ED ALS Module 4: Acute Dysrhythmias

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Ilene Andrews
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ED ALS Mdule 4: Acute Dysrhythmias Ref: ARC guideline-11-9- Acute arrhythmias https://www.drpbx.cm/s/th5gxq89eixrhbl/arc%20guideline- 11-9-%20Acute%20arrhythmias.pdf?

1 ED ALS Mdule 4: Acute Dysrhythmias Ref: ARC guideline Acute arrhythmias %20Acute%20arrhythmias.pdf?dl=0 Nte: ARC guidelines in standard print, additinal infrmatin/recmmended PAH ED apprach in italics. Bradyarrhythmias Treatment is usually reserved fr symptmatic arrhythmia. Cmmn indicatins fr immediate treatment may include HR < 40 BP < 90 Ventricular arrhythmia Heart failure Nte: A pulseless patient requires CPR as per the ALS algrithm.

2 Drug therapy Atrpine 1 st line, mg up t 3 mg Adrenaline Clinical pint: Safe but unlikely t be effective in the setting f CHB with an infra-ndal escape. It is apprpriate t g direct t adrenaline in this setting. Ptential t precipitate CHB in type II secnd degree HB. 2 nd line (ARC): blus r infusin 2-10 mcg/min Clinical pint: A small blus (eg mcg = ml f 1:10 000) may be used as a temprising measure while transcutaneus pacing is being established r as a test dse f the effectiveness f drug therapy. Dses may be escalated as required. Infusins may be run peripherally (eg. ACF vein) in the medium term. Isprenaline 3 rd line agent (ARC): 2-5 mcg/min Clinical pint: Cmmnly used fr bradycardia in the setting f degenerative disease eg. sick sinus. Isprenaline is a vasdilatr and reduces diastlic mycardial perfusin thus shuld be avided in the setting f acute ischaemia (eg. inferir MI) Specific situatins Hyperkalaemia: Aggressive treatment is indicated (see Mdule 1) B-blcker use: Higher dses f catechlamines may be required. Hi-dse Insulin/ glucse therapy may be indicated. Glucagn may be trialled (1-5 mg) Electrical pacing CaCB use: Calcium and hi-dse Insulin/ glucse therapy may be indicated (see Mdule 1) Digxin: Digibind FAB may be indicated. (see Mdule 1) Indicated if a failure t respnd t drug therapy r a higher risk f prgressin t asystle Perids f asystle Ventricular pauses f > 3 secnds Mbitz type II 2 nd degree HB r 3 rd degree (cmplete) HB Clinical pint: T assess the effect f chrntrpic drug therapy (eg. adrenaline infusin) intrduced in a patient being trans-cutaneusly paced press and hld dwn the pause buttn n the pacer this stps pacing fr as lng as yu are hld the buttn dwn allwing assessment f the intrinsic respnse t the current rate f infusin.

Tachyarrhythmias DCCV Synchrnised (resynchrnise after each shck) Energy levels: 100-200J (reasnable t use 200J). VT sensitive t DCCV and likely t respnd t 100J.

3 Tachyarrhythmias DCCV Synchrnised (resynchrnise after each shck) Energy levels: J (reasnable t use 200J). VT sensitive t DCCV and likely t respnd t 100J. Clinical pint: DCCV is a brief, mderately painful stimulus. The level f sedatin required is nly light. If a patient is cmprmised due t hyptensin etc then they are likely t already be clse t the desired endpint withut sedatin. Excess delays until DCCV may nt be in the patient s best interest. 1. Regular Brad Cmplex tachycardia In the peri-arrest setting assume that brad-cmplex tachyarrhythmias are ventricular in rigin treating an SVT (with aberrancy) as VT is less likely t lead t deteriratin than the reverse Clinical pint: VT is much mre likely than SVT with aberrancy in patients with a cardiac histry (IHD, CCF) r thse >40 years. In the absence f prir ECG s dcumenting BBB/aberrancy it is safest t treat as VT. In the absence f adverse features give amidarne 300 mg ver mins fllwed by infusin f 900mg/24 hrs. Ligncaine is a 3rd line agent with a ptential rle in stable VT in the setting f ischaemia Clinical pints: DCCV is almst always an apprpriate treatment fr VT. It shuld always be a first line cnsideratin. Crrect electrlytes (K > 4.0, Mg > 1.0)

Recurrent VT suggests a need fr 1) reversal f the cause/cntributing factrs 2) Anti-arrhythmic therapy. DCCV can be repeated/trialled nce this has ccurred.

4 Recurrent VT suggests a need fr 1) reversal f the cause/cntributing factrs 2) Anti-arrhythmic therapy. DCCV can be repeated/trialled nce this has ccurred. Amidarne 300mg may be give as an IV blus (arrest) r mre usually as an IV infusin ver 30 minutes. The vehicle in amidarne tends t cause sme vasdilatin and pssible hyptensin thus the usual rate f 30 mins. If yur patient has a tachyarrhythmia where amidarne rate/rhythm management is urgently indicated (and DCCV is nt r has been ineffective) then a mre rapid infusin may be in yur patient s best interests eg minutes. 2. Irregular brad-cmplex tachycardia The key differentials are A. AF + BBB Treat as per AF B. AF with aberrancy (Wlf-Parkinsn-White) High risk arrhythmia due t ptential t deterirate int VF Recgnitin: High rates (eg > 180) AV nde cant g this fast Delta waves DCCV 1 st line the safest ptin. Amidarne 2 nd line. Avid agents which may blck AV nde and increase aberrant cnductin: NO B-Blckers, Ca++-blckers, adensine, digxin C. Plymrphic VT (Trsades de Pintes) Plymrphic VT in setting f lng QT. May be self-limiting r lead t arrest.

