1. Bradycardia Risk of asystole? History of asystole Mobitz II AV block Any pause  3 s Complete heart block, wide QRS Adverse signs? Clinical evidence of low cardiac output Hypotension: Systolic BP  90 mmHg Heart failure Rate < 40 bpm Presence of ventricular arrhythmias requiring suppression Consider as interim measures External pacing iv isoprenaline/orciprenaline Satisfactory response? Atropine iv 500 µg initially to max 3 mg and Atropine iv 500 µg initially to max 3 mg Seek expert help transvenous pacing observe Yes No Seek expert help

2. Broad Complex Tachycardia (sustained ventricular tachycardia) pulse? Adverse signs? Systolic BP  90 mmHg Chest pain Heart failure Rate  150 bpm For refractory cases consider other pharmacological agents: procainamide,flecainide, bretylium and overdrive pacing Use VF protocol sedation YesNo Seek expert help synchronised DC shock 100J:200J:360J start lignocaine ± potassium and magnesium as opposite further cardioversion as necessary lignocaine iv 50 mg over 2 mins repeated every 5 mins to total dose of 200 mg start infusion 2 mg/min after first bolus dose if potassium known to be low: give KCl up to 60 mmol, max rate 30 mmol/h give MgSO 4 iv 10 ml 50% in 1 hour synchronised DC shock 100J:200J:360J amiodarone 300 mg over 5- 15 min preferably by central line then 600 mg over 1 hour synchronised DC shock 100J:200J:360J YesNo

3. Narrow Complex Tachycardia (supraventricular tachycardia) Adverse signs? Hypotension: systolic BP  90 mmHg Chest pain Heart failure Impaired consciousness Rate  200 bpm Seek expert help vagal manoeuvres (caution possible digitalis toxicity, acute ischaemia or presence of carotid bruit) sedation synchronised cardioversion 100J:200J:360J amiodarone 300 mg over 15 mins then 600 mg over 1 hour preferably by central line and repeat cardioversion YesNo adenosine 3 mg by bolus injection repeat if necessary every 1-2 mins using 6 mg then 12 mg then 12 mg (ATP is an alternative) Atrial fibrillation (  130 bpm) choose from: esmolol: 40 mg over 1 min + infusion 4 mg/min (iv injection can be repeated with increments of infusion to 12 mg/min) digoxin: max dose 500 µg over 30 min x 2 verapamil: 5 - 10 mg iv amiodarone: 900 mg over 1 hour overdrive pacing (not AF)

4. Ventricular Fibrillation VF PULSELESS VT 10 CPR sequences of 5:1 compression/ventilation Adrenaline 1 mg iv PRECORDIAL THUMP If not already: intubate iv access DC shock 200J (1) DC shock 200J (2) DC shock 360J (3) DC shock 360J (4) DC shock 360J (5) DC shock 360J (6)

5. EMD Think of, and if indicated give specific treatment for: hypovolaemia tension pneumothorax cardiac tamponade pulmonary embolism drug overdose/intoxication hypothermia electrolyte imbalance asystole 10 CPR sequences of 5:1 compression/ventilation Adrenaline 1 mg iv If not already: intubate iv access

6. Doctors.net.uk would like to thank James Burton for contributing this presentation