Guideline for the management of arrhythmias

The following guideline is approved only for use at University College London
Hospitals NHS Foundation Trust. It is provided as supporting information for the
UCLH Injectable Medicines Administration Guide. Neither UCLH nor Wiley accept
liability for errors or omissions within the guideline. Wherever possible, users of
the Guide should refer to locally produced practice guidelines. UCLH’s guidelines
represent the expert opinion of the clinicians within the hospital and may not be
applicable to patients outside the Trust.

Adapted from UCLH Guidelines for the management of common medical

emergencies and for the use of antimicrobial drugs

Reviewed by: Dr Martin Lowe, Consultant Cardiologist UCLH

Amended July 06

Remember - treat the patient, not the ECG!

SINUS BRADYCARDIA
Treatment: none unless hypotensive, then atropine 600 micrograms IV. Repeat
up to total of 2.4mg, then pace. If you have the experience, consider atrial pacing
if AV nodal conduction is normal. Ventricular pacing may actually worsen cardiac
output and blood pressure.

SINUS PAUSES (pause > 2 Sec)

Treatment: atropine or transvenous pacing if prolonged or symptomatic.

FIRST DEGREE AV BLOCK (PR Interval > 0.20 Sec)

Treatment: None. Observe and check drug treatment for beta-blockers, calcium-
channel blockers etc.

SECOND DEGREE HEART BLOCK

(a) Mobitz type I (Wenckebach) AV block (PR increasing then dropped beat)
Treatment: If symptoms, then atropine and if after anterior MI then
temporary transvenous pacemaker.
(b) Mobitz type II (2:1, 3:1, etc)
Treatment: Consider temporary transvenous pacemaker if symptomatic.
Atropine injection and isoprenaline infusion may be tried in the interim: 2mg
isoprenaline in 500ml 5% glucose (4mcg/ml). Start at a rate of 1

July 2006 ‘Common medical emergencies – arrhythmias’

 microgram/minute (15ml/hr) titrating up in steps of 1microgram/minute at
intervals of 2-3minutes, until a satisfactory heart rate is achieved or adverse
effects such as hypotension or ventricular arrhythmias occur (Usual max: 10
micrograms/min).

COMPLETE HEART BLOCK

Treatment: Temporary transvenous pacemaker or external pacemaker if
severely bradycardic, hypotensive and reduced consciousness (almost always
required if complete heart block after anterior MI).

NEW BIFASCICULAR BLOCK - (RBBB + L axis deviation; LBBB + R axis

deviation)
OR
TRIFASCICULAR BLOCK - bifascicular block and long PR
Treatment: If these develop in the context of acute myocardial infarction,
consider temporary transvenous pacing.

TEMPORARY PACING IN ACUTE MI

Rate/conduction disturbance Indication

Sinus bradycardia without hypotension, ventricular ectopics, -
angina, LVF, syncope
Sinus bradycardia with any of the above despite atropine +
Accelerated idioventricular rhythm -
Idioventricular rhythm with rate <45 bmp and/or hypotension +
Recurrent sinus pauses >2 sec +
Torsade de pointes +
First degree AV block -
Wenckebach (unless hypotension) -
Wenckebach with hypotension/bradycardia +
Mobitz II (dropped beats) +
Complete heart block +
Isolated left anterior hemiblock, left posterior hemiblock or -
RBBB
New LBBB +
New bifascicular block (alternating RBBB and LBBB, RBBB
and LAD, or RBBB with RAD) +
Trifascicular block (BBB with PR prolonged) +
Asystole +

If pacing is anticipated (rhythm disturbance on presentation), someone with wide

experience of central lines should gain central venous access via the external
jugular (ask ITU team) before thrombolysis. The alternative is access through a

July 2006 ‘Common medical emergencies – arrhythmias’

femoral or antecubital vein. 2D echo localisation of great veins is now
recommended. Consider the use of external pacing in an emergency until
transvenous pacing can be established.

