Cardiac Arrythmias

	Type	Management
Cardiac Arrest	–Shockable •VF, Pulseless VT –Non Shockable •Asystole, PEA	Shockable or non-shockable? Resume CPR immediately after the shock when IV/IO available, give vassopressor during CPR (before or after the shock) Epinephrine 1mg IV/IO repeat every 3-5 min or 1 dose of vasopressin 40U IV/IO to replace first or second dose of epinephrine Note that by this time, if 3rd shock is required, it is the DRUG →SHOCK→ CPR sequence. It is the same sequence thereafter After the 3rd sequence and giving adrenaline/vasopressin, consider giving antiarrhythmics like amiodarone for VF or magnesium for torsades de pointes. The sequence is still the same DRUG→SHOCK→ CPR. At any time, if rhythm becomes non-shockable, follow the non-shockable algorithm
•Peri arrest rhythms	–Tachyrrhythmias –Bradyarrhythmias •2nd degree Mobitz type 1 •the block is at AV Node •Often transient •Maybe asymptomatic •2nd degree Mobitz type 2 •Block most often below AV node, at bundle of His or BB •May progress to 3rd degree AV block Four Rhythms At Risk Of Developing Asystole 1.Recent asystole 2.Mobitz II 2nd degree AV Block 3.Complete Heart Block (especially with broad QRS or initial heart rate <40/min) 4.Ventricular standstill more than 3 sec	Stable or not stable? Four main signs 1.Signs of low cardiac output – systolic hypotension < 90 mmHg, altered mental status 2.Excessive rates: <40/min or >150/min 3.Chest pain 4.Heart failure •If unstable, electrical therapy: cardioversion for tachyarrhythmias, pacing for bradyarrhythmias Atropine 0.5 mg each bolus up to 3 mg. Atropine as temporizing measure only. Needs transcutaneous/transvenous pacing For polymorphic VT – if patients become unstable, perform defibrillation rather than cardioversion. If ever in doubt whether to perform cardioversion or defibrillation, then perform DEFIBRILLATION Rule of thumb – if your eye cannot synchronize to each QRS complex, neither can the machine! •For stable tachyarrhythmias, we need to further decide whether it is NARROW QRS or WIDE QRS •For each type, further divide into –Regular Irregular •Narrow QRS tachyarrhythmias –Regular •Sinus Tachycardia, PSVT, atrial flutter with regular AV conduction –Irregular •Atrial Fibrillation, Atrial flutter with variable AV Block •Wide (Broad) QRS tachyarrhythmias –Regular •Ventricular Tachycardia, SVT with BBB –Irregular Polymorphic VT, AF with BBB Narrow complexes and regular – attempt vagal maneuver and adenosine; Narrow complexes but not regular- likely AF. Don’t give adenosine.  May attempt rate control using beta blocker or diltiazem Amiodarone can be given for both regular and irregular broad complexes