Management of Tachyarrhythmia

• Is this a primary cardiac problem?
  • Remember fast AF may reflect hypovolaemia not inadequate rate control
• Is the patient compromised?
  • e.g significant escalation in vasopressors, hypotension, cardiac failure or ischaemia
  • If yes then synchronised DC cardioversion
  • Do you need to initiate ALS?
• Broad or narrow complex?
• Regular or irregular?
• Is there a correctable precipitating cause?
  • e.g CVC in too far, electrolyte abnormality, prolonged QTc

Narrow complex

• Regular
  • SVT
  • Vagal maneuvers
  • Adenosine 6mg, 12mg, 12mg
  • If SR not restored consider B blockers (e.g. metoprolol)
  • Atrial flutter treat as per AF
• Irregular
  • New AF or A.flutter with variable block
  • Magnesium 5g over 1hr
  • If no response amiodarone 300mg over 20-60 mins
  • Consider follow up 900mg amiodarone 24hr infusion
  • If no/inadequate response consider digoxin or B blockers
• If unclear rhythm then short acting B blockers may reveal underlying pathology

Broad complex

• Regular
  • Amiodarone 300mg over 20 – 60 mins
  • Beware pre-existing bundle branch block and SVT
• Irregular
  • AF with bundle branch block – treat as for AF
  • Polymorphic VT – Torsades de pointes – Magnesium 2g over 10 mins

AF in Wolf Parkinson White

• Avoid adenosine, B blockers, Ca channel blockers. Amiodarone may be unsafe also.
• DC cardioversion, procainamide, ibutilide may be options – suggest d/w cardiology/ICU.

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