General approach to All Patients

Cardiac Arrhythmias

Atrial Fibrillation or Flutter

Basic Life Support

  • Supplemental oxygen

Advanced Life Support

  • Full ALS Assessment and Treatment
  • Do not delay treatment by obtaining 12 lead ECG if patient is unstable unless diagnosis is in question

Stable or borderline (systolic blood pressure > 90 mmHg):Supraventricular Tachycardia

  • Rate < 150 beats/min
    • No anti-arrhythmic indicated
    • Provide supportive care and expedite transport
  • Rate ≥ 150 beats/min AND symptomatic (chest pain, palpitations, dyspnea)
    • Administer Diltiazem (Cardizem) 0.25 mg/kg IV (maximum dose 20 mg) over two minutes if available
      • If BP < 90 mm Hg systolic, administer boluses of 0.9% NaCl at 250 ml until systolic BP < 90 mm Hg
      • Contraindicated if wide complex (QRS > 120 msec) or history of Wolf-Parkinson- White (WPW) syndrome

Unstable with serious signs and symptoms (Ventricular rate > 150):

  • Unstable is defined as systolic blood pressure less than 90 mmHg, acutely altered mental status and signs of shock
  • Synchronized cardioversion
    • 1st energy level 100 Joules
    • If no response 200 J
    • If no response 300 J
    • If no response 360 J

Bradycardia (Heart Rate less than 50)

Basic Life Support

  • Supplemental oxygen

Advanced Life Support

  • Full ALS Assessment and Treatment
    • Administer boluses of 0.9% NaCl at 250 ml until systolic BP > 90 mm Hg
      • Contraindicated if evidence of congestive heart failure (e.g. rales)
  • Do not delay treatment by obtaining 12 lead ECG if patient is unstable unless diagnosis is in question
  • If the patient is normotensive, with no signs of shock, provide supportive care and expedite transport.

Unstable with serious signs and symptoms (Heart rate < 50):

  • Unstable is defined as systolic blood pressure less than 90 mmHg, acutely altered mental status and signs of shock
  • Atropine 0.5 mg IV
    • Repeat every 3 minutes as needed (Maximum 3 mg)
  • If symptoms persist after Atropine, or any delay in establishing IV, initiate transcutaneous pacing using Demand Mode:
    • Start at lowest MA’s; increase until electrical capture with pulses achieved
    • Start rate at 70 or default and increase rate to achieve systolic BP ≥ 90 mm Hg(Maximum 100 beats/minute)
    • If systolic BP returns to ≥ 90 mmHg consider sedation, Midazolam 2.5 mg slow IV
  • For hypotension (systolic BP < 90 mmHg) not improved by the above:
    • Dopamine infusion at 2-10 mcg/kg/min titrated to maintain systolic BP > 90 mm Hg
  • If above unsuccessful:
    • Epinephrine infusion at 2-10 mcg/minute IV
  • If drug induced, treat for specific drug overdose:
    • Beta blocker OD, administer Glucagon 5 mg IV
    • Calcium channel blocker OD, administer Calcium Chloride 1 gram IV/IO
      • Contraindicated if patient on Digoxin / Lanoxin
      • Glucagon 5 mg IV if no response to Calcium Chloride
    • Opioid OD, administer Naloxone (Narcan) 2 mg IV (start at 0.4 mg for patients over 65 years old)
      • Naloxone (Narcan) can be given in 0.4 mg increments titrated to mental status and respiratory drive
      • If IV access has not been established, give IM or intranasal via MAD
    • Tricyclic Antidepressant OD, administer Sodium Bicarbonate 1 mEq/kg IV

Supraventricular Tachycardia

Basic Life Support

  • Supplemental oxygen

Advanced Life Support

  • Full ALS Assessment and Treatment
  • Do not delay treatment if patient is unstable by obtaining 12 lead ECG unless diagnosis is in question

Stable or borderline (Ventricular rate > 150):

  • Vagal maneuvers (Valsalva or cough)
    • Ice water contraindicated in patients with ischemic heart disease
  • Adenosine Phosphate (Adenocard) 6 mg rapid IV over 1-3 seconds
    • If no response in 2 minutes, 12 mg rapid IV over 1-3 seconds
    • If no response in 2 minutes, repeat 12 mg IV over 1-3 seconds

Unstable with serious signs and symptoms (Ventricular rate > 150):

  • Unstable is defined as systolic blood pressure less than 90 mmHg, acutely altered mental status and signs of shock
  • May give brief trial of Adenosine 6 mg rapid IV over 1-3 seconds
  • Synchronized Cardioversion
    • 1st energy level 100 Joules
    • If no response 200 J
    • If no response 300 J
    • If no response 360 J

Wide Complex Tachycardia

Basic Life Support

  • Supplemental oxygen

Advanced Life Support

  • Full ALS Assessment and Treatment
  • Do not delay treatment by obtaining 12 lead ECG if patient is unstable unless diagnosis is in question
  • In general, assume unknown wide complex tachycardias, at rates over 150, represent ventricular tachycardia

Stable and SVT highly likely (rate > 150):

  • Adenosine Phosphate (Adenocard) 6 mg rapid IV over 1-3 seconds
    • If no response in 2 minutes, 12 mg rapid IV over 1-3 seconds
    • If no response in 2 minutes, repeat 12 mg rapid IV over 1-3 seconds

Stable wide complex or ventricular tachycardia likely (rate > 150):

  • Amiodarone 150 mg IV Piggyback over 10 minutes
    • Repeat Amiodarone 150 mg IV Piggyback over 10 minutes every 10-15 minutes (Maximum of 450 mg total)

Unstable wide complex tachycardia (rate > 150):

  • Unstable is defined as systolic blood pressure less than 90 mmHg, acutely altered mental status and signs of shock
  • Synchronized cardioversion
    • 1st energy level 100 Joules
      • If no response 200 J
      • If no response 300 J
      • If no response 360 J
  • If delays in synchronization occur and clinical condition is critical, go immediately to unsynchronized shocks
  • If wide complex tachycardia re-occurs following electrical cardioversion:
    • Amiodarone 150 mg IV Piggyback over 10 minutes
      • Repeat Amiodarone 150 mg IV Piggyback over 10 minutes every 10-15 minutes (Maximum of 450 mg total)
  • If hyperkalemia suspected in any wide complex tachycardia (e.g. renal failure patient) administer the following medications:
    • Calcium Chloride 1 gram IV
      • Contraindicated if patient on Digoxin/Lanoxin
    • Sodium Bicarbonate 1 mEq/kg IV

Polymorphous VT (Torsades)

Basic Life Support

  • Supplemental oxygen

Advanced Life Support

  • Full ALS Assessment and Treatment
  • Do not delay treatment by obtaining 12 lead ECG if patient is unstable unless diagnosis is in question

Stable:

  • Magnesium Sulfate2 g slow IV in 100 ml D5W over 5-10 minutes
  • If no response, Amiodarone 150 mg IV Piggyback over 10 minutes
    • Repeat Amiodarone 150 mg IV Piggyback over 10 minutes every 10-15 minutes (Maximum of 450 mg total)

Unstable – or if no response to the above measures:

  • Unstable is defined as systolic blood pressure less than 90 mmHg, acutely altered mental status and signs of shock
  • Unsynchronized Cardioversion
    • 1st energy level 100 Joules
    • If no response 200 J
    • If no response 300 J
    • If no response 360 J