Peri-arrest rhythms

Question 1

What does the management of bradycardia depend on?

Answer 1

1. Identifying the presence of signs indicating haemodynamic compromise - ‘adverse signs’
2. Identifying the potential risk of asystole

Question 2

Give examples of advserse signs which indicate heamodynamic compromise during peri-arrest bradycardia?

Answer 2

1. Shock:

• ​hypotension (systolic blood pressure < 90 mmHg)
• Pallor
• Sweating
• Cold
• Clammy extremities
• Confusion or impaired consciousness

1. Syncope
2. Myocardial ischaemia
3. Heart failure

Question 3

What is the treatment for advserse signs during bradycardia?

Answer 3

1. Atropine (500mcg IV) is the first line treatment in this situation
2. If there is an unsatisfactory response the following interventions may be used:

• Atropine, up to maximum of 3mg
• Transcutaneous pacing
• Isoprenaline/adrenaline infusion titrated to response

Specialist help should be sought for consideration of transvenous pacing if there is no response to the above measures.

Question 4

What are risk factors of asystole?

Answer 4

• Complete heart block with broad complex QRS
• Recent asystole
• Mobitz type II AV block
• Ventricular pause > 3 seconds

Even** if there is a **satisfactory response to atropine** specialist help is indicated to consider the need for **transvenous pacing

Question 5

What should be given in the event of adverse signs in perri-arrest tachycardias?

Answer 5

1. Synchronised DC shocks should be given
2. Treatment following this is given according to whether the:
   
   • QRS complex is narrow or broad
   • Rhythm regular or irregular

Question 6

If there are adverse signs then what is the patient classified as?

Answer 6

Unstable

Question 7

Management for broad-complex tachycardia with regular rhythm?

Answer 7

• Assume ventricular tachycardia (unless previously confirmed SVT with bundle branch block)
• Loading dose of amiodarone followed by 24 hour infusion

Question 8

Management of broad-complex tachycardia with irregular rhythm?

Answer 8

1. AF with bundle branch block - treat as for narrow complex tachycardia
2. Polymorphic VT (e.g. Torsade de pointes) - IV magnesium

Question 9

What is the management for narrow-complex tachycardia with regular rhythm?

Answer 9

1. vVgal manoeuvres followed by IV adenosine
2. If above unsuccessful consider diagnosis of atrial flutter and control rate (e.g. Beta-blockers)

Question 10

Management of narrow-complex tachycardia with irregular rhythm?

Answer 10

1. Probable atrial fibrillation
2. If onset < 48 hr consider electrical or chemical cardioversion
3. Rate control (e.g. Beta-blocker or digoxin) and anticoagulation