Management of Wide Complex Tachycardia

Assessment and Initial Management

The American Heart Association recommends immediate synchronized cardioversion for hemodynamically unstable patients with wide complex tachycardia 1, 2
Signs of hemodynamic instability include hypotension, acutely altered mental status, signs of shock, chest pain, or acute heart failure symptoms 2

For hemodynamically unstable patients, the American College of Cardiology recommends performing immediate synchronized cardioversion (with prior sedation in the conscious patient) 2, 4
Cardioversion is highly effective in terminating wide-complex tachycardia and avoids complications associated with antiarrhythmic drug therapy 1
The American Heart Association recommends procainamide for patients who do not have severe congestive heart failure or acute myocardial infarction 1, 5
Amiodarone is recommended for patients with or without severe congestive heart failure or acute myocardial infarction 1, 5

For regular stable wide-complex tachycardia of uncertain etiology, IV adenosine may be considered relatively safe for both treatment and diagnosis if the rate is regular and the QRS is monomorphic 1, 2, 4
Adenosine should NOT be given for unstable or irregular or polymorphic wide-complex tachycardias, as it may cause degeneration to ventricular fibrillation 4
For polymorphic wide-complex tachycardia associated with familial long QT syndrome, IV magnesium, pacing, and beta-blockers are recommended; avoid isoproterenol 1, 5

The American College of Cardiology advises against delaying cardioversion in hemodynamically unstable patients to attempt pharmacological conversion 3
Calcium channel blockers such as verapamil and diltiazem should be avoided in patients with ventricular tachycardia, as they can worsen hemodynamic status 3