In the June 2008 issue, Drs. Subramanian and Bray discuss the diagnosis and management of wide complex tachycardia in the ED. It is an excellent summary of the available evidence; the article lays out a step-by-step process to approaching this complex problem.
I would just like to add my paradigm, which was created with the thinking that if you have an opportunity to reduce your cognitive load, always take it.
- Unstable is easy–shock
- If they’re stable and the rhythm is fast (>200 bpm), wide, and irregular; assume WPW with antidromic conduction/atrial fibrillation: give procainamide (or if you’re familiar with it, ibutilide)
- If they’re stable with a WCT and none of the above, give amiodarone.
- If it starts to look like TdP or the patient is not getting better, try some Bicarb
They’re you go, basically an acerebrate approach, but you’ll rarely get burned. Now the clever reader may say that this algorithm can be further reduced to shock unstable rhythms and give amio to everyone else and the ACLS guidelines will agree with you. However, there is a small literature out there saying that amiodarone may not be a clever choice for antidromic WPW.
See:
Can J Emerg Med 2005;7(4):262
Certainly not definitive, but makes you think. Perhaps, the authors can comment?
Posted by emcrit 
