Background
- Cardiac arrhythmias are relatively common presentations to ED.
- There are many causes, some more sinister than others.
- If your patient is not acutely unwell then expert advice may be required.
Assessment (ABCDE) – How sick is your patient?
History (especially any of…)
- Chest pain suggestive of ischaemia
- Any collapse or syncope
- Shortness of breath
- Swelling of peripheries
Examination
- Signs of shock – pallor, sweating, cold, clammy, confusion
- Signs of heart failure – Bibasal chest crackles, raised JVP, hepatomegaly, peripheral oedema
Investigations
- ECG
- Observations esp BP
- IV access – FBC, U&E, Mg2+, Ca2+, Trop, TFT
- CXR
Treatment
Any Adverse Features (Unstable) = DC cardioversion
- Shock
- Syncope
- Myocardial ischaemia
- Heart failure
DC cardioversion – get help as sedation will be required
- Broad Complex or AF: 120J-150J- 200Jsynchronised shock
- Narrow Complex or Atrial Flutter: 70-120J- 200J synchronised shock
Stable Narrow Complex (QRS <0.12sec)
Regular – Sinus Tachycardia, AVNRT (SVT), Atrial flutter with regular block, AVRT (WPW)
- Sinus Tachycardia – Look for the cause ?infection ?pain ?anaemia ?hypovolaemia ?anxiety ?drugs
- SVT – Stepwise treatment until NSR regained (ensure cardiac monitoring): –
- Vagal Manoeuvres – Lie flat and head down, Carotid sinus massage (ensure no bruit 1st), Blow into 50ml syringe
- Adenosine – 6mg, 12mg, 18mg boluses (not in severe Asthma)
- Not reverted – call for expert help
- Atrial Flutter with 2:1 block (150bpm) – consider rate controlling drugs
- AVRT (WPW) – get expert help (DO NOT give Adenosine)
PDF: Arrhythmia Clinic referral form (Print and Fax OR can email – use fill and sign function to enter details)
PDF: Patient Info
Irregular – likely AF (Follow AF Pathway)
Broad Complex (QRS >0.12sec)
- Irregular – likely AF with BBB
- Get Expert help
- Regular – VT
- IV Amiodarone 300mg over 20 mins
- Consider expert help
DVLA – if caused or likely to cause incapacity
References
