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ACLS Tachycardia with Pulse Algorithm (AHA 2025)

ACLS Tachycardia with Pulse Algorithm (AHA 2025): Adult tachycardia with a pulse → Assess and support; look for the cause → Is a tachyarrhythmia the cau...

Pathway Overview

25 steps

Algorithm Steps

25 total

  1. 01Start

    Adult tachycardia with a pulse

    No pulse: use the cardiac arrest algorithm. If the arrhythmia causes the symptoms, the rate is usually 150/min or more.

  2. 02Action

    Assess and support; look for the cause

    Identify and treat the underlying cause.

    • Airway and breathing; oxygen if hypoxaemic
    • Cardiac monitor, BP, SpO2 and IV access
    • 12-lead ECG if it does not delay treatment
    • Look for hypoxia, bleeding, sepsis, pain, fever, drugs and electrolyte disorders
  3. 03Decision

    Is a tachyarrhythmia the cause of the symptoms?

    Sinus tachycardia is usually a response to illness, not the cause.

  4. If Yes
    1. Tachyarrhythmia
    2. 04Decision

      Unstable because of the arrhythmia?

      Hypotension (eg SBP <90 mmHg), acute altered mental state, shock, ischaemic chest pain or acute heart failure.

    3. If Yes
      1. Unstable
      2. 05Action

        Adult, unstable from the arrhythmia: synchronised DC cardioversion

        Not for sinus tachycardia. Sedate if conscious. Polymorphic VT: unsynchronised shock instead. Pre-excited AF or torsades: no amiodarone. Suspected high K+, tricyclic or digoxin toxicity: shock if needed, and also treat the cause (IV calcium, sodium bicarbonate or digoxin Fab); get expert help.

        • AF: biphasic, start at 200 J or more; increase if the shock fails
        • Atrial flutter: start at 200 J biphasic; increase if the shock fails
        • Other rhythms: device maker's recommended energy; increase if it fails
        • Regular narrow QRS: adenosine may be tried while you prepare; do not delay the shock
        • Shock fails (not pre-excited AF, torsades, high K+ or drug toxicity): amiodarone 300 mg IV over 10-20 min, then shock again (ANZCOR)
        • Then amiodarone 900 mg IV over 24 h (ANZCOR)
      3. 06Decision

        Rhythm converted?

      4. If Yes
        1. 07Outcome

          Converted: monitor, repeat 12-lead ECG, find the cause

          SVT: consider EP referral. VT or pre-excitation: admit; look for ischaemia and structural heart disease; EP review.

        If No
        1. 08Outcome

          Not converted: urgent cardiology or EP advice

          Unstable: repeat synchronised cardioversion at higher energy. Avoid giving more antiarrhythmic drugs without expert advice. Stable, and adenosine showed atrial flutter or atrial tachycardia: rate control as for AF (see the AF pathway).

      If No
      1. Stable
      2. 09Decision

        Stable: is the QRS narrow (<0.12 s)?

        Use a 12-lead ECG. Wide QRS means 0.12 s (120 ms) or more.

      3. If Yes
        1. Narrow <0.12 s
        2. 10Decision

          Narrow QRS: is the rhythm regular?

        3. If Yes
          1. Regular
          2. 11Warning

            Narrow regular: check adenosine cautions first

            Give adenosine only with a monitor and a defibrillator ready. Theophylline and caffeine reduce its effect.

            • Asthma or COPD with bronchospasm: do not give adenosine; use verapamil
            • 2nd or 3rd degree AV block, sick sinus (no pacemaker) or long QT syndrome: do not give
            • Heart transplant, central line, dipyridamole or carbamazepine: lower dose; get advice
          3. 12Action

            Narrow regular (likely SVT): vagal manoeuvre, then adenosine

            Verapamil, diltiazem and beta-blockers: avoid if hypotensive or in systolic heart failure.

