Peri-arrest arrhythmias
1. The guideline process
2. Summary of changes since 2010 Guidelines
3. Introduction
4. Sequence of actions
5. Tachycardia
6. Bradycardia
7. References
Authors
David Pitcher, Jerry Nolan
1. The guideline process
The process used to produce the Resuscitation Council (UK) Guidelines 2015 has been accredited by the National Institute for Health and Care
Excellence. The guidelines process includes:
Systematic reviews with grading of the quality of evidence and strength of recommendations. This led to the 2015 International Liaison
Committee on Resuscitation (ILCOR) Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with
Treatment Recommendations.1,2
The involvement of stakeholders from around the world including members of the public and cardiac arrest survivors.
Details of the guidelines development process can be found in the Resuscitation Council (UK) Guidelines Development Process Manual.
www.resus.org.uk/publications/guidelines-development-process-manual/
These Resuscitation Council (UK) Guidelines have been peer reviewed by the Executive Committee of the Resuscitation Council (UK), which
comprises 25 individuals and includes lay representation and representation of the key stakeholder groups.
2. Summary of changes since 2010 Guidelines
There are relatively few changes from Guidelines 2010. The basic principles of assessment and treatment of a suspected cardiac arrhythmia are
unchanged. Use of oxygen therapy is not recommended unless the patient is hypoxaemic, in which situation the concentration of oxygen delivered
should be guided by monitoring arterial oxygen saturation whenever possible. There is stronger emphasis on the use of antithrombotic therapy in
atrial fibrillation (AF) and the importance of assessing thromboembolic risk in people with AF.
, 3. Introduction
Cardiac arrhythmias are relatively common in the ‘peri-arrest’ period. An arrhythmia may precede the development of ventricular fibrillation (VF) or
asystole or may develop after successful defibrillation. Although arrhythmias are common in the setting of acute myocardial infarction, there are
many other causes. Some rhythm abnormalities are usually benign and others usually dangerous; each rhythm encountered requires assessment
and treatment in the context of the individual clinical circumstances at the time.
If a patient with an arrhythmia is not acutely ill there may be other treatment options, including the use of drugs (oral or parenteral), that are less
familiar to the non-expert. In this situation advice should be sought from the most appropriate experts (e.g. cardiologists).
The treatment algorithms described in this section have been designed to enable the non-specialist advanced life support (ALS) provider to treat a
patient effectively and safely in an emergency; for this reason they have been kept as simple as possible. They are based on current national and
international guidelines for management of arrhythmia.3-9
4. Sequence of actions
Assess a patient with a suspected arrhythmia using the ABCDE approach
In particular, note the presence or absence of ‘adverse features’
Give oxygen immediately to hypoxaemic patients and adjust delivery according to observed arterial oxygen saturations
Insert an intravenous (IV) cannula
Whenever possible, record a 12-lead ECG; this will help identify the precise rhythm, which may guide immediate treatment and/or be crucial
to planning later treatment
Correct any electrolyte abnormalities (e.g. K+, Mg2+, Ca2+).
When you assess and treat any arrhythmia address two factors:
1. the condition of the patient (stable versus unstable – determined by the absence or presence respectively of adverse features)
2. the nature of the arrhythmia.
Adverse features
The presence or absence of adverse symptoms or signs will dictate the appropriate immediate treatment for most arrhythmias. The following
adverse features indicate that a patient is at high risk of early deterioration and death (‘unstable’), either because of the arrhythmia itself or
because of underlying heart disease with the arrhythmia superimposed:
Shock – hypotension (systolic blood pressure <90 mm Hg), pallor, sweating, cold, clammy extremities, confusion or impaired
consciousness
Syncope – transient loss of consciousness due to global reduction in blood flow to the brain
Myocardial ischaemia – typical ischaemic chest pain and/or evidence of myocardial ischaemia on 12-lead ECG
Heart failure – pulmonary oedema and/or raised jugular venous pressure (with or without peripheral oedema and liver enlargement).
Treatment options
Depending on the nature of the underlying arrhythmia and clinical status of the patient (in particular the presence or absence of adverse features)
immediate treatment options can be categorised under four headings:
1. No treatment needed
2. Simple clinical intervention (e.g. vagal manoeuvres, fist pacing)
3. Pharmacological (drug treatment)
4. Electrical (cardioversion for tachyarrhythmia or pacing for bradyarrhythmia).
Most drugs act more slowly and less reliably than electrical treatments, so electrical treatment is usually the preferred treatment for an unstable
patient with adverse features.
If a patient develops an arrhythmia during, or as a complication of some other condition (e.g. infection, acute myocardial infarction, heart failure),
make sure that the underlying condition is assessed and treated appropriately, involving relevant experts if necessary.
Once an arrhythmia has been treated successfully, continue to assess the patient (ABCDE) and repeat a 12-lead ECG to detect any other
abnormalities that may require treatment, either immediately or in the longer term.
5. Tachycardia
The approach to an adult with tachycardia and a palpable pulse is shown in the Adult Tachycardia (with pulse) algorithm (Figure 1).