ATRIAL FLUTTER
"Saw-tooth" baseline rate about 300/minute. Variable degree of block. If
ventricular response is fast, carotid massage or IV adenosine (see below) may
increase block and unmask the flutter waves.
Treatment: If hypotensive and unwell then urgent DC cardioversion. If the
ventricular rate is fast (> 100/minute), rate control may be achieved with beta
blockers and/or digoxin. The patient should be heparinised/given treatment dose
low molecular weight heparin (LMWH)* and then anticoagulated with warfarin. If
flutter persists, DC cardioversion may be performed electively. For recurrent
flutter, discuss the possibility of catheter ablation with cardiologists.

ATRIAL FIBRILLATION
(see algorithm of >48 hours or <48 hours AF)
• If haemodynamically compromised and of recent onset then consider DC
cardioversion (+ heparinisation/treatment dose LMWH*)
• If well tolerated then heparinise/give treatment dose LMWH*, arrange 2D
echo and plan elective cardioversion (DC or pharmacological, eg. flecainide
if ventricular function is good, amiodarone if not) after 48 hours.
• If chronic and well tolerated then control ventricular response with digoxin ±
verapamil or a beta-blocker.
• Anticoagulate for all but emergency cardioversion.
• Avoid digoxin and verapamil in Wolff-Parkinson-White syndrome
(suspect if ventricular response > 200/minute and broad, variable QRS
morphology).

*UCLH trust often uses treatment doses of dalteparin (i.e. 100 units/kg BD,
maximum 10,000 units BD) instead of unfractionated heparin infusions for
AF. This is an unlicensed indication.

Digitalisation: For long standing AF. (If haemodynamically unstable, then IV

verapamil OR beta-blocker). Digoxin loading dose: 500 micrograms orally, then
250 micrograms after 4 hours. If rate still poorly controlled, discuss with
cardiology. Maintenance digoxin dose is 125-250micrograms OD and will need
to be reduced in renal failure.

July 2006 ‘Common medical emergencies – arrhythmias’

 ATRIAL FIBRILLATION - duration > 48 hours
Anticoagulation for cardioversion (no previous thrombembolism)

Full anticoagulation with warfarin

Transthoracic echocardiography*
(to exclude undiagnosed cardiac pathology, to identify thrombus, to determine left atrial
and left ventricular size and to assess left ventricular function)**

If thrombus identified, If no thrombus identified,

6-8 weeks of anticoagulation 4 weeks of anticoagulation with warfarin
with warfarin

DC cardioversion
(full anticoagulation with warfarin)

Transoesophageal Atrial fibrillation Sinus rhythm

echocardiography, to Consider long-term
ensure left atrial and left anticoagulation with
appendage thrombus does warfarin.
not preclude cardioversion Control ventricular rate.
Stop antiarrhythmic drugs
Continue warfarin for at
least 4 weeks but consider
anticoagulation for longer
if recurrent AF
(antiarrhythmic also).

* Initial results suggest that, where available, transoesophageal echocardiography can

be used to guide cardioversion, obviating the need for prolonged anti-coagulation
precardioversion. Pending further studies, the above algorithm may be appropriate in
selected cases where reducing either the overall duration of anticoagulation or delay
before cardioversion is deemed of paramount importance. These patients will require
full anticoagulation at the time of cardioversion and following cardioversion as
elsewhere.

** If mitral stenosis is found, cardioversion should only be undertaken after a

transoesophageal study, in consultation with a cardiologist, since cardioversion may not
be appropriate. Long term warfarin is required.

July 2006 ‘Common medical emergencies – arrhythmias’

July 2006 ‘Common medical emergencies – arrhythmias’
*this assumes early cardioversion. If delay occurs and overall duration of atrial
fibrillation approaches 1 week, advise full anticoagulation for 4 weeks with warfarin.

** if mitral stenosis is found, cardioversion should only be undertaken after trans-

oesophageal study in consultation with a cardiologist, since cardioversion may not be
appropriate. Long term warfarin will be required.

