Advanced Cardiac Life Support (ACLS): Tachycardia

Updated: May 10, 2018
  • Author: James J Lamberg, DO; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Advanced Cardiac Life Support (ACLS): Tachycardia With Pulse

ACLS: Tachycardia

1. Initial evaluation is as follows: [1, 2, 3, 4]

  • Assess appropriateness for clinical condition (pulse present).
  • Heart rate typically ≥150 bpm in tachyarrhythmia

2. Initial intervention is as follows:

  • Maintain patent airway and assist breathing, as needed.
  • Administer oxygen if hypoxemic.
  • Attach monitor/defibrillator.
  • Monitor blood pressure and oximetry.

3. Assess for signs of poor perfusion, as follows:

  • Hypotension (systolic blood pressure [SBP] < 90 mm Hg)
  • Acutely altered mental status
  • Signs of shock
  • Ischemic chest discomfort
  • Acute heart failure

4. Therapeutic intervention is as follows if poor perfusion is present:

  • Perform immediate synchronized cardioversion.
  • Consider sedation; do not delay therapy.
  • If regular narrow complex, consider adenosine; do not delay therapy.

5. Measures are as follows if adequate perfusion and narrow QRS (< 0.12 seconds):

  • Obtain intravenous (IV)/intraosseous (IO) access.
  • Perform 12-lead electrocardiography (ECG), if available.
  • Perform vagal maneuvers first.
  • Consider adenosine (if regular) and if vagal maneuvers are unsuccessful.
  • Consider beta-blocker or calcium channel blocker if adenosine is unsuccessful.
  • Consider expert consultation.

6. Measures are as follows if adequate perfusion and wide QRS (≥0.12 seconds).

  • Obtain IV/IO access.
  • Perform 12-lead ECG; do not delay therapy.
  • Administer adenosine only if regular monomorphic.
  • Consider antiarrhythmic infusion.
  • Consider expert consultation.

Synchronized Cardioversion

Initial recommended doses are as follows:

  • Narrow regular: 50-100 J
  • Narrow irregular: 120-200 J biphasic or 200 J monophasic
  • Wide regular: 100 J
  • Wide irregular: defibrillation (not synchronized)


See the list below:

  • First dose: 6 mg rapid IV push
  • Follow adenosine with IV flush
  • Second dose: 12 mg rapid IV push
  • Have equipment for transcutaneous pacing available when administering adenosine.
  • Half dose (3 mg IV) if using central line, which includes peripherally inserted central catheter (PICC)
  • Dose 3 mg IV if patient is taking dipyridamole or carbamazepine
  • May need increased adenosine dose in patients on theophylline, caffeine, or theobromine
  • Caution with adenosine in patients with asthma and/or transplanted hearts

Antiarrhythmic Infusions

For stable wide QRS tachycardia, as follows:

  • Procainamide 20-50 mg/min IV until arrhythmia suppressed, hypotension ensues, QRS duration increases >50%, or maximum dose 17 mg/kg
    • Procainamide 1-4 mg/min IV maintenance infusion; avoid if prolonged QT or congestive heart failure (CHF)
  • Amiodarone 150 mg IV over 10 minutes first dose; repeat as needed if ventricular tachycardia (VT) recurs
    • Amiodarone 1 mg/min maintenance infusion for first 6 hours
  • Sotalol 100 mg (1.5 mg/kg) IV over 5 minutes; avoid in prolonged QT

Most Recent Guideline Changes

Changes from the 2010 guidelines include the following:

  • Simultaneous breathing and pulse check in less than 10 seconds
  • Administer epinephrine as soon as feasible after the onset of cardiac arrest due to an initial nonshockable rhythm.
  • Provide opioid overdose education, either alone or coupled with naloxone distribution and training, to persons at risk for opioid overdose.
  • In pregnancy, if the fundus height is at or above the level of the umbilicus, manual left uterine displacement can be beneficial in relieving aortocaval compression during chest compression.

Changes from the 2010 ACLS guidelines: For simplicity, vasopressin has been removed from the adult algorithm.