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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.

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Bradycardia

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  1. 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 Seek expert help Seek expert help Bradycardia No Yes Atropine iv 500 µg initially to max 3 mg and transvenous pacing Yes • Consider as interim measures • External pacing • iv isoprenaline/orciprenaline Atropine iv 500 µg initially to max 3 mg No No Yes Satisfactory response? observe

  2. pulse? Adverse signs? Systolic BP  90 mmHg Chest pain Heart failure Rate  150 bpm Seek expert help Broad Complex Tachycardia(sustained ventricular tachycardia) Yes No Use VF protocol No Yes • lignocaine iv • 50 mg over 2 mins • repeated every 5 mins • to total dose of 200 mg • start infusion 2 mg/min • after first bolus dose sedation synchronised DC shock 100J:200J:360J • if potassium known • to be low: • give KCl up to 60 mmol, • max rate 30 mmol/h • give MgSO4 iv 10 ml • 50% in 1 hour • start • lignocaine ± potassium and magnesium as opposite synchronised DC shock 100J:200J:360J further cardioversion as necessary amiodarone 300 mg over 5-15 min preferably by central line then 600 mg over 1 hour For refractory cases consider other pharmacological agents: procainamide,flecainide, bretylium and overdrive pacing synchronised DC shock 100J:200J:360J

  3. Adverse signs? Hypotension: systolic BP  90 mmHg Chest pain Heart failure Impaired consciousness Rate  200 bpm Seek expert help Narrow Complex Tachycardia(supraventricular tachycardia) vagal manoeuvres (caution possible digitalis toxicity, acute ischaemia or presence of carotid bruit) Atrial fibrillation ( 130 bpm) adenosine 3 mg by bolus injection repeat if necessary every 1-2 mins using 6 mg then 12 mg then 12 mg (ATP is an alternative) No Yes sedation • 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) synchronised cardioversion 100J:200J:360J amiodarone 300 mg over 15 mins then 600 mg over 1 hour preferably by central line and repeat cardioversion

  4. Ventricular Fibrillation VF PULSELESS VT PRECORDIAL THUMP DC shock 200J (1) DC shock 200J (2) DC shock 360J (3) • If not already: • intubate • iv access Adrenaline 1 mg iv 10 CPR sequences of 5:1 compression/ventilation DC shock 360J (4) DC shock 360J (5) DC shock 360J (6)

  5. If not already: • intubate • iv access Adrenaline 1 mg iv 10 CPR sequences of 5:1 compression/ventilation EMD EMD Think of, and if indicated give specific treatment for: • hypovolaemia • tension pneumothorax • cardiac tamponade • pulmonary embolism • drug overdose/intoxication • hypothermia • electrolyte imbalance • asystole

  6. Doctors.net.uk would like to thank James Burton for contributing this presentation

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