Narrow Complex Tachycardia or Atrial Fibrillation w/RVR - Adult Algorithm

What defines unstable/pre-arrest status in narrow complex tachycardia?

No radial pulse but carotid is palpable, HR typically greater than 150 bpm with altered mental status

What is the adenosine dose for regular symptomatic SVT with a sustained heart rate above 150 bpm?

12 mg IV/IO by rapid push

What is given immediately after adenosine administration for SVT?

20cc saline flush

How many times may adenosine be repeated for SVT and at what dose?

Once, 12 mg, if no rhythm change

What should be repeated after a rhythm change in narrow complex tachycardia?

12-lead ECG

What is the initial synchronized cardioversion energy for unstable narrow complex tachycardia?

200 Joules

What are the escalating cardioversion energies if a repeat shock is needed for narrow complex tachycardia?

300 joules, then 360 joules

What sedation may be considered prior to cardioversion for narrow complex tachycardia?

Ketamine 0.5 mg/kg IV/IO

What alternative sedation may be considered prior to cardioversion for narrow complex tachycardia?

Fentanyl 1 mcg/kg IV/IO/IN

What systolic BP is required to use midazolam prior to cardioversion for narrow complex tachycardia?

Greater than 90 mmHg

What is the midazolam dose and maximum prior to cardioversion for narrow complex tachycardia?

0.1 mg/kg IV/IO/IN, maximum 5 mg

What is the diltiazem dose for narrow complex tachycardia/Afib RVR if systolic BP is greater than or equal to 90?

20 mg slow IV/IO

What is the diltiazem dose for narrow complex tachycardia/Afib RVR patients age 60 or older?

10 mg, then repeat 10 mg in 5 minutes if SBP is greater than or equal to 90 mmHg

When may diltiazem be repeated again if the rate is not controlled in narrow complex tachycardia/Afib RVR?

In 15 minutes if SBP is greater than or equal to 90 mmHg

What is the lidocaine dose for narrow complex tachycardia/Afib RVR?

2% 1 mg/kg

What is the maximum number of lidocaine doses for narrow complex tachycardia/Afib RVR?

3 doses

What is the alternative amiodarone dose for narrow complex tachycardia/Afib RVR?

150 mg over 10 minutes IV/IO

What is the amiodarone dose for suspected Torsades de Pointes?

150 mg IV over 10 minutes

What is the magnesium dose for Torsades de Pointes?

2 grams IV/IO

What medications should be avoided in WPW presenting with narrow complex tachycardia?

AV nodal blocking agents such as adenosine, digoxin, diltiazem, verapamil

What medication is considered instead in WPW presenting with narrow complex tachycardia?

Amiodarone 150 mg IV over 10 minutes

What irregular rhythm with a rapid ventricular response above 120 bpm requires rate control treatment?

Atrial fibrillation or atrial flutter with symptomatic rapid ventricular response