If no pulse, follow ALS protocol

If patient has a pulse, check for adverse signs (systolic blood pressure <90mmHg, chest
pain, heart failure, heart rate >150/min)
If pulse is present, sedate and administer DC shock
If pulse is absent, correct underlying causes, try chemical cardioversion (amiodarone/
lidocaine) and then give DC shock
Vagal manoeuvres
Adenosine 6mg followed by 12mg and 12mg (into a central vein)
Rate control if no adverse signs (esmolol, digoxin, verapamil, amiodarone)
Sedation and synchronised shock if adverse signs

ST depression
Inverted T waves

Tall R waves and ST depression in leads V1V2

Characteristic broad complex tachycardia that should be instantly

recognised
No clear QRS complexes
Rate >120/min

Positive QRS concordance in chest leads

Left axis deviation
Rate >100/min
Fusion and capture beats
Atrioventricular dissociation
Polymorphic QRS complexes with constantly changing axis in torsade de
pointes

Rate >100/min
QRS <120ms
Rhythm regular

Irregular baseline
Irregularly irregular rhythm
Rate may be >100/min (or <100/min if on rate-controlling drugs)
No P waves

Posterior infarct

Ventricular fibrillation

Ventricular tachycardia

Supraventricular
tachycardia

Atrial fibrillation

Refer to NICE (2006) guidelines

See Chapter 69 on ALS

See ST segment elevation MI

Aspirin (300mg)+clopidogrel (300mg)+low molecular weight heparin

Nitrates, beta-blockers, ACE inhibitors, lipid management
Consider glycoprotein 2b/3a inhibitors

of streptokinase
Alteplase if previous adverse reaction to streptokinase

Non-ST segment
elevation MI

Specific points in management

Characteristic ECG features

ST elevation: (leads 2, 3, aVF inferior; V1V4 anteroseptal; V4V6,

1, aVL anterolateral)
Tall T waves in acute setting
Pathological Q waves (>0.04s wide and >2mm deep)
LBBB (of new onset)

Disease/abnormality

ST segment elevation MI

Summary of common ECGs seen in OSCEs