Peri-arrest arrhythmias – Tachycardias – Unstable

Last Updated on by frcemuser

  • Features unstable patient
    • shock – appreciated as hypotension (e.g. systolic blood pressure < 90 mmHg)
    • syncope
    • severe heart failure – manifested by pulmonary oedema (failure of the left ventricle) and/or raised jugular venous pressure (failure of the right ventricle)
    • myocardial ischaemia – may present with chest pain (angina) or may occur without pain as an isolated finding on the 12-lead ECG (silent ischaemia).
  • Management of unstable patient
  • synchronised Electrical cardioversion (up to 3 attempts )
  • For atrial fibrillation
    • An initial synchronised shock at maximum defibrillator output rather than an escalating approach
  • For atrial flutter and paroxysmal supraventricular tachycardia:
    • Give an initial shock of 70 – 120 J.
    • Give subsequent shocks using stepwise increases in energy.
  • For ventricular tachycardia with a pulse:
    • Use energy levels of 120-150 J for the initial shock.
    • Consider stepwise increases if the first shock fails to achieve sinus rhythm.
  • If cardioversion fails to restore sinus rhythm and the patient remains unstable, give amiodarone 300 mg intravenously over 10–20 minutes (or procainamide 10–15 mg kg-1 over 20 minutes) and re-attempt electrical cardioversion. The loading dose of amiodarone can be followed by an infusion of 900 mg over 24 hours.
  • Management of Stable Patient
  • pharmacological treatment may be possible
  • A.Fib: Consider amiodarone for acute heart rate control in AF patients with haemodynamic instability and severely reduced left ventricular ejection fraction (LVEF). For patients with LVEF < 40% consider the smallest dose of beta-blocker to achieve a heart rate less than 110 min-1. Add digoxin if necessary.

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