Part 7.3: Management of Symptomatic Bradycardia and tachycardia Cac a aohithrnnas she u (do ommon cause of sudden death A comprehensive presentation of the evaluation and man- be established on as agement of bradyarrhythmias and tachyarrhythmias is beyond possible for all patients who collapse suddenly or have the scope of these guidelines. For further information see the symptoms of coronary ischemia or infarction. To avoid delay, apply adhesive electrodes with a conventional or automated external defibrillator(AED)or use the"quick-look"paddles American College of Cardiology/American Heart Associ- feature on conventional defibrillators. For patients with acute ation/European Society of Cardiology Guidelines for the coronary ischemia, the greatest risk for serious arrhythmias Management of Patients With Supraventricular Arrhyth- occurs during the first 4 hours after the onset of symptoms mias,availableatthefollowingsiteswww.acc.org, (see Part 8: " Stabilization of the Patient With Acute Coronary www.americanheart.organdwww.escardio.org ACLS: Principles and Practice, Chapters 12 through 16.4 Principles of Arrhythmia Recognition There are 3 major sections in Part 7.3. The first 2 sections and management Bradycardia"and"Tachycardia, "begin with evaluation and The ECG and rhythm information should be interp treatment and provide an overview of the information sum- within the context of total patient assessment. Errors marized in the aCls bradycardia and tachycardia algorithms. iagnosis and treatment are likely to occur if ACLS providers To simplify these algorithms, we have included some recom base treatment decisions solely on rhythm interpretation and mended drugs but not all possible useful drugs. The overview presents information about the drugs cited in the algorithms. neglect clinical evaluation. Providers must evaluate the pa- The third section, ""Antiarrhythmic Drugs, provides more tient's symptoms and clinical signs, including ventilation, oxygenation, heart rate, blood pressure, and level of con detailed information about a wider selection of drug sciousness, and look for signs of inadequate organ perfusion. therapies These guidelines emphasize the importance of clinical eval- uation and highlight principles of therapy with algorithms Bradycardia that have been refined and streamlined since the 2000 edition See the Bradycardia Algorithm, Figure 1. Box numbers in the of the guidelines. 2 The principles of arrhythmia recognition text refer to the numbered boxes in the algorithm and management in adults are as follow Evaluation If brady altered mental status, ongoing severe ischemic chest pain, Bradycardia is generally defined as a heart rate of <60 congestive heart failure, hypotension, or other signs of per minute( Box 1). A slow heart rate may be physiologically normal for sol shock) that persist despite adequate airway and breathing and heart rates >60 beats prepare to provide pacing. For symptomatic high-degree minute may be inadequate for others. This bradycardia (second-degree or third-degree) atrioventricular (AV algorithm focuses on management of clinically significant block, provide transcutaneous pacing without delay. bradycardia (ie, bradycardia that is inadequate for clinical If the tachycardic patient is unstable with severe signs and condition) symptoms related to tachycardia, prepare for immediate Initial treatment of any patient with bradycardia should cardioversion focus on support of airway and breathing(Box 2). Provide If the patient with tachycardia is stable, determine if the supplementary oxygen, place the patient on a monitor, eval patient has a narrow-complex or wide-complex tachycardia uate blood pressure and oxyhemoglobin saturation, and and then tailor therapy accordingly tablish intravenous (IV) access. Obtain an ECG to better You must understand the initial diagnostic electrical and define the rhythm. While initiating treatment, evaluate the drug treatment options for rhythms that are unstable or clinical status of the patient and identify potential reversible immediately life-threatenin causes Know when to call for expert consultation regarding The provider must identify signs and symptoms of poor complicated rhythm interpretation, drugs, or management perfusion and determine if those signs are likely to be caused by the bradycardia(Box 3). Signs and symptoms cardia may be mild, and asymptomatic patients do not require ( Circulation. 2005: 112: IV-67-IV-77. reatment. They should be monitored for signs of deteriora- o 2005 American Heart Association tion(Box 4A) Provide immediate therapy for patients with This special supplement to Circulation is freely available http://www.circulationaha.org hypotension, acute altered mental status, chest pain, conges- ive heart failure, seizures, syncope, or other signs of shock DOI: 10.1161/CIRCULATIONAHA 105. 