###### Created: 2024-06-11 15:25 ###### Areas & Topics: #medicine ###### Note Type: #permanent ###### Connected to: [[Atrial Fibrillation]] - The term peri-arrest refers to the time frame when a patient exhibits signs and/or symptoms of impending cardiac arrest, but they have not gone into cardiac arrest as of yet. - Therefore, peri-arrest management can come before [[Adult Advanced Life Support (AALS)]] or directly after it depending on the situation. Peri-arrest arrythmias can be put into two main categories: - Arrhythmias that may lead to cardiac arrest - Arrhythmias that occur initially after cardiac arrest resuscitation ### ABCDE Assessment 1. Oxygen (if SpO2 is less than 94%) 2. IV Access (two large-bore IV cannulas) 3. Cardiac Monitoring (ECG, BP, SpO2 etc.) 4. Identify and treat reversible causes (e.g. electrolyte disturbance, hypovolaemia etc.) ### Life Threatening Features - Shock (signs of shock including hypotension with systolic BP < 90, pallor, sweating, cold extremities, confusion/impaired consciousness etc.) - [[Syncope]] - [[Heart Failure]] (e.g. pulmonary oedema, raised JVP etc.) - Myocardial Infarction (see [[Acute Coronary Syndrome (ACS)]]) - Extreme Tachycardia (e.g. HR > 150bpm) - Extreme Bradycardia (e.g. HR < 40bpm) ## Peri-Arrest Rhythms Step-By-Step Management 1. ABCDE (Oxygen, Cardiac Monitoring, Reversible Causes) 2. Is the patient Tachycardic or Bradycardic? 3. Are there Adverse Features? N.B. If the patient is stable you should seek expert help for further management ### Tachyarrhythmia Management If there are adverse features/the patient is unstable: 1. Shock (synchronised DC Shock up to 3 times) 2. Amiodarone 300mg IV over 10 to 20 minutes 3. Repeat Shock 4. Amiodarone 900mg over 24 hours If there are no adverse features/the patient is stable: 1. Is the QRS narrow or broad? #### Narrow QRS ##### Regular Narrow QRS If the rhythm is regular and the QRS is narrow (i.e. less than 0.12 seconds): 1. [[Vagal Manoeuvres]] If ineffective: 1. [[Adenosine]] 6mg rapid IV bolus 2. If unsuccessful, [[Adenosine]] 12mg 3. If unsuccessful, another [[Adenosine]] 18mg 4. Monitor ECG Continuously If still ineffective: 2. Verapamil or [[Beta Blockers]] (as atrial flutter should be considered) If still ineffective: - Shock (synchronised DC shock up to 3 times) - Sedation (if patient is conscious) ##### Irregular Narrow QRS If the patient has an irregular rhythm with a narrow QRS then it is likely to be [[Atrial Fibrillation]] (AF) Therefore, these patients should be treated according to the management for acute presentations of AF (see [[Atrial Fibrillation]]), so consider: 1. Beta-Blockers 2. Digoxin OR Amiodarone (if evidence of [[Heart Failure]]) 3. Anticoagulation (if onset was more than 48 hours ago) #### Broad QRS ##### Regular Broad QRS If the rhythm is regular and the QRS is broad (i.e. more than 0.12s) If ventricular tachycardia (or the rhythm is uncertain): 1. Amiodarone 300mg IV over 10 to 60 minutes 2. Amiodarone 900mg over 24 hours If previously confirmed supraventricular tachycardias (see [[Tachycardias]]) with bundle branch block or aberrant conduction: 1. Treat as regular narrow complex tachycardia (e.g. adenosine etc.) If treatments are ineffective: - Shock (synchronised DC shock up to 3 times) - Sedation (if patient is conscious) ##### Irregular Broad QRS If the rhythm is irregular and the QRS is broad (i.e. more than 0.12s) [[Atrial Fibrillation]] (AF) with bundle branch block: 1. Treat as irregular narrow complex tachycardia Pre-excited [[Atrial Fibrillation]] (AF) 1. Consider Amiodarone Polymorphic Ventricular Tachycardia (e.g. [[Torsade de Pointes]]) 1. Magnesium 2g over 10 minutes ![[pdd965b.png]] ![[Pasted image 20240611153743.png]] ### Bradyarrhythmia Management If there are adverse features/the patient is unstable: 1. [[Atropine]] 500 micrograms IV If ineffective, interim measures are: - [[Atropine]] 500 micrograms IV repeated (up to a maximum of 3mg) OR - Isoprenaline 5 micrograms/min IV OR - Adrenaline 2 to 10 micrograms/min IV OR - Alternative Drugs OR - Transcutaneous Pacing THEN 1. Seek Expert Help 2. Arrange Transvenous Pacing If there are no adverse features OR the patient is stable OR [[Atropine]] has produced a satisfactory response: Assess for risk of asystole, indicated by: - Recent Aystsole - Mobitz II AV Block (see [[Atrioventricular Block (Heart Block)]]) - Complete Heart Block with Broad QRS - Ventricular Pause > 3 seconds If there is risk of asystole: - Treat with interim measures If there is no risk of asystole: - Observe patient ![[pdd966b.png]] ### Resources Tachycardia Algorithm - Resuscitation Council https://www.resus.org.uk/sites/default/files/2021-04/Tachycardia%20Algorithm%202021.pdf Bradycardia Algorithm - Resuscitation Council https://www.resus.org.uk/sites/default/files/2021-04/Bradycardia%20Algorithm%202021.pdf Peri-Arrest (Chapter 11) - Resus.org https://lms.resus.org.uk/modules/m10-v2-cardiac-arrest/10346/resources/chapter_11.pdf Peri-Arrest- PassMed