In the preceding chapters (Chapters 34 through 36), we provided you with a great foundation to the evaluation and clinical management of the wide-complex tachycardias (WCTs). In this chapter, we will cover a few cases to show you how the system works. We will focus primarily on the WCTs only. (We also have a “putting it all together” chapter for arrhythmias in general in Chapter 40.) Feel free to skip the introductory material and go right to the cases, if you feel confident enough in your knowledge of this information.
Why have we created this separate putting it all together chapter just for the WCTs? Because the WCTs are ridiculously simple to diagnose at the umbrella-term level, and it takes only seconds to figure out, if you know what you are doing. Simply look at the strip and see if you are dealing with a tachycardia greater than 100 beats per minute (BPM) associated with wide QRS complexes (greater than or equal to 0.12 seconds). Despite the simplicity of the diagnosis of this very lethal group of arrhythmias, it is one of the most commonly misdiagnosed and mismanaged groups around. Clinicians just don’t seem to understand that diagnosing the umbrella group is simple; diagnosing the different subgroups or the individual rhythms is the hard part.
Remember to tailor your diagnosis and management to the clinical stage of the patient. In the emergent stage, keep it simple: Diagnose the rhythm as a WCT and treat it according to the unified guidelines. In the nonurgent stage, do a more thorough workup and use the criteria and algorithms to correctly identify the rhythm as either a supraventricular tachycardia with aberrancy (SVT-A) or a ventricular tachycardia (VTach).