ACLS - Tachycardia 

Updated: Mar 21, 2014
  • Author: James J Lamberg, DO; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Advanced Cardiac Life Support (ACLS): Tachycardia With Pulse

1. Initial evaluation [1, 2, 3]

  • Assess appropriateness for clinical condition
  • Heart rate typically ≥150 bpm in tachyarrhythmia

2. Initial intervention

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

3. Assess for signs of poor perfusion

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

4. Therapeutic intervention for poor perfusion

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

5. Measures for adequate perfusion, narrow QRS

  • 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 for adequate perfusion, QRS ≥0.12 seconds

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

Synchronized cardioversion

See the list below:

  • Narrow regular: 50-100 J
  • Narrow irregular: 120-200 J biphasic
  • Narrow irregular: 200 J monophasic
  • Wide regular: 100 J
  • Wide irregular: defibrillation (no sync)


See the list below:

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

Antiarrhythmic infusions

See the list below:

  • For stable wide QRS tachycardia
  • Procainamide 20 mg/min IV until arrhythmia suppressed, hypotension ensues, QRS duration increases >50%, or maximum dose 17 mg/kg
  • In urgent situations, up to 50 mg/min IV may be initially given up to total dose of 17 mg/kg
  • Procainamide 1-4 mg/min IV maintenance infusion; avoid in 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
  • Magnesium 1-2 g IV load over 15 minutes, then infuse

Sedation therapy

See the list below:

  • Midazolam 1-5 mg IV (0.05 mg/kg) titrated OR diazepam 5-10 mg IV (0.1 mg/kg) titrated OR lorazepam 1-2 mg IV (0.1 mg/kg, max 2 mg/dose) titrated
  • Seek expert consultation (anesthesia) if available; do not delay therapy
  • Sedatives: Diazepam, midazolam, etomidate, methohexital, propofol
  • Analgesics (consider in addition to sedation): Fentanyl, morphine