Approach to Wide Complex Tachycardia
Ramon Kumar M.D.
A. History and Physical
1. Stable or not? If no, emergency DCCV according to ACLS
2.
History of CAD or cardiomyopathy? (95% accuracy using history alone)* Am J
Med 1988 Jan;84(1):53-6
3. Press on neck:
a) if SVT  ventricular rate will slow
b) if VT  exposes AV dissociation by slowing retrograde conduction
B) ECG—AV dissociation and axis (strong associations)
1. Regular? If no, NOT MMVT (except in first 30 beats—warmup phenomenon)
2. Concordance? ** remember, positive concordance can come from left bypass tract
and antidromic AVRT (down bypass tract and up AV node).
3. Fusion or Capture: Proves VT
4. Axis:
- Northwest
-Rightward Axis with Left bundle pattern
-Leftward Axis with Right bundle pattern
C) ECG—Morphology Criteria (weaker associations)
1. V1: Up or down (RBBB or LBBB respectively)
2. RBBB:
a) V1  anything other than rSR’ (i.e. RS or RSr’) favors VT
b) V6  rS favors VT and Rs favors SVT
3. LBBB:
a) V1  notched downsloap (Josephson sign) and delayed intrisicoid
deflection of 60 msec (time from start of QRS origin to nadir of S) favors
VT
b) V6  Presence of any Q wave favors VT
4. Really Wide? >140msec RBBB and >160msec LBBB favors VT
Tx MMVT: *** if patient is normotensive, NOT SOB, and mentating, then you can use
IV medications (amiodorone 150mg IV over 10 minutes q10 minutes and hang 1mg/min
or lidocaine 0.75mg/kg IV push q10 minutes and hang at 1-4mg/min). If not, use
synchronized DCCV. If clinical status deteriorates (i.e. LOC or patient looses pulse, use
asynchronized DCCV according to ACLS).