1. The guideline process
2. Summary of changes since 2010 Guidelines
3. Introduction
4. Sequence of actions
5. Tachycardia
6. Bradycardia
7. References
Authors
David Pitcher, Jerry Nolan
1. The guideline process
The process used to produce the Resuscitation Council (UK) Guidelines 2015 has been accredited by the National Institute for Health and Care
Excellence. The guidelines process includes:
Systematic reviews with grading of the quality of evidence and strength of recommendations. This led to the 2015 International Liaison
Committee on Resuscitation (ILCOR) Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with
Treatment Recommendations.1,2
The involvement of stakeholders from around the world including members of the public and cardiac arrest survivors.
Details of the guidelines development process can be found in the Resuscitation Council (UK) Guidelines Development Process Manual.
www.resus.org.uk/publications/guidelines-development-process-manual/
These Resuscitation Council (UK) Guidelines have been peer reviewed by the Executive Committee of the Resuscitation Council (UK), which
comprises 25 individuals and includes lay representation and representation of the key stakeholder groups.
2. Summary of changes since 2010 Guidelines
There are relatively few changes from Guidelines 2010. The basic principles of assessment and treatment of a suspected cardiac arrhythmia are
unchanged. Use of oxygen therapy is not recommended unless the patient is hypoxaemic, in which situation the concentration of oxygen delivered
should be guided by monitoring arterial oxygen saturation whenever possible. There is stronger emphasis on the use of antithrombotic therapy in
atrial fibrillation (AF) and the importance of assessing thromboembolic risk in people with AF.
, 3. Introduction
Cardiac arrhythmias are relatively common in the ‘peri-arrest’ period. An arrhythmia may precede the development of ventricular fibrillation (VF) or
asystole or may develop after successful defibrillation. Although arrhythmias are common in the setting of acute myocardial infarction, there are
many other causes. Some rhythm abnormalities are usually benign and others usually dangerous; each rhythm encountered requires assessment
and treatment in the context of the individual clinical circumstances at the time.
If a patient with an arrhythmia is not acutely ill there may be other treatment options, including the use of drugs (oral or parenteral), that are less
familiar to the non-expert. In this situation advice should be sought from the most appropriate experts (e.g. cardiologists).
The treatment algorithms described in this section have been designed to enable the non-specialist advanced life support (ALS) provider to treat a
patient effectively and safely in an emergency; for this reason they have been kept as simple as possible. They are based on current national and
international guidelines for management of arrhythmia.3-9
4. Sequence of actions
Assess a patient with a suspected arrhythmia using the ABCDE approach
In particular, note the presence or absence of ‘adverse features’
Give oxygen immediately to hypoxaemic patients and adjust delivery according to observed arterial oxygen saturations
Insert an intravenous (IV) cannula
Whenever possible, record a 12-lead ECG; this will help identify the precise rhythm, which may guide immediate treatment and/or be crucial
to planning later treatment
Correct any electrolyte abnormalities (e.g. K+, Mg2+, Ca2+).
When you assess and treat any arrhythmia address two factors:
1. the condition of the patient (stable versus unstable – determined by the absence or presence respectively of adverse features)
2. the nature of the arrhythmia.
Adverse features
The presence or absence of adverse symptoms or signs will dictate the appropriate immediate treatment for most arrhythmias. The following
adverse features indicate that a patient is at high risk of early deterioration and death (‘unstable’), either because of the arrhythmia itself or
because of underlying heart disease with the arrhythmia superimposed:
Shock – hypotension (systolic blood pressure <90 mm Hg), pallor, sweating, cold, clammy extremities, confusion or impaired
consciousness
Syncope – transient loss of consciousness due to global reduction in blood flow to the brain
Myocardial ischaemia – typical ischaemic chest pain and/or evidence of myocardial ischaemia on 12-lead ECG
Heart failure – pulmonary oedema and/or raised jugular venous pressure (with or without peripheral oedema and liver enlargement).
Treatment options
Depending on the nature of the underlying arrhythmia and clinical status of the patient (in particular the presence or absence of adverse features)
immediate treatment options can be categorised under four headings:
1. No treatment needed
2. Simple clinical intervention (e.g. vagal manoeuvres, fist pacing)
3. Pharmacological (drug treatment)
4. Electrical (cardioversion for tachyarrhythmia or pacing for bradyarrhythmia).
Most drugs act more slowly and less reliably than electrical treatments, so electrical treatment is usually the preferred treatment for an unstable
patient with adverse features.
If a patient develops an arrhythmia during, or as a complication of some other condition (e.g. infection, acute myocardial infarction, heart failure),
make sure that the underlying condition is assessed and treated appropriately, involving relevant experts if necessary.
Once an arrhythmia has been treated successfully, continue to assess the patient (ABCDE) and repeat a 12-lead ECG to detect any other
abnormalities that may require treatment, either immediately or in the longer term.
5. Tachycardia
The approach to an adult with tachycardia and a palpable pulse is shown in the Adult Tachycardia (with pulse) algorithm (Figure 1).
