Recognising that someone may be approaching the end of their life can be difficult, particularly in the busy and sometimes unpredictable environment of the Emergency Department. We may meet people and families at a moment of profound distress, with little time to build a relationship or understand what matters most to them. It is understandable that these conversations feel daunting.
Yet recognising the possibility of dying creates an opportunity to offer the right care: to treat distress, consider reversible problems, explain uncertainty honestly and help patients and those close to them make informed choices. End of life care is not an alternative to good emergency medicine; it is part of it. Compassionate care remains active care.
Bloods: FBC, U&E, Bone profile, Magnesium, LFT, TFT, Clotting, Glucose
Others: individualised to the patient.
First line:
β-Blocker – outperforms calcium channel blockers in studies
Non-dihydropyridine calcium channel blockers (Diltiazem/Verapamil) – esp. in Severe COPD/Asthma
Second Line:Consider adding in
Digoxin – however, digoxin alone is not effective in patients with increased sympathetic drive. Observational studies have associated digoxin use with excess mortality in AF patients)
Amiodarone can be useful as a last resort when heart rate cannot be controlled with combination therapy in patients who do not qualify for non-pharmacological rate control
Rhythm control in ED
“Early cardioversion is not recommended without appropriate anticoagulation or transoesophageal echocardiography if AF duration is longer than 24 h, or there is scope to wait for spontaneous cardioversion.”
In reality risks increase beyond 12hrs from onset, and those reverted in ED will often return to AF by the time they get to AF clinic follow up.
AF increases the chance of Stroke by 5x (and those recently diagnosed are least likely be on any form of protection)
ESC/NICE recommends using the CHADS-VASc to assess stroke risk and ORBIT to assess bleeding risk
There are currently significant delays getting to “New AF” clinic as well as to GP’s, making assessment of Stroke risk in ED more important than ever
CHADS-VASc outcome recommendations
Males (0), Female (1) – No anticoagulation recommended
Males (1) – Consider anticoagulation (DOAC) in light of bleed risk
Use Apixaban where first line, significantly cheaper. If using alternative please document reasons.
ORBIT outcome recommendations
Modifiable risks – Address ALL modifiable risk factors
Most will benefit from anticoagulation – but discuss personalised risk with patients
Contraindications to Anticoagulation inc:
Active serious bleeding (where the source should be identified and treated)
Associated comorbidities (e.g. severe thrombocytopenia <50 platelets/lL, severe anaemia under investigation, etc.)
Recent high-risk bleeding event such as intracranial haemorrhage (ICH).
Life Style
Obesity: Risk of AF, Recurrence of AF and Stoke all increase with BMI
Alcohol: Alcohol excess both increases the risk of AF and of Bleeding, so patient should support to reduce aldol intake is recommended
Caffeine: It is unlikely caffeine consumption causes AF. Habitual caffeine use may reduce the risk of developing AF. But increases the symptoms
Exercise: Moderate cardiavasclar exercise is protective, however higher rates of AF are seen in elite athletes and vigorous physical activity
Specific conditions- patient should follow up with GP/Clinic (treatment may start in ED)
Hypertension
Heart Failure
Coronary artery disease
Diabetes Mellitus
Sleep Apnoea
Arrhythmia clinic is for patients with newly diagnosed and symptomatic AF/SVT (if the patient is not symptomatic they should be followed up through their GP).
It should be remembered that patients will be seen after at least 6 weeks so anticoagulation decisions should not be delayed for clinic.
Sinus tachycardia is usually compensatory — identify and treat the cause. Do NOT cardiovert sinus tachycardia.
INITIAL ASSESSMENT
ABCDE
Cardiac monitor BP and SpO₂ 12-lead ECG IV access Bloods as clinically indicated: FBC U&E / Mg²⁺ / Ca²⁺ glucose troponin where indicated other investigations directed by likely cause Give oxygen only if SpO₂ <94%, unless an alternative target is appropriate.
Think WHY the patient is tachycardic?
Sepsis/Hypovolaemia/Haemorrhage Pain/Anxiety Hypoxia Fever PE ACS/Heart failure Thyrotoxicosis Drugs/Withdrawal Pregnancy
Do not attempt to normalise an appropriate sinus tachycardia with anti-arrhythmics or electrical cardioversion.
Electrical cardioversion is an appropriate first-line strategy
Especially where structural heart disease is present or cannot be excluded.
