Stable ectopic or multifocal atrial tachycardia

Algorithm Normal EF: Calcium channel blocker or beta blocker or amiodarone Low EF: Amiodarone or diltiazem Adult doses and precautions

diltiazem dose = 0.25mg/kg IV over 2 minutes then 0.35mg/kg IV over 2 minutes after 15 minutes if the ventricular rate still > 100 bpm => maintenance IV infusion rate of 5 15mg/kg/hour erapamil dose = 2.5 5mg over 2 minutes IV! secon" "ose of 5 10 mg in 15 30 minutes prn! ma#imum "ose of 20mg esmolol dose = IV loa"ing "ose of 0.5mg/kg over 1 minute => maintenance IV infusion rate of 50mcg/kg/min for $ minutes => secon" bolus "ose of 0.5mg/kg over 1 minute if response ina"e%uate => increase maintenance infusion rate to 100mcg/kg/min for $ minutes => repeat se%uence of 0.5mg/kg bolus "ose & increasing maintenance rate b' 50mcg/kg/min ever' $ minutes to a ma#imum IV infusion rate of 300mcg/kg/min metoprolol dose = 5mg IV over 5 minutes % 5 minutes # 3 prn amiodarone dose = 150mg over 10 minutes IV at 15mg/min !arnings ()* can be "istinguishe" from )+ b' noting 3 "ifferent , -ave configurations an ectopic atrial tach'arr'thmia can be "istinguishe" from ,.V* because it often starts gra"uall' /slo- -arm up0 an" it continues "espite the use of )V no"al blocking "rugs a"enosine ma' unmask an ectopic atrial arrh'thmia man' cases of ()* are "ue to secon"ar' causes /eg 12,30 an" respon" to primar' treatment of the un"erl'ing "isease s'nchronise" electrical car"ioversion is usuall' unsuccessful for automatic atrial arrh'thmias an" it is not recommen"e" for patients -ith either normal or lo- 4+

Stable "unctional tachycardia

Algorithm Normal EF: Amiodarone or calcium channel blocker or beta blocker Low EF: Amiodarone Adult doses and precautions

diltiazem dose = 0.25mg/kg over 2 minutes IV => 0.35mg/kg in 15 minutes if not effective => temporar' IV infusion rate of 5 15mg/hour prn if chemical conversion is successful erapamil dose = 2.5 5mg over 2 minutes IV! secon" "ose of 5 10 mg in 15 30

minutes prn! ma#imum "ose of 20mg esmolol dose = IV loa"ing "ose of 0.5mg/kg over 1 minute => maintenance IV infusion rate of 50mcg/kg/min for $ minutes => secon" bolus "ose of 0.5mg/kg over 1 minute if response ina"e%uate => increase maintenance infusion rate to 100mcg/kg/min for $ minutes => repeat se%uence of 0.5mg/kg bolus "ose & increasing maintenance rate b' 50mcg/kg/min ever' $ minutes to a ma#imum IV infusion rate of 300mcg/kg/min metoprolol dose = 5mg over 5 minutes IV # 3 prn to a total "ose of 15mg over 15 minutes amiodarone dose = 150mg over 10 minutes IV at 15mg/min !arnings true 5unctional tach'car"ia is usuall' a manifestation of "igo#in to#icit' or e#ogenous catecholamines or theoph'lline there is no true scientific evi"ence to support the use of the recommen"e" "rugs recommen"ations are base" on the kno-n anti s'mpathetic an" no"al effects of the recommen"e" "rugs 31 car"ioversion is contra in"icate" in stable patients -ith normal or lo- 4+

Stable wide#comple$ tachycardia # unknown type

Algorithm Normal EF: (a' procee" "irectl' to synchronised cardio ersion or use amiodarone or procainamide or sotalol => synchronised cardio ersion is man"ator' if electe" "rug therap' is unsuccessful Low EF%C&F: (a' procee" "irectl' to synchronised cardio ersion or use amiodarone => synchronised cardio ersion is man"ator' if amio"arone therap' fails Adult doses and precautions

