Risk Management Pitfalls:
1. “Look at this rhythm strip. It’s a narrow complex tachycardia. We have an SVT on our hands.” Avoid making a diagnosis of narrow complex tachycardia by one or two lead rhythm strips alone. Only when the QRS is narrow in all 12-leads can a classification of narrow complex tachycardia be used. Many wide QRS tachycardias have a narrow QRS complex in a few leads (because a portion of the QRS is isoelectric in those leads). In the unstable patient with WCT, DC cardioversion is the treatment of choice. The management of stable patients with WCT will be greatly facilitated by a 12-lead ECG that demonstrates the tachycardia.
2. “That looks like VT on the telemetry monitor. Get the paddles.” Avoid making a diagnosis of VT vs. SVT with only a rhythm strip or by monitoring the rhythm on a telemetry screen. If the patient is unstable, then “getting the paddles” is the correct next step (regardless of whether the rhythm is a VT or SVT with AVC). A stable patient will benefit from a paper copy of the 12-lead. Many of the specific signs for VT are quite subtle (e.g., AV dissociation) and need a few minutes of your time with the paper copy of the ECG. Since the specific diagnosis (SVT with AVC or VT) can never be made with 100% certainty in every case, a paper copy of the tachycardia is very useful in the longterm management of the patient.
3. “He looks very good. It’s probably an SVT.” Avoid the assumption that a patient with stable vital signs or minimal symptoms could only have SVT. The literature is also littered with cases of wide complex tachycardias where the incorrect diagnosis of SVT was made partly because of “how well the patient looked.”
4. “This is SVT with aberrancy. See, it meets all the QRS morphological criteria on the 12-lead ECG.” No single electrocardiographic criterion or combination of criteria are adequate to distinguish between SVT and VT. While the Griffith or Brugada algorithms are quite accurate, neither of them is 100% accurate. The patient’s history, physical examination, and laboratory data can be very helpful. Therefore, ask a stable patientmregarding any history of MI, CHF, recent unstable angina, complex congenital heart disease, and allergies.
5. “This is VT. SVT with aberrancy never looks this bizarre.” Do consider electrolyte abnormalities and drug toxicity in the differential. While the timely treatment of VT with cardioversion is quite important, it can sometimes be ineffective in patients with metabolic derangement, especially hyperkalemia or toxic ingestion. If possible, question patients and their families regarding drug ingestion, and check laboratory studies for electrolyte levels.
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