SYNCHRONISED CARDIOVERSION For VT with a pulse: 120–150 J initially, escalating if required
If sedation / anaesthesia presents significant risk
Drug treatment may be considered:
Procainamide 10–15 mg/kg IV over 20 minutes Maximum 1 g OR
Amiodarone 300 mg IV over 10–60 minutes followed by: 900 mg IV over 24 hours
If ineffective: SYNCHRONISED CARDIOVERSION WITH EXPERT ADVICE
STOP — HIGH-RISK RHYTHM
Consider:
1. AF WITH BUNDLE BRANCH BLOCK
2. PRE-EXCITED AF / WPW
3. POLYMORPHIC VT
Seek senior / cardiology support early.
PRE-EXCITED AF
Think pre-excitation when there is:
very rapid irregular broad-complex tachycardia
varying QRS morphology
ventricular rates sometimes >200 bpm
known WPW / previous delta wave
DO NOT GIVE AV-NODAL BLOCKING DRUGS
Avoid the following as these may increase conduction through the accessory pathway and precipitate VF:
Adenosine
Beta-blockers
Verapamil
Diltiazem
Digoxin
Treatment
Procainamide OR
Synchronised cardioversion
If polymorphic VT occurs with QT prolongation:
Magnesium: Mg²⁺ 8 mmol IV over 10 minutes
Also:
Correct K⁺ / Mg²⁺ abnormalities.
Stop QT-prolonging drugs.
Treat reversible causes.
Seek expert help.
For recurrent pause-dependent torsades consider increasing the heart rate with:
Isoprenaline OR
Temporary pacing
❌ AVOID AMIODARONE because it may further prolong the QT interval.
⚠️ PITFALLS
FAST ≠ ARRHYTHMIA
Do not treat physiological sinus tachycardia as an arrhythmia.
BROAD + REGULAR = VT UNTIL PROVEN OTHERWISE
Do not delay appropriate treatment while attempting to prove SVT.
BROAD + IRREGULAR ≠ ROUTINE AF
Always consider pre-excited AF.
ADENOSINE IS NOT FOR IRREGULAR BROAD-COMPLEX TACHYCARDIA
DO NOT GIVE AMIODARONE FOR TORSADES / LONG-QT POLYMORPHIC VT
Give magnesium and correct the underlying problem.
CARDIOVERSION REQUIRES SYNC
Confirm the machine is marking the R waves before delivering the shock.
Re-check SYNC after each shock — some defibrillators automatically revert out of synchronised mode.
DISPOSITION
Consider admission / cardiology assessment for:
VT
broad-complex tachycardia of uncertain cause
syncope associated with tachyarrhythmia
significant structural heart disease
ACS / myocardial ischaemia
heart failure
recurrent arrhythmia despite treatment
pre-excitation
significant electrolyte disturbance
drug-induced arrhythmia
prolonged QT / torsades
haemodynamic instability
arrhythmia requiring electrical cardioversion
Patients with uncomplicated successfully terminated SVT may be suitable for discharge following senior review, appropriate investigation and follow-up depending on the clinical circumstances.
GUIDANCE
Based primarily on:
Resuscitation Council UK — Guidelines 2025: Adult Advanced Life Support
Resuscitation Council UK — Adult Tachyarrhythmia Algorithm, current version March 2026
First take a good history, not ALL chest pain needs to be investigated as ACS. However, its worth noting older patients and women are more likely to have atypical presentations. Be wary that some patients with negative troponin give a history of Unstable Angina and therefore require admission.
Anticoagulated with a DOAC, or with Warfarin (with a therapeutic INR),
Aspirin 300mg stat
Clopidogrel 300mg stat
ACS &Aspirin Allergy
If the history suggests intolerance (GI upset, dyspepsia, nausea etc) rather than allergy, aspirin rechallenge is justifiable.
In TRUE allergy aspirin should be avoided. > Give Ticagrelor 180mg + Fondaparinux 2.5mg (unless contraindicated)
Any doubts contact Cardiology on-call Con
Treatment STEMI going for PPCI
Aspirin 300mg stat
Plus Either:
Ticagrelor 180mg stat (Hx of CVA)
Prasugrel 60mg stat (NO Hx of CVA)
Direct admissions to CCU
Patients with ST Elevation (if not accepted for primary PCI) or those with CP + new ST Depression should be discussed with a local Cardiologist and come directly to CCU.
As it is difficult to be prescriptive for every other circumstance, a discussion with a senior/cardiologist may be worthwhile in order to best manage and place your patient within the hospital.
Patients where MI is excluded
If patients do exit the pathway (no new symptoms, no new ECG ischemia and troponins that meet the exit criteria to exclude an MI), two other important possibilities still require consideration:
Is the history in keeping with unstable angina? (This is still an ACS). If so the patient will require an acute inpatient admission with telemetry and IP cardiology review.
Is the chest pain due to a significant alternative diagnosis? If so this still needs to be actively considered/ investigated/ treated.
