TACHYCARDIA

Complete COVER ABCD - A SWIFT CHECK
Do not hesitate to treat as Cardiac Arrest  (1)
If hypertensive (2)
If hypotensive  (3)
     Confirm change in blood pressure is real (4)
     Recheck that vaporiser(s) are off
     Crystalloid 10 ml/kg bolus and repeat if necessary.
 

If primary sinus tachycardia, with or without hypotension, treat tachycardia first  (5)
If non-sinus tachycardia, choose treatment based on severity of hypotension (6)
If severe, use cardioversion
     For adults, start at 100 Joules, if unsuccessful, 200 Joules (synchronised mode)
     For children
          for pulseless VT:            
                start at 2 Joules/kg, try twice then increase to 4 J/kg (unsynchronised mode)
          for SVT:
                0.5 – 1 Joules/kg (synchronised mode)
     Consider antiarrhythmic drugs.
If mild, use appropriate antiarrhythmic drugs - adult doses only:
     VT: Lignocaine 70mg IV (or amiodarone 200mg IV over 10 min) (7)
     AF: Digoxin 0.5 mg IV (or amiodarone 200mg IV over 10 min) (8)
     SVT: Adenosine 6-12 mg IV (or titrated beta blocker: atenolol 1 mg boluses) (9)

     For less urgent SVT in children: Adenosine 0.05 mg/kg, increasing to 0.25 mg/kg, by rapid IV or intraoral bolus.

Hypovolaemia (10)
      Consider: Blood loss, dehydration, diuresis, sepsis Þ page xxx
      Ensure: Adequate IV access, fluid replacement cross match and check haematocrit.
Drugs (11)
     Consider: Induction and inhalation agents, atropine, local anaesthetic toxicity, adrenaline, cocaine, vasopressors.
Airway: (12)
     Hypoventilation 
     Hypoxia (see Desaturation)
     Anaphylaxis (13) 
Reflex Stimulation (14)
     Consider: Laryngoscopy, CVC insertion, surgical manipulation.
     Consider Awareness
Cardiopulmonary Problems (15)
     Consider: Tension pneumothorax, haemothorax, tamponade,
                     embolism (gas, amniotic or thrombus),
                     sepsis ,
                     myocardial irritability (from drugs, ischaemia, electrolytes,
                                                       trauma),
                     pulmonary oedema.
Ensure: Review of appropriate pages in manual, including both cardiac arrest pages:
              (advanced life support, and basic life support during anaesthesia)
 

Monitor for myocardial ischaemia
Consider further drug therapy

The figures reported here are based on an analysis of 123 of the first 4000 AIMS anaesthesia incidents. A correct use of the algorithms would have led to earlier recognition of the problem and/or better management in 3% of the 123 relevant cases reported to AIMS.
(1) 17% presented as cardiac arrest.
(2) There was associated hypertension in 26% of cases.
(3) There was associated hypotension in 33% of cases.
(4) Use sphygmomanometer and auscultate the blood pressure. When using an arterial line check the zero and calibration.
(5) With sinus tachycardia, treatment is that of the primary cause. In the vast majority of cases this alone will result in resolution. If it is persistent and associated with hypotension, refer to hypotension
(6) Non sinus tachycardia was present in 46% of cases, including ventricular tachycardia in 13%, paroxysmal supraventricular tachycardia in 9%, atrial fibrillation in 8% and atrial flutter in 1%..
(7) Ventricular tachycardia (VT)
          100-200/min slightly irregular, broad complexes
          IV lignocaine 1mg/kg (or amiodarone 5 mg/kg) for adults
     Also, see pulseless VT.
(8) Atrial fibrillation/flutter
          fibrillation 100-200/min, irregular narrow complexes, no P waves
          (flutter: P waves 250-300/min, ventricular rate 100 or 150),
          IV digoxin 0.01 mg/kg (or amiodarone 5 mg/kg) for adults.
(9) Paroxysmal supraventricular tachycardia
          150-250/min, regular narrow complexes, obscured P waves,
          IV adenosine 6-12 mg (or atenolol 1mg IV boluses) for adults
                               0.05-0.25 mg/kg IV for children
(10) Hypovolaemia was associated with 4% of cases, however it is the commonest cause of tachycardia and hypotension. It is so common it is not usually regarded as an incident.
(11) Drugs were associated in 33% of cases. The most commonly implicated were induction and volatile agents, atropine, local anaesthetic toxicity, adrenaline, cocaine and vasopressors.
(12) Airway problems were often one of multiple contributing factors but were specifically reported in 4% of cases. Hypoventilation/hypoxia occurred in the setting of difficult intubation and with circuit problems, causing secondary light anaesthesia in some instances.
(13) Anaphylaxis was a factor in 11% of cases.
(14) Autonomic reflex stimulation was reported in 9% of cases.
(15) Cardiopulmonary problems were reported in 8% of cases.