Bradycardia

Risk of asystole?• History of asystole• Mobitz II AV block• Any pause 3 s• Complete heart block, wide QRS

Adverse signs?• Clinical evidence of low cardiac

output• Hypotension: Systolic BP 90

mmHg• Heart failure• Rate < 40 bpm• Presence of ventricular arrhythmias

requiring suppression

Consider as interim measures• External pacing• iv isoprenaline/orciprenaline

Satisfactory response?

Atropine iv500 µg initially

to max 3 mgand

Atropine iv500 µg initially

to max 3 mg

Seek expert help

transvenous pacing

observe

Yes

Yes

Yes

No

No

No

Seek expert help

Broad Complex Tachycardia(sustained ventricular tachycardia)

pulse?

Adverse signs?• Systolic BP 90 mmHg• Chest pain• Heart failure• Rate 150 bpm

For refractory cases consider other pharmacological agents:

procainamide,flecainide, bretylium and overdrive pacing

Use VF protocol

sedation

Yes No

Seek expert help

synchronised DC shock100J:200J:360J

start• lignocaine ± potassium and magnesium as

opposite

further cardioversion as necessary

• lignocaine iv 50 mg over 2 mins

repeated every 5 minsto total dose of 200 mg

• start infusion 2 mg/minafter first bolus dose

if potassium knownto be low:

• give KCl up to 60 mmol,max rate 30 mmol/h

• give MgSO4 iv 10 ml50% in 1 hour

synchronised DC shock100J:200J:360J

amiodarone 300 mg over 5-15 min preferably by central line then 600 mg over 1 hour

synchronised DC shock100J:200J:360J

YesNo

Narrow Complex Tachycardia(supraventricular tachycardia)

Adverse signs?• Hypotension: systolic BP 90 mmHg• Chest pain• Heart failure• Impaired consciousness• Rate 200 bpm

Seek expert help

vagal manoeuvres(caution possible digitalis toxicity,

acute ischaemia or presence of carotid bruit)

sedation

synchronised cardioversion

100J:200J:360J

amiodarone 300 mg over 15 mins then 600 mg over 1 hour preferably by central

line and repeat cardioversion

YesNo

adenosine 3 mg by bolus injectionrepeat if necessary every 1-2 mins using 6 mg then 12 mg then 12 mg

(ATP is an alternative)

Atrial fibrillation ( 130 bpm)

choose from:• esmolol: 40 mg over 1 min +

infusion 4 mg/min (iv injection can be repeated with increments of infusion to 12 mg/min)

• digoxin: max dose 500 µg over 30 min x 2

• verapamil: 5 - 10 mg iv• amiodarone: 900 mg over 1 hour• overdrive pacing (not AF)

Ventricular FibrillationVF

PULSELESS VT

10 CPR sequences of 5:1 compression/ventilation

Adrenaline 1 mg iv

PRECORDIAL THUMP

If not already:• intubate• iv access

DC shock 200J (1)

DC shock 200J (2)

DC shock 360J (3)

DC shock 360J (4)

DC shock 360J (5)

DC shock 360J (6)

EMDEMD

Think of, and if indicated give specific treatment for:• hypovolaemia• tension pneumothorax• cardiac tamponade• pulmonary embolism• drug overdose/intoxication• hypothermia• electrolyte imbalance• asystole

10 CPR sequences of 5:1 compression/ventilation

Adrenaline 1 mg iv

If not already:• intubate• iv access

Doctors.net.uk would like to thank James Burton for

contributing this presentation