amiodarone dose = 150mg over 10 minutes IV at 15mg/min => 1mg/min IV infusion rate if chemical conversion is successful procainamide dose = 20mg/min IV infusion to a ma#imum "ose of 16mg/kg /or if 78. comple# prolongs > 509! or if h'potension ensues0 => 1 $ mg/min IV infusion rate if chemical conversion is successful sotalol dose = 1 1.5mg/kg IV at 10mg/min 'ediatric doses and precautions amiodarone dose = 5mg/kg over 20 :0 minutes IV/I2 procainamide dose = 15mg/kg over 30 :0 minutes IV/I2 synchronised cardio ersion = 0.5 1;/kg !arnings al-a's presume that a -i"e comple# tach'arrh'thmia is V* until proven other-ise al-a's avoi" using a"enosine! "igo#in! beta blockers an" calcium channel blockers

unless there is 1009 certaint' that the -i"e comple# tach'arrh'thmia is a ,.V* especiall' if the rh'thm is irregular /suggestive of )+ in a patient -ith <,< s'n"rome0 note that li"ocaine an" bret'llium are no longer recommen"e" use s'nchronise" car"ioversion as primar' therap' if there is an' uncertaint' about clinical stabilit' prior to! or "uring a"ministration of "rug therap' avoi" using multiple anti arrh'thmic "rugs in se%uence because of potential pro arrh'thmic effects

(entricular fibrillation%'ulseless entricular tachycardia

Algorithm )efibrillation $ * /200;! 200 300;! 3:0; or e%uivalent biphasic shocks0 => assess rh'thm after each initial shock => persistent or recurrent V+/V* => A+C) => epinephrine 1mg IV push! an" repeate" ever' 3 5 minutes prn= or asopressin $0 > IV push # 1 => resume attempts to "efibrillate /3:0; -ithin 30 :0 secon"s0 => consi"er anti arrh'thmics /amiodarone 300mg b' IV bolus an" then 150mg IV % 3 5 minutes prn= or magnesium if h'pomagnesemic 2g "ilute" in 10cc 35< b' IV push0 => consi"er bicarb buffer /bicarb 1me%/kg b' rapi" IV bolus0 if prolonge" arrest! bicarbonate responsive aci"osis! tric'clic 23 or h'perkalemia in"uce" car"iac arrest => resume attempts to "efibrillate Adult doses and precautions

the optimal number of imme"iate shocks is unkno-n => it is reasonable to a"minister pharmacological therap' if there is no response to 3# initial shocks "eliver' of the $th shock is mainl' time "epen"ent an" usuall' follo-s -ithin a feminutes after the patient is intubate" an" an IV is establishe" => ho-ever! "o not empiricall' -ait until vasopressors are given if there is an inor"inate time "ela' in establishing IV access anticipate the nee" for amio"arone prepare the solution b' "iluting the 300mg "ose in 20 30 ml of saline or -ater amio"arone can be repeate" prn 150mg b' rapi" IV bolus % 3 5 minutes! follo-e" b' 1mg/min IV infusion rate /mi# ?00mg in 500cc saline0 for : hours => 0.5mg/min IV infusion rate to a ma#imum "ail' "ose of 2g/"a' if "efibrillation is successful procainami"e /30 50mg/min b' IV infusion to a ma#imum "ose of 16mg/kg0 can be use" => ho-ever! it takes too long to a"minister an" is a secon" tier recommen"ation a"minister 20cc of saline as chaser flush after each bolus "ose of a "rug is a"ministere" in a peripheral limb vein an" elevate that limb for 10 20 secon"s 'ediatric doses epinephrine dose = 0.01mg/kg IV/I2 bolus! 0.1mg/kg 4* amiodarone dose = 5mg/kg IV/I2 bolus lidocaine dose = 1mg/kg IV/I2 bolus! or same "ose 4* magnesium dose = 20 50mg/kg IV/I2 bolus to ma#imum "ose of 2g cardio ersion = 2;/kg => $;/kg

!arnings

li"ocaine an" bret'llium are no longer recommen"e" as primar' anti arrh'thmic "rugs li"ocaine is of in"eterminate value an" is onl' recommen"e" as a secon" tier anti arrh'thmic "rug /1 1.5mg/kg initial IV bolus => repeat IV boluses of 0.5 0.65mg/kg prn % 3 5minutes to a ma#imum total "ose of 3mg/kg0 high "ose epinephrine is no longer recommen"e" "o not "ela' shocks in or"er to a"minister pharmacological therap' avoi" using multiple anti arrh'thmic "rugs in se%uence because of potential pro arrh'thmic effects