WIDE COMPLEX
TACHYCARDIA
Puja Chopra, PGY-1
Emergency Medicine
May 19, 2011
Objectives
Differential Diagnosis of wide complex tachycardia
Approach to wide complex tachcardia
Examples of wide complex tachycardia
Adenosine/ACLS
DDx:
Ventricular tachycardia
SVT with a preexisting bundle branch block or a
functional rate related bundle branch block
SVT with antegrade conduction via an accessory
pathway
Drug induced – TCA, Class one antiarryhtmic
Electrolyte - hyperkalemia
Wellen’s Criteria
RBBB Pattern
LBBB Pattern
Sensitivity: 98.7%
Specificity: 96.5%
Brugada Criteria:
-Sensitivity: 79 to 91%
-Specificity: 43 to 70%
Approach to WCT
1. History
2. Physical Exam
3. ECG
Regular: VT, SVT with aberrancy, SVT with accessory
pathway, Electrolyte abnormalities, Medications
Irregular: a fib + pre-excitation, a fib + BBB, a flutter +
BBB, MAT + BBB, polymorphic Vtach (torsades)
?AV dissociation, Fusion beats, capture beats
4. Adenosine (?Diagnostic, ?therapeutic)
70 yo male with palpitations and history of angina
61 yo male with productive cough and fever
65 yo male with syncope, PMHx: DM
30 yo female with palpations
30 yo female with palpations
28 yo male, altered and agitated after an unknown
overdose
45 yo male, previously healthy, with palpitations
44 year old chronic alcoholic male with persistent vomiting and
becomes unresponsive
65 yo female with palpations
48 yo male with palpitations
Adenosine in the Diagnosis of Broad
Complex Tachycardia
- Griffith et al. The Lancet March 1988
89% Sensitivity, 95%
specificity, 92% predictive
accuracy for SVT origin
Broad
Complex
Tachycardia
SVT
VT
8/9
1/17
Atrial
Fibrillation
with WPW
0/6
No change
in mean RR
Intravenous Adenosine Triphosphate During Wide QRS
Complex Tachycardia: Safety, Therapeutic Efficacy and
Diagnostic utility
- Sharma et al. The American Journal of Medicine, April 1990
Broad
Complex
Tachycardia
SVT not
requiring the
AV node
1/10
Significant
shortening of
RR interval
Sensitivity: 70%,
Specificity: 92%, PPV: 85%
VT
SVT requiring
the AV node
1/14
7/10
Adenosine for the Management of Patients
with Tachycardias – A new Protocol
- Domanovits et al. European Heart Journal, 1994
Wide
Complex
Tachycardia
SVT
VT
Afib/Aflutter
with
aberrancy
17/22
0/4
0/3
Adenosine For Wide Complex Tachycardia:
Efficacy and Safety
- Marill et al. Critical Care Medicine, 2009
Regular Wide
Complex
Tachycardia
Primary outcome:
termination of
tachycardia with
adenosine, AV block
allowing rhythm
identification
- The odds of SVT
increase by a factor of
36 after a positive
response to adenosine
SVT
VT
104/116
2/81
- Odds of VT increase
by factor of 9 after a
negative response to
adenosine
Thanks!
Questions?