            • Modified Valsalva: strain, then lie flat and raise the legs
            • Adenosine 6 mg rapid IV push, then flush with at least 20 mL saline
            • No response in 1-2 min: adenosine 12 mg rapid IV; may repeat 12 mg once
            • Adenosine fails or is contraindicated: verapamil 2.5-5 mg IV over 2 min (ANZCOR), or an IV beta-blocker (eg metoprolol)
            • Rate slows but tachycardia persists: look for atrial flutter or atrial tachycardia
            • Drugs fail: synchronised cardioversion with sedation
          4. Path rejoins step 06Shared downstream outcome
          If No
          1. Irregular
          2. 13Action

            Narrow irregular (likely AF, flutter or MAT): control the rate

            Known WPW or pre-excitation: no AV-nodal blockers or IV amiodarone; get expert help. AF over 48 h or unknown onset: no cardioversion unless anticoagulated or TOE shows no clot.

            • IV beta-blocker or verapamil if no pre-excitation, hypotension or systolic heart failure. No beta-blocker in asthma or bronchospasm
            • Critically ill or heart failure: IV amiodarone or digoxin (no pre-excitation)
            • Suspected digoxin toxicity (on digoxin, high K+, atrial tachycardia with block): no more digoxin; digoxin Fab; Poisons Information 13 11 26
            • MAT: treat the cause (hypoxia, COPD, low K+ or Mg)
            • Adenosine does not treat AF or flutter
            • Assess stroke risk and anticoagulation
          3. 14Outcome

            Irregular, no pre-excitation: continue AF or flutter care

            Rate or rhythm control and anticoagulation (see the AF pathway). Cardiology advice if the rate stays uncontrolled.

        If No
        1. Wide >=0.12 s
        2. 15Warning

          Wide QRS: exclude high potassium and sodium-channel-blocker poisoning first

          These can look like VT. Check K+ on a blood gas and ask about drugs (eg tricyclics, flecainide). Amiodarone does not treat them and can make them worse. Do not delay a shock for polymorphic VT or deterioration.

          • High K+ (renal failure, peaked T waves, sine wave): give IV calcium now; see the hyperkalaemia pathway
          • Tricyclic or other sodium-channel-blocker poisoning (adult): sodium bicarbonate 8.4% 1-2 mL/kg IV (max 100 mL) every 3-5 min until the QRS narrows; max total 6 mL/kg
          • Do not give amiodarone for these; call Poisons Information 13 11 26
        3. 16Decision

          Wide QRS: is it regular and monomorphic?

        4. If Yes
          1. Regular monomorphic
          2. 17Action

            Wide regular: treat as VT unless proven otherwise

            Do not give verapamil or diltiazem. Have a defibrillator ready. Get expert help. Drugs fail or patient worsens: synchronised cardioversion with sedation.

            • Amiodarone 150 mg IV over 10 min; repeat if VT recurs; then 1 mg/min for 6 h (AHA)
            • ANZCOR: amiodarone 300 mg IV over 20-60 min, then 900 mg over 24 h
            • Adenosine may be tried only if regular and monomorphic, to treat or to diagnose
            • VT with acute ischaemia or infarction: IV lignocaine is an option (ANZCOR); get expert advice on the dose
            • Procainamide or IV sotalol (AHA options): not on the ARTG in Australia
            • Do not give 2 antiarrhythmic drugs together without expert advice
          3. Path rejoins step 06Shared downstream outcome
          If No
          1. Irregular or polymorphic
          2. 18Warning

            Wide irregular: get expert help now

            Likely AF with bundle branch block, pre-excited AF, or polymorphic VT. Get a 12-lead ECG.

            • Polymorphic VT: unsynchronised shock, not synchronised cardioversion
            • Possible pre-excited AF: no AV-nodal blockers or IV amiodarone
            • Do not give adenosine for irregular or polymorphic wide QRS tachycardia
          3. 19Decision

            Wide irregular: polymorphic VT (including torsades)?

          4. If Yes
            1. Polymorphic VT
            2. 20Action

              Polymorphic VT: unsynchronised shock (defibrillate)

              It cannot be synchronised. Use maximum energy. Sedate if conscious and time allows. Pulse lost: cardiac arrest algorithm.

