Today, I review, link to, and excerpt from Stable Wide Complex Tachhydsrhythmias from Emergency Medicine Cases‘ EM Quick Hits 66.*
*Helman, A. Schonfeld, D. Swaminathan, A. Petrosoniak, A. Morgenstern, J. Tagg, A. Myers, V. Tintinalli, J. EM Quick Hits 66 – Pediatric Torticollis, Stable Stable Wide Complex Tachydysrhythmias, Post-intubation Neurocritical Care, Hyponatremia Correction Rates, Paronychia Management, Women in EM Leader Series with Judith Tintinalli https://emergencymedicinecases.com/em-quick-hits-july-2025/. Accessed August 9, 2025.
All that follows is from the above resource.
Anand Swaminathan on stable wide-complex tachycardia (28:24 – 33:42)
Approach to Stable Wide-Complex Tachydysrhthmias
Regular, Wide, Fast Tachycardia? Assume VT.
Rhythms >120 bpm that are regular, wide, and fast are usually Ventricular Tachycardia (VT)—rarely SVT with aberrancy.
In unstable patients, decision making is typically straighforward with immediate electrical cardioversion.
When stable, we may be tempted to reach for diagnostic algorithms to distinguish VT vs. SVT—but:
- Algorithms are ≤80% accurate
- They waste precious time
- Patients may decompensate rapidly
Rapid approach:
Assume regular wide-complex tachycardia (>110–120 bpm) is VT.
- VT treatment works for SVT with aberrancy—not the reverse.
- Consider hyperkalemia if rate <110 bpm.
Management:
- Treat with electrical cardioversion in all cases unless contraindicated.
- ACLS suggests chemical cardioversion, but efficacy is variable.
- Procainamide is more effective than amiodarone (67% vs. 38% success, Ortiz et al. 2017).
- 200 J biphasic is safe and most effective.
- Use light sedation (e.g., propofol or etomidate) if patient is alert.
Bottom Line
In any hemodynamically stable patient with regular, wide, fast tachycardia, skip the guessing—electrical cardioversion is your safest and fastest option.ECG Cases 19 – Tachycardias: Approach, WIDER mnemonic for Wide SVT DDx, VT vs SVT
Episode 112 Tachydysrhthmias with Amal Mattu & Paul Dorian
References
- Ortiz M, Martín A, Arribas F, Coll-Vinent B, Del Arco C, Peinado R, Almendral J; PROCAMIO Study Investigators. Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. Eur Heart J. 2017 May 1;38(17):1329-1335.
- Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline For The Management Of Adult Patients With Supraventricular Tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2016;133:e506-e574.
- Vereckei A. Current algorithms for the diagnosis of wide QRS complex tachycardias. Curr Cardiol Rev. 2014 Aug;10(3):262-76.
