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Bradycardia

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					                      Bradycardia

                     Risk of asystole?
                     • History of asystole
          No         • Mobitz II AV block                        Yes
                     • Any pause 3 s
                     • Complete heart block, wide QRS




                                                      Atropine iv
Adverse signs?                                      500 µg initially
• Clinical evidence of low cardiac                   to max 3 mg
   output                                                and
• Hypotension: Systolic BP  90
   mmHg
• Heart failure                                        Seek expert help
• Rate < 40 bpm
• Presence of ventricular
   arrhythmias requiring suppression

                                                  transvenous pacing
                           Yes
                                           Consider as interim measures
                                           • External pacing
                          Atropine iv      • iv isoprenaline/orciprenaline
                        500 µg initially
    No                   to max 3 mg


                                           Seek expert help

                                                  No

               Yes
observe                  Satisfactory response?
 Broad Complex Tachycardia
          (sustained ventricular tachycardia)
                            Yes                  No
                                      pulse?             Use VF protocol

            Seek expert help

                          Adverse signs?
                          • Systolic BP  90 mmHg
                          • Chest pain
           No             • Heart failure                          Yes
                          • Rate  150 bpm


                      • lignocaine iv
                    50 mg over 2 mins
                  repeated every 5 mins                     sedation
                 to total dose of 200 mg
                • start infusion 2 mg/min
                   after first bolus dose          synchronised DC shock
                                                      100J:200J:360J
    if potassium known
          to be low:                                           start
• give KCl up to 60 mmol,                                • lignocaine ±
    max rate 30 mmol/h                                   potassium and
  • give MgSO4 iv 10 ml                                  magnesium as
        50% in 1 hour                                        opposite

                synchronised DC shock                 further cardioversion
                   100J:200J:360J                          as necessary

             amiodarone 300 mg over 5-
             15 min preferably by central      For refractory cases consider
            line then 600 mg over 1 hour       other pharmacological agents:
                                               procainamide,flecainide,
                synchronised DC shock          bretylium and overdrive pacing
                   100J:200J:360J
Narrow Complex Tachycardia
          (supraventricular tachycardia)
                           vagal manoeuvres
                  (caution possible digitalis toxicity,
                    acute ischaemia or presence of
                             carotid bruit)
                                                                  Atrial
                                                               fibrillation
                  adenosine 3 mg by bolus injection            ( 130 bpm)
                  repeat if necessary every 1-2 mins
                  using 6 mg then 12 mg then 12 mg
                        (ATP is an alternative)


                            Seek expert help


               Adverse signs?
               • Hypotension: systolic BP  90 mmHg
               • Chest pain
    No         • Heart failure                                     Yes
               • Impaired consciousness
               • Rate  200 bpm


 choose from:                                                sedation
 • esmolol: 40 mg over 1 min +
    infusion 4 mg/min (iv injection
    can be repeated with increments                        synchronised
                                                           cardioversion
    of infusion to 12 mg/min)
                                                          100J:200J:360J
 • digoxin: max dose 500 µg over
    30 min x 2
 • verapamil: 5 - 10 mg iv                       amiodarone 300 mg over 15
 • amiodarone: 900 mg over 1 hour                  mins then 600 mg over 1
 • overdrive pacing (not AF)                       hour preferably by central
                                                 line and repeat cardioversion
Ventricular Fibrillation
          VF
     PULSELESS VT

     PRECORDIAL THUMP

       DC shock 200J (1)

       DC shock 200J (2)

       DC shock 360J (3)

         If not already:
         • intubate
         • iv access

       Adrenaline 1 mg iv

     10 CPR sequences of 5:1
     compression/ventilation

       DC shock 360J (4)

       DC shock 360J (5)

       DC shock 360J (6)
             EMD
               EMD


Think of, and if indicated
give specific treatment for:
•   hypovolaemia
•   tension pneumothorax
•   cardiac tamponade
•   pulmonary embolism
•   drug overdose/intoxication
•   hypothermia
•   electrolyte imbalance
•   asystole


            If not already:
            • intubate
            • iv access

          Adrenaline 1 mg iv

       10 CPR sequences of 5:1
       compression/ventilation
Doctors.net.uk would like to
   thank James Burton for
contributing this presentation

				
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posted:11/22/2011
language:Swedish
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