Tachyarrhythmias in the ER

  • Carlos Jerjes-Sánchez
  • Jose Gildardo Paredes-Vázquez
  • Mariana Vanoye-Tamez
  • David Rodríguez
  • Raul del Toro-Mijares
  • Mauricio Vázquez Guajardo
  • Yoe Flores


Cardiac arrhythmias are one of the most prevalent cardiovascular causes of consult in the emergency room. The tachyarrhythmias have a broad clinical presentation spectrum with life-threatening implications in several cases, demanding an accurate and prompt diagnosis and initial treatment. The initial approach represents to determine the clinical stability of the patient. The electrocardiogram is the principal diagnosis tool and will divide the tachyarrhythmias in narrow or wide QRS complex, an aspect that guides the initial treatment. In wide QRS complex tachycardias, the main challenge during the diagnosis approach recognizes supraventricular tachycardias from ventricular tachycardias, and validated algorithms have been described as a tool to distinguish between these two types of arrhythmias. If the arrhythmia is not possible to be differentiated, it is recommended it be treated as ventricular tachycardia, especially in patients over 40 years and major risk factors to coronary artery disease. The initial treatment in stable patients with supraventricular tachycardia is vagal maneuvers and/or adenosine in bolus, which is effective to stop the arrhythmia and to figure out the auricular activity in atrial and flutter fibrillation. In unstable patients, the treatment of choice is electric cardioversion. Every tachyarrhythmia has different acute and maintenance therapy options that must be assessed depending on patient comorbidities and baseline medication. The reader will find practical elements for the early recognition of tachyarrhythmias, as well as examples and flowcharts for a fast-track evaluation. Also, you will find tables with drugs and doses that could facilitate the management in the emergency room.


Tachyarrhythmia Tachycardia Supraventricular Ventricular Atrial fibrillation Flutter 


  1. 1.
    Bellew SD, Bremer ML, Kopecky SL, Lohse CM, Munger TM, Robelia PM, et al. Impact of an emergency department observation unit management algorithm for atrial fibrillation. J Am Heart Assoc [Internet]. 2016 [cited 2018 Oct 10];5. Available from:
  2. 2.
    Dewland TA, Oesterle A, Stein J, Marcus GM. Health care utilization among adenosine-sensitive supraventricular tachycardia patients presenting to the emergency department. J Interv Card Electrophysiol. 2017;49:103–9.CrossRefGoogle Scholar
  3. 3.
    Page RL, Joglar JA, Caldwell MA, Calkins H, Conti JB, Deal BJ, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia. J Am Coll Cardiol. 2016;67:e27–115.CrossRefGoogle Scholar
  4. 4.
    Long B, Koyfman A. Best clinical practice: emergency medicine management of stable monomorphic ventricular tachycardia. J Emerg Med. 2017;52:484–92.CrossRefGoogle Scholar
  5. 5.
    Katritsis DG, Boriani G, Cosio FG, Hindricks G, Jaïs P, Josephson ME, et al. European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia (SOLAECE). EP Eur Heart J. 2017;19:465–511.Google Scholar
  6. 6.
    Brady WJ, Laughrey TS, Ghaemmaghami CA, Tintinalli JE, Stapczynski JS, Ma OJ, et al. Chapter 18.- Cardiac Rhythm Disturbances. In: Tintinalli’s Emerg Med Compr Study Guide [Internet]. 8a ed. New York, NY: McGraw-Hill Education; 2016.. Available from: Scholar
  7. 7.
    Mann DL, Zipes DP, Libby P, Bonow RO, Braunwald E. Braunwald’s heart disease. A textbook of cardiovascular medicine. Braunwalds Heart Dis Textb Cardiovasc Med. 10th ed. USA: Elsevier Saunders; 2015.Google Scholar
  8. 8.
    Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Heart Rhythm. 2018;15:e73–189.CrossRefGoogle Scholar
  9. 9.
    Vereckei A. Current algorithms for the diagnosis of wide QRS complex tachycardias. Curr Cardiol Rev. 2014;10:262–76.CrossRefGoogle Scholar
  10. 10.
    Chin A, Vezi B, Namane M, Weich H, Scott-Millar R. An approach to the patient with a suspected tachycardia in the emergency department. S Afr Med J. 2015;106:246.CrossRefGoogle Scholar
  11. 11.
    Kowey PR. Pharmacological effects of antiarrhythmic drugs. Review and update. Arch Intern Med. 1998;158:325–32.CrossRefGoogle Scholar
  12. 12.
    Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, et al. Part 7: adult advanced cardiovascular life support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132:S444–64.CrossRefGoogle Scholar
  13. 13.
    Priori SG, Blomström-Lundqvist C, Mazzanti A, Blom N, Borggrefe M, Camm J, et al. 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: the task force for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death of the European Society of Cardiology (ESC) endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J. 2015;36:2793–867.CrossRefGoogle Scholar

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© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Instituto de Cardiología y Medicina Vascular, TecSalud, Escuela de Medicina y Ciencias de la Salud, Tecnológico de MonterreySan Pedro Garza GarcíaMéxico
  2. 2.Centro de Investigación Biomédica del Hospital Zambrano Hellion, TecSalud, Escuela de Medicina, Tecnológico de MonterreySan Pedro Garza GarcíaMéxico
  3. 3.Escuela de Medicina y Ciencias de la Salud, Tecnológico de MonterreyMonterreyMéxico

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