Young Man with a Heart Rate of 257. What is it and how to manage?

A 30-something was in the ED for some minor trauma when he was noted to have a fast heart rate.  He acknowledged that he had palpitations. but only when asked.  He had a history heavy alcohol use.  Blood pressure was normal (109/83).Here is his 12-lead:There is a wide complex tachycardia with a rate of 257, with RBBB and LPFB (right axis deviation) morphology.The Differential Diagnosis is: SVT with aberrancy(#)     [AVNRT vs. WPW (also called AVRT*)]    Atrial flutter with 1:1 conduction, with aberrancy    VT coming from the anterior fascicle (fascicular VT)@*AVRT = AV Reciprocating Tachycardia (Tachycardic loop that uses both the AV node and an accessory pathway.  Depending on whether the accessory pathway is unidirectional or bidirectional, this can go down the AV node and up the accessory pathway (orthodromic), or down the pathway and up the AV node (antidromic).#Aberrancy means that the impulse coming from (AVNRT) or through (Orthodromic AVRT) the AV node is too rapid to allow for repolarization of all the conducting fibers.  In this case, the right bundle and the posterior fascicle are unable to repolarize, but the anterior fascicle is. The impulse goes through the (left) anterior fascicle (which is superior) and then goes from this superior left location through non-conducting fibers to the inferior and right.  Hence the latter part of the QRS is to the right and inferior (RBBB mor...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs