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Stable Tachycardia

ACLS Stable Tachycardia Case

Define stable tachycardia. heart rate >100/min, no significant signs or symptoms
What questions do you ask yourself to determine the tachycardic patient’s classification? symptoms present or absent? Due to tachycardia? Stable or unstable? QRS wide or narrow? Rhythm regular or irregular? QRS monomorphic or polymorphic? Sinus tachycardia?
What are some things that can help you distinguish sinus tachycardia from SVT. Sinus tachycardia does not exceed 220/min, usually does not even exceed 120-130/min and has a gradual onset and termination. SVT has an abrupt onset/termination.
What causes sinus tachycardia? External influences on the heart such as fever, anemia, hypotension, blood loss, pain, or exercise
What is the treatment for sinus tachycardia? Fix the cause. Vagal maneuvers may work. No cardioversion!
Describe how and why beta blockers could cause clinical deterioration in the patient with sinus tachycardia. A condition that impairs stroke volume such as large MI requires beta receptor mediated HR to compensate.
Broadly define the steps to managing a patient with tachycardia. What do you need to figure out? First determine if pulses are present (not present = Cardiac arrest algorithm). If pulses are present manage the patient according to tachycardia algorithm. Next determine if the patient is stable are unstable. Provide treatment accordingly.
What is the first step in the adult tachycardia with a pulse algorithm? Assess appropriateness for clinical condition = Assess condition, typically heart rate >150 is due to tachyarrhythmia and not sinus rhythm
What is the second step in the adult tachycardia with a pulse algorithm? identify and treat underlying cause, Maintain patent airway, assist with breathing as necessary, oxygen if hypoxemic, monitor to identify rhythm, monitor BP and pulse ox
What is the third step in the adult tachycardia with a pulse algorithm? determine if the patient is experiencing symptoms from the tachyarrhythmia (hypotension, AMS, signs of shock, ischemic chest discomfort, acute heart failure)
What is the course of action if the patient does not have symptoms and does not have wide QRS? IV access, 12 lead ECG, Vagal maneuvers, Adenosine if regular,BB or CCB, Expert consultaion
What is the course of action if the patient is asymptomatic and has wide QRS? IV access, 12 lead ECG, Adenosine for regular and monomorphic rhythm, Antiarrhythmic infusion, expert consultation
What is the course of action if the patient is stable and has monomorphic wide complex tachycardia? Expert consultation
What is the course of action if the patient is unstable and has polymorphic wide complex tachycardia? immediate cardioversion
What is the course of action if the patient is stable and has wide complex tachycardia? Transport and monitor, expert consultation because treatment has potential for harm
What two rhythms could be represented by regular wide complex tachycardia? VT or SVT with aberrancy
It can be difficult at times to distinguish ventricular wide complex rhythms from SVT with abberancy. Which rhythm is most likely? Most wide complex rhythms are ventricular in origin.
Which common forms of wide complex tachycardias are likely to deteriorate to VF? monomorphic VT and polymorphic VT
What rhythms could be represented by irregular wide complex tachycardias? A fib with aberrancy, pre-excited atrial fibrillation (using accessory pathway for antegrade conduction), Polymorphic VT/torsades des pointes
What is the treatment for likely VT or SVT in an stable patient even if the rhythm cannot be determined for sure, but it is regular and monomorphic? IV adenosine is relatively safe for both treatment and diagnosis. IV antiarrhythmics, procainamide, amiodarone, or sotalol may also be effective
What is the course of action for irregular wide complex tachycardia? Control the rate, convert hemodynamically unstable afib to sinus rhythm or both – Expert consultation.
What drugs should be avoided when patients have irregular wide complex tachycardia? AV nodal blocking agents such as adenosine, CCBs, Digoxin, and possibly BB, because if the rhythm is pre-excitation A fib these drugs can cause paradoxical increase in ventricular response.
What is the treatment for narrow QRS with regular rhythm? vagal maneuvers, adenosine
Describe administration of adenosine when SVT does not respond to vagal maneuvers. Give adenosine 6 mg rapid IV push, 20 mL saline flush, elevate arm, If SVT does not convert in 1-2 minutes follow with adenosine 12 mg rapid IV push
How can adenosine be diagnostic? What does adenosine do to A fib and A flutter? It won’t stop it but it will slow AV conduction so that fibrillation or flutter waves can be identified
Is adenosine safe for pregnant women and their babies? yes
What drugs if present at significant levels in the patient’s blood would require larger doses of adenosine for effectiveness? Theophylline, caffeine, or theobromine
What cases would require a 3mg dose of adenosine? Patient’s taking dipyridamole or carbamazepine, or patients with transplanted heart
Why shouldn’t adenosine be used if the patient has asthma? May cause bronchospasm
Treatment with adenosine has resolved a narrow complex tachycardia causing you to believe the rhythm was likely SVT. After resolution the rhythm recurs. What is your next action? administer adenosine or longer acting AV nodal blocking agents such as Verapamil and Diltiazem or Beta blockers. Typically, you should obtain expert consultation if the rhythm recurs.
If you treat a regular narrow complex tachycardia with vagal and adenosine unsuccessfully, what is your next action? Transport and seek expert consultation because stable tachycardia can wait and treatment can cause harm.