From the Guidelines
Tachyarrhythmias and vomiting are medical emergencies that require immediate attention, with management focusing on treating the underlying cause, which may include antiarrhythmic medications, antiemetics, and electrolyte replacement, as evidenced by the 2009 ACCF/AHA focused update on perioperative beta blockade 1. The causes of tachyarrhythmia and vomiting can be multifactorial, including cardiac conditions like atrial fibrillation, ventricular tachycardia, or supraventricular tachycardia, as well as non-cardiac causes such as dehydration, electrolyte imbalances, thyroid disorders, anxiety, medications, or stimulant use. Vomiting can be caused by gastrointestinal issues, medications, vestibular disorders, or as a symptom of cardiac conditions through vagal stimulation or decreased cardiac output. Some key points to consider in management include:
- Addressing the underlying cause of the symptoms
- Using antiarrhythmic medications like beta-blockers, such as metoprolol (5mg IV every 5 minutes for 3 doses), which have been shown to be effective in controlling the ventricular response during atrial fibrillation 1
- Using antiemetics such as ondansetron (4-8mg IV/oral) or promethazine (12.5-25mg IV/oral/IM) for vomiting
- Electrolyte replacement, particularly potassium and magnesium, to prevent further complications
- Monitoring patients for vital signs, electrolyte levels, and cardiac function, with follow-up care including lifestyle modifications such as avoiding triggers, maintaining hydration, and managing stress. It is also important to note that cardioversion may be necessary for unstable tachyarrhythmias, and that patients with an ischemic or nonischemic cardiomyopathy, particularly those with an ejection fraction of less than 35%, a history of HF, and nonsustained ventricular tachycardia in the perioperative period, may benefit from ICD therapy for primary prevention of sudden cardiac death, as indicated by the 2009 ACCF/AHA focused update on perioperative beta blockade 1.
From the Research
Causes of Tachyarrhythmia
- Tachyarrhythmias are abnormal heart rhythms with a ventricular rate of 100 or more beats per minute 2
- These rhythms can be classified as either narrow or wide-complex tachycardia with further subdivision into regular or irregular rhythm 2
- Neurologic conditions can precipitate tachyarrhythmia 2
- Electrolyte abnormalities, such as hypokalemia, can trigger ventricular arrhythmia 3
- Gastrointestinal illness and recent increases in diuretic dose can be associated with severe hypokalemia in patients with ventricular tachycardia or ventricular fibrillation (VT/VF) 3
Causes of Vomiting
- Gastrointestinal illness can be a cause of vomiting, which can also lead to electrolyte depletion and potentially trigger ventricular arrhythmia 3
- There is no direct evidence in the provided studies that links vomiting as a direct cause of tachyarrhythmia, but it can be a contributing factor to electrolyte imbalances 4, 3
Management of Tachyarrhythmia and Vomiting
- The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach can be used for immediate assessment and treatment of clinical emergencies, including tachyarrhythmia 5
- Accurate diagnosis of the rhythm, plus a detailed clinical history, are critical for best management and optimal outcome of tachyarrhythmias 6
- A 12-lead electrocardiogram is the cornerstone for diagnosis of tachyarrhythmias 6
- Maintaining the balance of fluid and electrolytes is crucial to the care of patients with tachyarrhythmia and vomiting 4
- Treatment of electrolyte imbalances, such as hypokalemia, is important to prevent arrhythmia risk reduction 3