Adult Tachycardia With a Pulse Algorithm

This flowchart depicts the Adult Tachycardia with a Pulse Algorithm. It consists of numbered boxes and hexagons linked together with arrows, as well as an inset table to the right. It originates at the top with box number 1. This orange box instructs, “Assess appropriateness for clinical condition. Heart rate typically greater than or equal to 150 beats per minute if tachyarrhythmia.” From here, an arrow points downward to box 2. This green box is titled, “Identify and treat underlying cause.” It contains three main points:

• Maintain patent airway; assist breathing as necessary.
• Oxygen (if hypoxemic).
• Cardiac monitor to identify rhythm; monitor blood pressure and oximetry.

This points downward to a red hexagon, which asks: “Persistent tachyarrhythmia causing: Hypotension? Acutely altered mental status? Signs of shock? Ischemic chest discomfort? Acute heart failure?” If the answer is “Yes,” an arrow points to the right to box 4. This green box is titled “Synchronized cardioversion.” It contains two points of text:

• Consider sedation.
• If regular narrow complex, consider adenosine.

However, if the answer is “No,” an arrow points downward to another red hexagon that asks, “Wide QRS? Greater than or equal to 0.12 second.” If the answer is “Yes,” an arrow points to the right to box 6. This green box contains four points:

• I.V. access and 12-lead ECG if available.
• Consider adenosine only if regular and monomorphic.
• Consider antiarrythmic infusion.
• Consider expert consultation.

If the answer is “No,” an arrow points downward to box 7. This green box contains five points:

• I.V. access and 12-lead ECG if available.
• Vagal maneuvers.
• Adenosine (if regular).
• Beta-blocker or calcium channel blocker.
• Consider expert consultation.

The inset table has three rows. The first one contains the title: “Doses or Details.” The second row begins with “Synchronized cardioversion” in bold followed by this text: “Initial recommended doses:

• Narrow regular: 50 to 100 Joules.
• Narrow irregular: 120 to 200 Joules biphasic or 200 Joules monophasic.
• Wide regular: 100 joules.
• Wide irregular: defibrillation dose (not synchronized).

Then it says in bold, “Adenosine IV dose.” Text goes on to say: “First dose: 6 milligram rapid I.V. push; follow with NS flush. Second dose: 12 milligrams if required.” The third row begins with “Antiarrhythmic Infusions for Stable Wide-QRS Tachycardia” in bold italic text. Bold text then says, “Procainamide I.V. dose.” Its text instructs, “20 to 50 milligrams per minute until arrhythmia suppressed, hypotension ensues, QRS duration increases more than 50 percent, or maximum dose 17 milligrams per kilogram given. Maintenance infusion: 1 to 4 milligrams per minute. Avoid if prolonged QT or CHF.” Bold text then says, “Amiodarone I.V. dose.” Text then instructs, “First dose: 150 milligrams over 10 minutes. Repeat as needed if VT recurs. Follow by maintenance infusion of 1 milligram per minute for first 6 hours.” The text “Sotalol I.V. dose” appears in bold. This is followed by, “100 milligrams (or 1.5 milligrams per kilogram) over 5 minutes. Avoid if prolonged QT.” This figure is copyright 2015 by the American Heart Association.