The initial step in the management of tachyarrhythmia is to determine whether there is any hemodynamic compromise. The patient should be quickly evaluated for any change in mental status, blood pressure, and respiration, as well as for any signs of acute distress. Care must be taken to treat the patient and not the apparent dysrhythmia, as artifacts may be produced by patient movement or equipment problems. If the patient is hemodynamically unstable, whether due to a rapid supraventricular or a ventricular arrhythmia, electrical cardioversion is the treatment of choice, using sedation if the patient is alert. Evidence of hemodynamic compromise must be carefully documented, as mild hypotension may be due to a rapid rate and resolve quickly after intravenous drug administration as the arrhythmia is slowed or terminated. This may be true even if the medication utilized has potential vasodilatory and/or negative inotropic effects.
If the patient is hemodynamically stable, the diagnosis and etiology of the arrhythmia should be sought. Treatment is geared towards eliminating the underlying mechanism if possible and using appropriate medication.
In the case of supraventricular tachyarrhythmias, carotid sinus massage may not only help with the diagnosis but may also be therapeutic in certain supraventricular arrhythmias that utilize re-entry circuits ( Fig 1). These arrhythmias may be interrupted, provided that the sinoatrial or atrioventricular node is involved, since these are the only areas that are affected by increased vagal tone. Otherwise, carotid sinus massage or a Valsalva maneuver will increase atrioventricular block without interrupting the re-entry circuit.
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