ARRHYTHMIA
TREATMENT
ALGORITHMS
NCORT, ALS SUBCOMMITTEE 2021
1
Objectives
Upon completion of this session, you will be able to :
List the four arrhythmias leading to cardiac arrest
State the treatment algorithms for VF/ pulseless
VT (pVT), PEA and Asystole
Understand the principles of management of
tachy and brady arrythmias
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Cardiac Arrest
Occurs with one of four arrhythmias:
Ventricular fibrillation (VF)
Pulseless ventricular tachycardia (pVT)
Pulseless electrical activity (PEA)
Asystole
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Cardiac Arrest Algorithm.. cont..
Return of
High Quality CPR Shock Energy Drug Advanced Airway Spontaneous Reversible Causes
for Defibrillation therapy Circulation
(ROSC)
• Push hard(at least 5cm) Biphasic Adrenaline • Endotracheal • Pulse present 5Hs
and fast(at least 100- Manufacturer IV/IO dose1 mg intubation or and blood • Hypovolemia
120/min) and allow recommendation every 3-5 supraglottic pressure • Hypoxia
complete chest recoil (eg initial dose of minutes advanced airway recordable • Hydrogen ion
• Minimise interruptions 120-200J); If • Waveform (acidosis)
in compression unknown, use Amiodarone capnography or • Abrupt and • Hypo/ hyperkalaemia
• Avoid excessive maximum available. IV/IO dose capnometry to sustained • Hypothermia
ventilation Second and First dose confirm and monitor increase in
• Change compressor subsequent doses 300mg bolus ETT placement ETCO2 5Ts
every 2 min or sooner should be Second dose • Once advanced • Tension
if fatigued equivalent, and 150mg airway in place, give • Spontaneous pneumothorax
• If no advanced airway, higher doses may Or 1 breath every 6 arterial • Tamponade, cardiac
30:2 compression: be considered Lignocaine seconds pressure • Toxins
ventilation ratio or 1 IV/IO dose • (10 breaths/minute) waves with • Thrombosis,
breath every 6 seconds Monophasic First dose 1- with continuous intra-arterial pulmonary
• Qualitative waveform 360J 1.5mg/kg chest compressions monitoring • Thrombosis,
capnography – if ETCO2 coronary
is low or decreasing, Second dose
reassess CPR quality 0.5-0.75mg/kg
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Causes: 5H’s and 5T’s
• Hypoxia
• Hypokalemia/hyperkalemia
• Hypothermia
• Hypovolaemia
• Hydrogen ions (acidosis)
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Causes: H’s and T’s ….cont
• Tamponade (cardiac)
• Thrombosis (pulmonary)
• Thrombosis (coronary)
• Toxins
• Tension pneumothorax
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What is this rhythm?
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What is this rhythm?
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What is this rhythm?
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ALS Subcommittee
2010
What is this rhythm?
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ALS Subcommittee
2010
What is this rhythm?
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Cardiac Tamponade
• Chest x-ray
• Widened mediastinum
• Pneumo- or
haemothorax
• Electrical alternans
• Note rounded bottle shape
to left side of heart
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Tension Pneumothorax
A: Air under
A tension in
left thorax
Pleural margin;
partial lung
collapse
Left
Right
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Asystole/PEA Algorithm
Adrenaline 1 mg IV push,
repeat every 3 to 5 minutes,
If Asystole persists
Withhold or cease resuscitation efforts?
• Consider quality of resuscitation?
• Atypical clinical features present?
• Search for DNR order
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Tachy/bradyarrhythmias
Is patient stable or unstable?
Patient has serious signs or symptoms?
Chest pain (ischemic? possible ACS?)
Shortness of breath (lungs getting ‘wet’? possible CCF?)
Low blood pressure (orthostatic? dizzy? lightheaded?)
Decreased level of consciousness (poor cerebral perfusion?)
Clinical shock (cool and clammy? peripheral vasoconstriction?)
Are the signs and symptoms due to the slow or
rapid heart rate?
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Bradycardia Algorithms
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Adult
Bradycardia
Algorithm
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Adult bradycardia algorithm..con’t
DRUGS
Atropine Aminophylline
First dose 0.5 mg IV bolus. Repeat every If beta blocker overdose, spinal cord
3 – 5 minutes. Maximum 3 mg injury or post heart transplant recipient
100 - 200 mg IV slow injection
Dopamine Glucagon
5 - 20 ug/kg/min IV infusion titrated to If calcium channel blocker or beta
patient response. Taper slowly blocker overdose 50 ug/kg IV loading
followed by 1-15 mg/hour infusion
Adrenaline 2 – 10 ug/min IV infusion titrated to patient response
titrated to patient response
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Tachycardia Algorithms
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212021
NCORT, ALS SubCommittee
Adult tachycardia..con’t..
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Adult tachycardia with pulse
algorithm..con’t..
DRUGS
Adenosine
6mg rapid IV push followed with NS flush;
2nddose 12mg if required;
3rddose 18mg if required
Amiodarone
300 mg IV infusion over 10 -20 minutes
if unstable; over 60 minutes if stable
Consider IV infusion 900mg over 24 hours if
needed
Lignocaine
1-1.5 mg/kg IV bolus.
2nd dose 0.5 – 0.75 mg/kg if required
Magnesium
1 to 2 grams IV over 15 minutes, may be followed
by an infusion
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Tachyarrhythmia
CARDIOVERSION
Synchronized cardioversion:
Refer to your device’s specific recommended
energy level to maximize first shock success
Recommended energy level:
Waveform Biphasic Monophasic
energy energy
Narrow regular 70 – 120J 100J
(SVT, atrial flutter)
Narrow irregular 120 – 150J 200J
(AF)
Broad complex
tachycardia (VT) 120 – 150J 200J
Monomorphic VT 120 – 150J 200J
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Summary
• Effective ALS begins with high quality CPR
• Uninterrupted high quality chest compressions
improve outcome
– Rhythm check, rescue breath, even drug administration
should NOT interrupt compressions
• Early recognition & treatment of arrhythmias
give the best chance of survival
• Treat the underlying cause
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