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ACLS Tachycardia Algorithm Review

Updated: Oct 18, 2021


The American Heart Association ACLS Tachycardia Algorithm is an important tool for the management of Stable and Unstable Tachycardia. It includes the management of Ventricular Tachycardia, Torsades, SVT, Atrial Fibrillation, and Atrial Flutter.


Does the patient have a pulse? If No, immediate high-quality CPR is indicated.

Most symptomatic Tachycardia will present with a Heart Rate typically of 150 or more


Tachycardia with pulse present:

•A- Open, Maintain and Protect

•B- Rate & Saturation- Start Oxygen if below 94%

•C- Pulse & BP- Monitor, Identify & IV

•C- 12 Lead ECG, if available

🚨 STABLE or UNSTABLE??

🚨Persistent Tachyarrhythmia causing:

•Hypotension?

•Acutely Altered Mental Status?

•Signs of Shock?

•Ischemic Chest Discomfort?

•Acute Heart Failure?


⚠️ YES- UNSTABLE

⚡️If the patient is unstable, immediate Cardioversion is indicated. As always, we need to follow the recommendation from the manufacturer for the appropriate energy level to maximize the success of the first shock.


💉If time permits, establish an IV access before Cardioversion and administer sedation if the patient is conscious. If the patient is extremely unstable, do not delay Cardioversion.


If Cardioversion is Unsuccessful, consider the following:

•Underlying Causes

•Need to increase energy level for next Cardioversion

•Addition of anti-arrhythmic drug

•Expert consultation ☎️


⚠️ YES- STABLE


The treatment path is determined by whether the QRS is Narrow or Wide and whether the rhythm is Regular or Irregular.

  • If a Monomorphic wide-complex rhythm is present and the patient is stable, expert consultation is advised, as treatment has the potential of harm ☎️

  • If you are not sure if the rhythm is Ventricular Tachycardia or Supra Ventricular Tachycardia and the patient is stable and the rhythm is regular, IV adenosine is relatively safe for both the treatment and diagnoses.

  • The AHA recommends Procainamide 20-50mg/min until arrhythmia is suppressed, hypotension, QRS duration increases more than 50%, or a maximum of 17mg/kg;

  • You can also consider the Big A, or Amiodarone 150mg over 10 minutes. Take note that this is a different dose than in a Cardiac arrest.

  • Also, Soltalol is an option at 100mg over 5 minutes.

  • If you are dealing with Torsades, Magnesium is also a consideration.


  • The therapy for Narrow Complex Tachycardia with a regular rhythm is to attempt Vagal maneuvers. Caution should be used when considering the use of Carotid Sinus massage, specifically in older patients.

  • If vagal stimulation does not resolve the Narrow complex Tachycardia, administer Adenosine 6mg. Adenosine slows electrical conduction through the AV node and terminates about 90% of reentry Tachyarrhythmias within 2 minutes. Before Adenosine administration, please explain the process to the patient. Adenosine needs to be given with a rapid IV push, followed by 20ml of saline and elevate the arm. Remember Adenosine has a very short half-life.

  • Although it doesn’t terminate Atrial flutter or Atrial fibrillation, it will slow the AV conduction, allowing for identification of flutter or fibrillation waves, thereby allowing confirmation of the underlying Tachyarrhythmia.

  • If the rhythms convert with Adenosine administration, it’s most likely reentry SVT. Monitor for recurrence, Treat recurrence with more Adenosine or a longer-acting Calcium channel blocker or Beta-Blockers. Expert consultation is advised ☎️

⚠️Do not use Adenosine for unstable or irregular or polymorphic wide-complex tachycardias, because it can cause degeneration into Ventricular Fibrillation.


AHA 2020 Guidelines: https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines


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