SUPRAVENTRICULAR TACHYCARDIA:
Regular, narrow complex tachycardia, rate usually in the range 140-220 beats per
minute. Includes:
- sinus tachycardia
- focal atrial tachycardia
- atrial flutter
- atrial fibrillation (almost regular response)
- paroxysmal AV nodal tachycardia (AVNRT)
- AV re-entrant tachycardia (AVRT) through accessory pathway

Diagnosis:
By ECG ± carotid sinus massage, valsalva, or IV adenosine.
- It is especially useful to record a rhythm strip of all 12 ECG leads during
vagotonic manoeuvres or adenosine administration.
- AVNRT, AVRT and some focal atrial tachycardias will terminate with
adenosine.
- Other focal atrial tachycardias, atrial flutter and atrial fibrillation will continue
but the atrial activity will be unmasked

Treatment as appropriate for diagnosis (AF etc) or by interrupting re-entrant

circuit:
- If patient shocked or haemodynamically compromised then DC cardioversion,
50, 200, 360 J, less if patient digoxin toxic.
- Adenosine IV: Monitor ECG and give fast boluses of incremental doses every
1-2 mins, eg. 3mg, 6mg, then 12mg. Avoid in asthmatics. If essential to
give to patients who have taken dipyridamole within the past 24 hours, then
reduce the incremental doses to 0.5-1mg, 1.5mg then 3mg every 2mins
(dipyridamole potentiates plasma levels of adenosine and slows its
clearance).
- Verapamil IV: Boluses of 5mg over 2 mins (3 mins in elderly), at 15minute
intervals to maximum of 20mg (10mg in patients with IHD or aged > 60 years).
May aggravate hypotension. Avoid in patients already on a beta-blocker.

If adenosine and verapamil are ineffective then reconsider the diagnosis. Is

patient septic or haemorrhaging?

Other drugs:

July 2006 ‘Common medical emergencies – arrhythmias’

• Esmolol IV: short acting. Maintenance infusion dose of 50-200
micrograms/kg/minute by IV infusion
• Dilute 2.5g esmolol ampoule to 250ml 5% glucose or NaCl 0.9% (final
concentration of 10mg/ml). Infuse peripherally (large cannula if possible as
irritant).
• Assuming an infusion concentration of 10mg/ml:

Pump setting* (ml/hr) = dose (micrograms/kg/min) x pt weight (kg) x 6

1000

(*Pump to run at above calculated rate for desired duration, i.e. 1 minute, 4
minutes or as maintenance infusion)

e.g. Pump setting for a 70kg patient, for an initial loading dose of
500mcg/kg/min for 1 min: 500 x 70 x 6 = 210ml/hour for 1 minute
1000

Load: 500mcg/kg/min for 1 minute Response:

THEN Maintenance infusion: Maintain infusion at 50mcg/kg/min
50mcg/kg/min for 4 minutes**

Inadequate response within 5minutes: Response:

Repeat 500mcg/kg/min for 1 minute Maintain infusion at 100mcg/kg/min
THEN Increase maintenance infusion to
100mcg/kg/min for 4 minutes**

Inadequate response within 5minutes: Response:

Repeat 500mcg/kg/min for 1 minute Maintain infusion at 150mcg/kg/min
THEN Increase maintenance infusion to
150mcg/kg/min for 4 minutes**

**Note: As the desired heart rate

Inadequate response within 5minutes:
Repeat 500mcg/kg/min for 1 minute
THEN Increase maintenance infusion to
200mcg/kg/min for 4 minutes** and
maintain
and BP are reached, OMIT the
loading infusion and reduce the
incremental dose in the
maintenance infusion from
50mcg/kg/min to 25mcg/kg/min or
lower. Intervals between titration
steps may be increased from 5 to
10minutes

• The safety of maintenance doses greater than 200mcg/kg/min has not been
demonstrated

July 2006 ‘Common medical emergencies – arrhythmias’

• Infusions of esmolol can constitute a substantial volume load; vasodilators
may also be required if the volume load is problematic but the desired anti-
hypertensive effect can not be reached with esmolol alone.

Discuss other intervention/drugs with cardiology team, eg.

• Flecainide IV 2mg/kg over 30 minutes (max. of 150mg) then if required an
infusion of 1.5mg/kg/hour for 1hour, then 100 to 250 micrograms/kg/hour for
up to 24 hours if good LV (maximum cumulative dose in first 24 hours 600mg).

