Tachyarrhythmias

Presentation

ECG shows a rate >100bpm

Management

Use ABCDE approach
Monitor oxygen saturations, ECG and blood pressure
Record 12 lead ECG
Obtain IV access

If the patient is unstable

(shock, myocardial ischaemia, syncope, heart failure)

  1. sedation
  2. synchronised DC shock (sedation or general anaesthesia required if patient is conscious) - 150J initially up to 360J
  3. after 3 attempts seek expert help
  4. give amiodarone 300mg IV over 10-20 minutes
  5. repeat shock
  6. give further amiodarone 900mg over 24 hours

If the patient is stable

Broad QRS

Correct any electrolyte abnormalities

  • Regular:

assume VT and give amiodarone 300mg IV over 20-60 minutes then 900mg over 24hrs
SVT with bundle branch block – treat as narrow complex tachycardia

  • Irregular:

Polymorphic VT (tornado de pointes) on ECG monitoring give magnesium 2g IV
Seek expert help for help with possible AF with bundle branch block or pre-excitation AF

Narrow QRS

  • Regular:

vagal manoeuvres
adenosine 6mg rapid IV bolus – can give a further 12mg twice if no effect
continuous ECG monitoring
If sinus rhythm is restored: probable re-entry paroxysmal SVT
If no return to sinus rhythm seek expert help for possible atrial flutter and control rate with a beta-blocker

  • Irregular:

Probable AF, control rate with beta blocker e.g. IV metoprolol 1-10mg given in small increments or digoxin 500μg IV max dose over 30 minutes, can be repeated after 90 minutes if required
Consider anticoagulation

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