Tachyarrhythmias in the emergency department

Meet the patient

A 34-year-old man lands in the resus bay with two hours of sudden palpitations, dyspnoea and central chest tightness. He is diaphoretic and cool peripherally: BP 82 over 50, HR 224 and regular. The monitor shows a regular narrow-complex tachycardia with no visible P waves, QRS 90 ms.[1]

One question decides his next minute, and it is not "what rhythm is this?" — it is "is he unstable?" He is: the hypotension, the ischaemic-sounding chest tightness at a rate of 224, and the cool shut-down peripheries all meet the instability criteria. So his next action is synchronised cardioversion now, before any vagal manoeuvre or drug. The QRS width and the drug ladder are problems for the stable patient — and he is not it.[1]

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