed a
hemoglobin of 6.5 and an elevated ESR and CRP. He was given more IVF, 2
units of pRBCs, ciprofloxacin, and metronidazole, and then admitted with a
GI consult.

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What went wrong?
There are several things to consider in this case, from documentation to systems
problems to knowledge review.
1. Crohn’s patients often have GI bleeding, but this was not documented (history or
exam) on the first visit. His second visit note says he had been having blood in
stool x 3 days. We all know history can change from one provider to another, but
get in the habit of asking and documenting this. No doubt his history of anemia
provided false reassurance that his hemoglobin of 9.3 was not serious.
2. Next a common system issue – he was discharged with tachycardia. It
frequently happens that vitals are measured after the order to discharge and are
not always seen by the responsible provider. Check that abnormal vitals have
normalized prior to discharge, or explain why you think they don’t need to.

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What went wrong?
3. It’s also advisable to have at least 2 exams documented on every patient you
see with abdominal pain. If the patient is being discharged, the second
documented exam should say he/she is better and tolerating PO.
4. Last, knowledge review – This patient had platelets > 600 on the first visit.
Thrombocytosis occurs in infections, postsurgical states, malignancy, post-
splenectomy state, acute blood loss, iron deficiency, or as a side effect of
certain medications (Tefferi, 2017). Think of it as an even less specific
inflammatory marker – something to explain if you’re sending someone home.

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Inappropriate Sinus Tachycardia
 It is a condition where there is no identifiable cause for Sinus
Tachycardia in an individual
 The cause is unknown but is considered to be because of
structural abnormality in Sinus node. Sinus node is more
susceptible to Catecholamine response. This leads to severe
spike in Heart rate even after minimal exertion
 It usually does not need treatment. Medical management with
rate controlling drugs and Surgical ablation of Sinus node is
considered in prolonged and severe cases.

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Diagnosing a Tachyrrhythmia -

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Stable vs Unstable Tachycardia
 Look for following signs of instability-
1. H – Hypotension
2. A – Acutely Altered Mental status
3. S – Signs of Shock
4. I – Ischemia (Chest Pain)
5. F – Failure (Pulmonary edema)

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Treating a Tachyrrhythmia -
 Unstable Tachycardia (Any type except sinus tachycardia) –
Electrical Cardioversion is indicated.
 Stable Tachycardia – Treatment depends on each type. This is
the part which is difficult.

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What rhythm is this?

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VT vs SVT with Abberancy

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VT vs SVT with Abberancy

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Let’s recheck the ECG -

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Let’s compare with SVT with
Abberancy-

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Case 2 -
• A 20-year-old male comes in with acute onset of severe dizziness and one
brief syncopal episode. He takes no medications and has been a very healthy
person. His heart rate is currently 220 beats per minute and his blood pressure
is 70/30 mm Hg. He is barely awake at the moment.
• What treatment will you provide to this patient?

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Post Electrical cardioversion

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A fatal mistake – Giving a AV
conduction blocking drug

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Learning Message -
 In case of SVT with abberancy, always look for possible WPW
syndrome. Especially if patients are young.
 Do not give ABCDs to patient with suspected WPW syndrome with
SVT with abberancy
 What to give such patients with stable tachycardia?
- Give Procainamide or Ibutilide
- Dosing for Procainamide – IV 15-18mg/kg over 30 minutes. Can
repeat after 5 minutes if no effect, but do not exceed more than 1g
- Dosing for Ibutilide – IV 1mg over 5 minutes, repeat if no effect
after 10 minutes

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One more ECG-

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Note -

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What is this?

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Remember -
In case of Ventricular rhythm-
• Rates < 50 bpm consistent with a Ventricular Escape
Rhythm
• Rates > 110 bpm consistent with Ventricular Tachycardia
• Rates between 50 to 110 bpm – Accelerated Idioventricular
Rhythm

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AIVR -

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AIVR -

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Treatment of Stable Monomorphic
VT -
 Current AHA guidelines suggest –
1. For Patients in VT with normal EF and normal QT interval –
First line is Procainamide (15mg/kg over 30minutes, can
repeat if no effect)
2. For Patients with reduced EF (Structural heart abnormality) –
First Line is Amiodarone (150mg diluted in D5% over 10mins
followed by infusion at 1mg/minute for 6 hours and
0.5mg/min for 18 hours.
Note – New drug ‘Nifekalant’ is used in Japan at 0.3 to 0.6 mg/kg
IV followed by 0.15 to 0.5 mg/kg/hr IV infusion.
2nd line drug - Sotalol

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V tach Mimics-
 SVT with abberancy
 WPW syndrome leading to Tachycardia
 Hyperkalemia (Sine wave pattern)
 TCA toxicity
 Idiopathic Ventricular tachycardia

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TCA Toxicity

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Ventricular Paced Rhythm

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Case 3-
• A 22-year-old female presents to the emergency department with a
“fast heart rate” and palpitations. She has experienced this before,
but she came today because the current episode is lasting longer
than usual. She is slightly dizzy but otherwise asymptomatic. She
is in no apparent distress, is breathing comfortably, and has 2+
peripheral pulses. Her vitals are within normal limits except a heart
rate of 162. Her EKG is shown below:

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Supraventricular Tachycardia

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Modified Vagal
Maneuvre

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Does patient with SVT need
HsTropI?
Which patients with SVT can we
discharge?

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Case 4 -

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What rhythm is this?

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Atrial Fibrillation Causes:

43. + Atrial Fibrillation

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Rate control vs Rhythm control

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Always consider Anti-coagulation in
A Fib (CHA2DS2VASc scoring)

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What rhythm is this? Treatment?

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Management:

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Thank you.