It may be apprpriate t give Mg++ 10 mml as a slw IV push fllwed by anther 10 mml ver 10 mins if TdP is frequent (in setting lng QT). Aggressive crrectin f K (> 4.0) is als indicated. iii.

5 Manage with DCCV/ ALS if lss f utput Specific therapy i. Crrect electrlyte abnrmalities (esp hypkalaemia) and underlying causes (ischaemia) ii. Mg++ 5 mml ver 10 minutes, may repeat, 20 mml ver 4 hurs (ARC) Clinical pint: Mg++ has a wide therapeutic safety windw. TdP can be an unstable arrhythmia. It may be apprpriate t give Mg++ 10 mml as a slw IV push fllwed by anther 10 mml ver 10 mins if TdP is frequent (in setting lng QT). Aggressive crrectin f K (> 4.0) is als indicated. iii. 2 nd line: Chrntrpic therapy: QT prlngatin and risk f TdP is greatest at slw rates. If TdP cntinues despite the abve then it is apprpriate t increase the resting HR twards 100/min. 1. Isprenaline r Adrenaline infusin (0-20 mcg/min), ccasinally transvenus pacing is indicated iv. 3 rd line: Ligncaine (1-1.5 mg/kg lad + infusin)

6 3. Regular narrw-cmplex tachycardia Differentials are Sinus tachycardia AV Ndal Re-entrant Tachycardia (AVNRT)- Cmmnest AV Re-entrant Tachycardia (AVRT) assciated with WPW AV flutter with regular AV cnductin (2:1) Management 1. If unstable r cmprmised then DCCV. Trial f adensine reasnable. 2. If stable 1 st line: Vagal maneuvres Mdified valsalva may increase success rate t > 40 %. 15 sec blwing at 40 mmhg (r 10 ml syringe just mving plunger) in semi recumbent psitin then lie flat and raise legs. (Appelbam A et al. Pstural Mdificatin t the Standard Valsalva Maneuvre fr Emergency Treatment f Supraventricular Tachycardias (REVERT): A Randmised Cntrlled Trial. Lancet 2015.) 2 nd line: Adensine 6/12/18 mg. IV blus. ACF + 20 ml flush. May unmask atrial flutter 3 rd line: Verapamil 2.5 5mg IV (ARC) ver 5 mins. Give 2.5 mg bluses every 3-5 min t a ttal f 15 mg. Verapamil is safe and effective. Indicated if 1) Adensine successful but SVT recurs r 2) Adensine unsuccessful. If reversin des nt ccur after mg then either repeat valsalva r adensine which may nw be successful. If SVT persists cnsider amidarne r DCCV. Amidarne indicated if maintenance f SR rather than reversin is the issue. Ensure K > 4.0. Mg > Irregular narrw-cmplex tachycardia Mst cmmnly AF r Atrial Flutter with variable blck. Differential includes frequent APC s (Atrial premature cntractins) and MAT (Multifcal atrial tachycardia) Atrial Fibrillatin Cmmnest arrhythmia, ften a marker f underlying disease r c-existent illness If the patient is unstable then urgent DCCV

7 Clinical pint: AF is cmmn yet DCCV ccurs rarely it is imprtant t cnsider the rle f DCCV. When seeing a patient in Resus with AF at a rate > 130 yu shuld ask Is DCCV indicated. DCCV may be indicated when i. Patient is unstable and it may be f benefit benefit > harms ii. Patients cnditin makes AF prly tlerated eg. STEMI + new AF, nncmpliant LV Therapeutic decisins Rate cntrl (drugs) Cmprmise due t rate is cmmn at rates > 150/min and uncmmn at rates < 130. Target HR in ED is usually ~ /min. Cncurrent treatment f cexisting illness is imprtant. Urgent rate cntrl is indicated in the setting f ACS. Mst cmmn apprach B-Blcker (metrprll) 1 st line. 2.5 mg IV repeated as necessary, ral mg. Avid if significant LVF, hyptensin, asthma Ca-blcker (verapamil/diltiazem) 2 nd line Digxin: Nt an emergency drug. Has a rle especially in the sedentary patient hwever nset f actin 6 hurs. This may be apprpriate in patients wh are relatively asymptmatic. Des nt cntrl rate with exercise inapprpriate fr yunger patients r parxysmal AF. Amidarne can be useful t cntrl the rate in AF when ther measures are unsuccessful r cntraindicated (ARC). Amidarne (300mg lad ver mins) is the ideal agent fr acute rate cntrl in the critically ill patient e.g. Sepsis, shck, CCF. Rhythm cntrl Patient identificatin f time f nset f AF can be unreliable. > 50% f patients with new AF will revert spntaneusly in the 1 st 24 hrs. Cardiversin within 1 st 48 hurs f nset is cnsidered lw risk f emblism. DCCV: Effective. Safe. Fast. Usually well tlerated. Drugs: Effective. Safe in the right patient. Flecainide: 1 st line in gd hearts = Nrmal LV and n IHD ( ideally pst ech). Use usually in cnjunctin with treating cardilgist. 2 mg/kg up t 150 mg ver 30 mins. Amidarne: Ideal in bad hearts Anticagulatin

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