166558 related to the bradycardia(Box 4)Part 7.3: Management of Symptomatic Bradycardia and Tachycardia Cardiac arrhythmias are a common cause of sudden death. ECG monitoring should be established as soon as possible for all patients who collapse suddenly or have symptoms of coronary ischemia or infarction. To avoid delay, apply adhesive electrodes with a conventional or automated external defibrillator (AED) or use the “quick-look” paddles feature on conventional defibrillators. For patients with acute coronary ischemia, the greatest risk for serious arrhythmias occurs during the first 4 hours after the onset of symptoms (see Part 8: “Stabilization of the Patient With Acute Coronary Syndromes”).1 Principles of Arrhythmia Recognition and Management The ECG and rhythm information should be interpreted within the context of total patient assessment. Errors in diagnosis and treatment are likely to occur if ACLS providers base treatment decisions solely on rhythm interpretation and neglect clinical evaluation. Providers must evaluate the pa￾tient’s symptoms and clinical signs, including ventilation, oxygenation, heart rate, blood pressure, and level of con￾sciousness, and look for signs of inadequate organ perfusion. These guidelines emphasize the importance of clinical eval￾uation and highlight principles of therapy with algorithms that have been refined and streamlined since the 2000 edition of the guidelines.2 The principles of arrhythmia recognition and management in adults are as follows: ● If bradycardia produces signs and symptoms (eg, acute altered mental status, ongoing severe ischemic chest pain, congestive heart failure, hypotension, or other signs of shock) that persist despite adequate airway and breathing, prepare to provide pacing. For symptomatic high-degree (second-degree or third-degree) atrioventricular (AV) block, provide transcutaneous pacing without delay. ● If the tachycardic patient is unstable with severe signs and symptoms related to tachycardia, prepare for immediate cardioversion. ● If the patient with tachycardia is stable, determine if the patient has a narrow-complex or wide-complex tachycardia and then tailor therapy accordingly. ● You must understand the initial diagnostic electrical and drug treatment options for rhythms that are unstable or immediately life-threatening. ● Know when to call for expert consultation regarding complicated rhythm interpretation, drugs, or management decisions. A comprehensive presentation of the evaluation and man￾agement of bradyarrhythmias and tachyarrhythmias is beyond the scope of these guidelines. For further information see the following sources: ● American College of Cardiology/American Heart Associ￾ation/European Society of Cardiology Guidelines for the Management of Patients With Supraventricular Arrhyth￾mias,3 available at the following sites: www.acc.org, www.americanheart.org, and www.escardio.org. ● ACLS: Principles and Practice, Chapters 12 through 16.4 There are 3 major sections in Part 7.3. The first 2 sections, “Bradycardia” and “Tachycardia,” begin with evaluation and treatment and provide an overview of the information sum￾marized in the ACLS bradycardia and tachycardia algorithms. To simplify these algorithms, we have included some recom￾mended drugs but not all possible useful drugs. The overview presents information about the drugs cited in the algorithms. The third section, “Antiarrhythmic Drugs,” provides more detailed information about a wider selection of drug therapies. Bradycardia See the Bradycardia Algorithm, Figure 1. Box numbers in the text refer to the numbered boxes in the algorithm. Evaluation Bradycardia is generally defined as a heart rate of
60 beats per minute (Box 1). A slow heart rate may be physiologically normal for some patients, and heart rates 60 beats per minute may be inadequate for others. This bradycardia algorithm focuses on management of clinically significant bradycardia (ie, bradycardia that is inadequate for clinical condition). Initial treatment of any patient with bradycardia should focus on support of airway and breathing (Box 2). Provide supplementary oxygen, place the patient on a monitor, eval￾uate blood pressure and oxyhemoglobin saturation, and es￾tablish intravenous (IV) access. Obtain an ECG to better define the rhythm. While initiating treatment, evaluate the clinical status of the patient and identify potential reversible causes. The provider must identify signs and symptoms of poor perfusion and determine if those signs are likely to be caused by the bradycardia (Box 3). Signs and symptoms of brady￾cardia may be mild, and asymptomatic patients do not require treatment. They should be monitored for signs of deteriora￾tion (Box 4A). Provide immediate therapy for patients with hypotension, acute altered mental status, chest pain, conges￾tive heart failure, seizures, syncope, or other signs of shock related to the bradycardia (Box 4). (Circulation. 2005;112:IV-67-IV-77.) © 2005 American Heart Association. This special supplement to Circulation is freely available at http://www.circulationaha.org DOI: 10.1161/CIRCULATIONAHA.105.166558 IV-67