              • Torsades (long QT): magnesium sulfate 5 mmol IV over 10 min; may repeat once (ANZCOR)
              • Then magnesium sulfate 20 mmol IV over 4 h (ANZCOR)
              • Torsades: stop QT-prolonging drugs; correct K+ and Mg; do not give amiodarone
              • Torsades with bradycardia or pauses: expert help (pacing, or isoprenaline if not congenital long QT)
              • Normal QT, recurrent: treat ischaemia; lignocaine or amiodarone may be considered
            3. Path rejoins step 06Shared downstream outcome
            If No
            1. Not polymorphic VT
            2. 21Decision

              Not polymorphic VT: could this be pre-excited AF (WPW)?

              Very fast, irregular and bizarre wide QRS complexes, or known WPW.

            3. If Yes
              1. Pre-excited AF possible
              2. 22Warning

                Pre-excited AF (WPW): do not give AV-nodal blockers

                They can speed conduction over the accessory pathway and cause VF.

                • Do not give adenosine, digoxin, verapamil, diltiazem, beta-blockers or IV amiodarone
                • Electrical cardioversion is usually the safest treatment
                • Get cardiology or EP help now
              3. 23Action

                Pre-excited AF: synchronised DC cardioversion

                Sedate if conscious. Start at 200 J biphasic or more. Expert (EP) advice for any drug treatment.

              4. Path rejoins step 06Shared downstream outcome
              If No
              1. AF with BBB
              2. 24Action

                Irregular wide QRS, no pre-excitation: likely AF with bundle branch block

                Manage as AF: rate control as for narrow irregular (no verapamil or beta-blocker if hypotensive or in systolic heart failure; no beta-blocker in asthma).

              3. Path rejoins step 14Shared downstream outcome
    If No
    1. Sinus/compensatory
    2. 25Outcome

      Sinus or compensatory tachycardia: treat the cause

      Do not cardiovert. Do not give drugs to slow the rate. Treat the cause (eg hypoxia, bleeding, sepsis, pain).

Guideline Source

2025 AHA Guidelines for CPR and ECC - Part 9: Adult Advanced Life Support

DOI: 10.1161/CIR.0000000000001376View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Adults with a pulse only. No pulse: cardiac arrest algorithm. Children: paediatric algorithm
  • Australia: ANZCOR amiodarone doses differ from AHA; procainamide, IV sotalol and IV diltiazem are not on the ARTG
  • Pre-excited AF, torsades and polymorphic VT need expert (cardiology or EP) help

Contraindicated Populations

pediatric

Applicable Regions

USEUAU

AU: ANZCOR 11.9: amiodarone 300 mg IV over 20-60 min (stable) or over 10-20 min after failed cardioversion, then 900 mg over 24 h. Procainamide, IV sotalol and IV diltiazem are not on the ARTG.

EU: ERC 2025 ALS follows a similar approach; check local drug availability.

US: AHA 2025: AF at least 200 J biphasic; other rhythms per device maker. Procainamide and IV sotalol are AHA options.

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the ACLS Tachycardia with Pulse Algorithm (AHA 2025)?

The ACLS Tachycardia with Pulse Algorithm (AHA 2025) is a emergency clinical algorithm for Cardiology. It provides a structured decision tree to guide clinical decision-making, based on 2025 AHA Guidelines for CPR and ECC - Part 9: Adult Advanced Life Support.

What guideline is the ACLS Tachycardia with Pulse Algorithm (AHA 2025) based on?

This algorithm is based on 2025 AHA Guidelines for CPR and ECC - Part 9: Adult Advanced Life Support (DOI: 10.1161/CIR.0000000000001376).

What are the limitations of the ACLS Tachycardia with Pulse Algorithm (AHA 2025)?

Known limitations include: Adults with a pulse only. No pulse: cardiac arrest algorithm. Children: paediatric algorithm; Australia: ANZCOR amiodarone doses differ from AHA; procainamide, IV sotalol and IV diltiazem are not on the ARTG; Pre-excited AF, torsades and polymorphic VT need expert (cardiology or EP) help. Individual patient factors may require deviation from these recommendations.

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