• Monitor ECG, BP, SpO2 Adult tachycardia algorithm • Record 12-lead ECG if possible; if not, record rhythm strip (with pulse) • Identify and treat reversible causes (e.g. electrolyte abnormalities)
Synchronised DC Shock * Unstable
Is patient stable? Up to 3 attempts Signs of instability include: 1. Reduced conscious level 2. Chest pain 3. Systolic BP < 90 mmHg 4. Heart failure • Amiodarone 300 mg IV over 10-20 min (Rate-related symptoms uncommon at less than 150 beats min-1) and repeat shock; followed by: • Amiodarone 900 mg over 24 h Stable
Is QRS narrow (< 0.12 sec)?
Broad Narrow
Broad QRS Narrow QRS
Is QRS regular? Is rhythm regular? Regular Irregular Irregular Regular • Use vagal manoeuvres Irregular Narrow Complex • Adenosine 6 mg rapid IV bolus; Tachycardia Seek expert help if unsuccessful give 12 mg; Probable atrial fibrillation if unsuccessful give further 12 mg. Control rate with: • Monitor ECG continuously Possibilities include: If Ventricular Tachycardia • β-Blocker IV or digoxin IV • AF with bundle branch block (or uncertain rhythm): If onset < 48 h consider: treat as for narrow complex • Amiodarone 300 mg IV • Amiodarone 300 mg IV 20-60 min; • Pre-excited AF over 20-60 min; Normal sinus rhythm restored? then 900 mg over 24 h consider amiodarone then 900 mg over 24 h • Polymorphic VT (e.g. torsade de pointes - give If previously confirmed SVT Yes No with bundle branch block: magnesium 2 g over 10 min) • Give adenosine as for regular Probable re-entry PSVT: narrow complex tachycardia Seek expert help * Attempted electrical cardioversion is • Record 12-lead ECG in sinus always undertaken under sedation rhythm or general anaesthesia • If recurs, give adenosine again & consider choice of anti-arrhythmic Possible atrial flutter prophylaxis • Control rate (e.g. β-Blocker)