What to do in a patient with sinus tachycardia at a rate of 200?

Management of Sinus Tachycardia at 200 BPM

Initial Assessment and Stabilization

For a patient with sinus tachycardia at a rate of 200 BPM, immediate assessment of hemodynamic stability is crucial, with synchronized cardioversion indicated if the patient shows signs of hemodynamic compromise.

• Evaluate for signs of hemodynamic instability including acute altered mental status, ischemic chest discomfort, acute heart failure, hypotension, or shock 1
• Assess oxygenation status and provide supplementary oxygen if inadequate, as hypoxemia is a common cause of tachycardia 1
• Obtain a 12-lead ECG to confirm the rhythm is sinus tachycardia rather than another supraventricular tachycardia 2

Management Algorithm Based on Hemodynamic Status

For Hemodynamically Unstable Patients:

• Proceed to immediate synchronized cardioversion if the patient demonstrates rate-related cardiovascular compromise 1
• Use appropriate sedation if the patient is conscious and time permits 1
• Initial biphasic energy dose for cardioversion should be 120-200 J 1

For Hemodynamically Stable Patients:

• Intravenous beta blockers, diltiazem, or verapamil are first-line treatments for acute management 1
• Esmolol (IV) is particularly effective with a short half-life, allowing for rapid titration:
  • Initial loading dose of 500 μg/kg over 1 minute, followed by a maintenance infusion of 50-300 μg/kg/min 3
  • Approximately 60-70% of patients develop either a 20% reduction in heart rate or decrease to less than 100 bpm 3
• Diltiazem (IV) is an alternative when beta-blockers are contraindicated:
  • Administer as a 10-20 mg (0.25 mg/kg) bolus over 2 minutes 4
  • Follow with an infusion at 5-15 mg/hour, titrated to heart rate response 4
• Verapamil (IV) can also be effective:
  • Administer as a slow injection over at least 2 minutes to avoid hypotension 5
  • Monitor closely for bradycardia and hypotension, which occur in 5-10% of patients 5

Identifying and Treating Underlying Causes

• Investigate common physiologic stimuli that can cause sinus tachycardia 2:
  • Fever, infection, hypovolemia, anemia
  • Pain, anxiety, or emotional stress
  • Hyperthyroidism
  • Medications (stimulants, anticholinergics)
  • Recreational drugs (cocaine, amphetamines)
  • Pulmonary embolism
• Treat the underlying cause while simultaneously managing the tachycardia 1

Special Considerations

• A heart rate of 200 BPM is at the upper limit of physiologic sinus tachycardia and may indicate a pathologic process 1
• With ventricular rates >150 bpm, the tachycardia is more likely to be the cause rather than the result of instability 1
• Monitor for hypotension during administration of rate-controlling medications, which occurs in 20-50% of patients 3
• Be prepared to reduce infusion rates or discontinue therapy if significant hypotension develops 3

Follow-up Care

• After acute rate control is achieved, transition to oral medications for ongoing management if needed 1
• Consider referral to an electrophysiologist if episodes are recurrent or if inappropriate sinus tachycardia is suspected 2
• Obtain an echocardiogram to evaluate for structural heart disease if episodes are persistent 2

Pitfalls to Avoid

• Do not administer verapamil concomitantly with IV beta-blockers, as this combination can cause severe bradycardia, hypotension, or asystole 5
• Avoid rate-controlling medications in patients with accessory pathways (WPW syndrome) as this can accelerate conduction through the accessory pathway 1
• Remember that sinus tachycardia may be compensatory; normalizing heart rate without addressing the underlying cause can be detrimental in compensatory tachycardias 1