VENTRICULAR ARRHYTHMIAS

ISOLATED VE’S (Ectopics): These are broad QRS complexes, not preceded by
P-waves.
Treatment:
None usually needed.
+
- check serum K .
- treat ischaemia and heart failure.

MONOMORPHIC VT:
More than 5 consecutive broad QRS complexes, regular rate (> 100/minute, if 60
to 100/minute = accelerated idioventricular rhythm).
Treatment:
- If shocked/hypotensive with sustained VT, then DC cardioversion.
- Correct electrolyte abnormalities, eg. potassium and magnesium

Drugs:
• Lidocaine:
- 50 to 100mg IV bolus (use the lower dose in lighter patients or in those
whose circulation is severely impaired). NB: short duration of action (15-
20mins) – see BNF re repeat dosing.
- If recurrent, consider a continuous lidocaine infusion after the bolus, of
4mg/minute for 30mins, then 2mg/minute for 2 hours then 1mg/minute –
reduce dose further if infusion continued beyond 24hours. No more than
200-300mg lidocaine should be administered during a 1hour period
- Decrease infusion regimen by half if patient has heart failure or cirrhosis.
- Patients on concurrent beta-blockers (especially propranolol), should be
monitored closely for signs of lidocaine toxicity (e.g. dizziness, nausea,
drowsiness, speech disturbance, numbness, confusion, respiratory
depression, convulsions and rarely, sinus arrest or severe bradycardia)
and the infusion dose reduced accordingly.
- Toxicity may be more likely to occur in the elderly (may therefore require
lower infusion doses).

July 2006 ‘Common medical emergencies – arrhythmias’

• If ineffective then IV amiodarone by central line (to avoid phlebitis). Load
with 300mg over 60 minutes (BP may fall), then give 900mg/24 hours. NB.
Incompatible with NaCl 0.9%

If resistant to both drugs and recurring after DC cardioversion then consult

cardiologist.

Other drugs to consider include the following but may get into problems with
pro-arrhythmic polypharmacy:
- Flecainide (see previous page for dose)
- Mexiletine: Loading dose: 100 to 250mg IV at 25mg/minute followed by
infusion of 250mg over 1 hour, then 125mg/hour for 2 hours (use dilution of
500mg in 500ml of 5% glucose or NaCl 0.9%). Maintenance dose: 500
micrograms/minute (use a dilution of 250mg in 500ml of 5% glucose or NaCl
0.9%).
- Sotalol 20 to 60mg IV over 10 minutes

POLYMORPHIC VT / TORSADE DE POINTES

- Frequently, the patient has an underlying bradycardia.

- It is often initiated by "late” ventricular ectopics (VE).
- Often self-terminating but recurrent.
- QT prolongation may predispose.
- Treat hypokalaemia, and give magnesium.
- Pace bradycardic patients and stop drugs which may predispose to QT
prolongation.

Treatment:
Isoprenaline IV may be useful initially i.e. 2mg isoprenaline in 500ml 5% glucose
(4mcg/ml). Start at a rate of 1 microgram/minute (15ml/hr) titrating up in steps of
1microgram/minute at intervals of 2-3minutes, until a satisfactory heart rate is
achieved or adverse effects such as hypotension or ventricular arrhythmias occur
(Usual max: 10micrograms/min).

July 2006 ‘Common medical emergencies – arrhythmias’

 DIFFERENTIAL DIAGNOSIS OF BROAD COMPLEX TACHYCARDIAS

If there is a history of ischaemic heart disease then > 95% of broad complex
tachycardias are VT. If in doubt treat as VT. Do not try verapamil.
If an SVT with aberrant conduction (usually RBBB and < 160 msec duration) is
strongly suspected, then IV adenosine should be tried.

Patient unwell

Yes No

No history History of
of IHD IHD

RBBB, QRS < 160msec

Adenosine IV

Cardioversion or increased block

Yes No

Treat Treat
as SVT as VT

DC cardioversion

July 2006 ‘Common medical emergencies – arrhythmias’