IV-76 Circulation December 13, 2005 with known pre-excitation (WPW) syndrome and pre- primary ventricular fibrillation complicating acute myocardial infarction: served ventricular function a communitywide perspective. Circulation. 1994: 89: 998-1003 of several drugs that can be used for AV 2. American Heart Association in collaboration with International Liaison Committee on Resuscitation. Guidelines 2000 for Cardiopulmonary narrow-complex tachycardias such as reentry SVT if Resuscitation and Emergency Cardiovascular Care. Circulation. 2000; rhythm is uncontrolled by adenosine and vagal maneuvers Il-1384 3. Blomstrom-Lundgvist C, Scheinman MM, Alot EM, Alpert JS, Calkins Camm AJ, Campbell WB. Haines DE, Kuck KH, Lerman Procainamide hydrochloride for non-VF/VT arrest may be DD. Shaeffer CW Jr. Stevenson wG, Tomaselli GF, Antman EM. Smith SC Jr, Alpert JS, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G. given in an infusion of 20 mg/min until the arrhythmia is Hiratzka LF, Hunt SA. Jacobs AK. Russell RO Jr. Priori SG. Blanc JJ suppressed, hypotension ensues, the QRs complex is pro- Budaj A, Burgos EF, Cowie M, Deckers Jw, Garcia MA, Klein ww. longed by 50% from its original duration, or a total of 17 Lekakis J, Lindahl B. Mazzotta G, Morais JC, Oto A, Smiseth O, Trappe mg/kg(1.2 g for a 70-kg patient) of the drug has been given HJ: American College of Cardiology: American Heart Association Task Force on Practice Guidelines: European Society of Cardiology Com Bolus administration of the drug can result in toxic concen- mittee for Practice Guidelines, Writing Committee to Develop Guidelines trations and significant hypotension. The maintenance infu- for the Management of Patients With Supraventricular Arrhythmias sion rate of procainamide hydrochloride is I to 4 mg/min ACC/AHA/ESC guidelines for the management of patients wit diluted in Ds w or normal saline. This should be reduced in upraventricular tachycardias-executive summary: a report of th he presence of renal failure. n Practice Guidelines and the European Society of Car Procainamide should be used cautiously in patients with mittee for Practice Guidelines (Writing Committee to Develop Guidelines reexisting QT prolongation. In general it should be used for the Management of Patients With Supraventricular Arrhythmias Circulation.2003;108:1871-1909 with caution if at all in combination with other drugs that 4. Cummins RO, Field JM, Hazinski MF, eds. ACLS: Principles an prolong the QT interval(consider obtaining expert consulta- Practice. Dallas. Tex: American Heart Association: 2003- 239-375 tion). Monitor the ECG and blood pressure continuously 5. Smith I, Monk TG, White PF. Comparison of transesophageal atrial istration of procainam pacing with anticholinergic drugs for the treatment of intraoperative 6. Brady wJ, Swart G, DeBehnke DJ, Ma OJ, Aufderheide TP. The efficacy Sotalol is not a first-line antiarrhythmic. Sotalol hydrochlo- of atropine in the treatment of hemodynamically unstable bradycardia and atrioventricular block: prehospital and emergency department consider- ride is an antiarrhythmic agent that ations. Resuscitation. 1999- 41: 47-55 longs action potential duration and increases cardiac tissue 7. Chadda KD, Lichstein E Gupta PK, Kourtesis P. Effects of atropine in refractoriness. It also has nonselective B-blocking properties mplicating myocardial infarction: use fulness of an optimum dose for overdrive. Am J Med. 1977: 63: 503-510 One randomized controlled trial (LoE 1)48 indicated that terminating acute sustained VT. This agent may be so or sotalol is significantly more effective than lidocaine 9. ge groups. C lin Pharmacol Ther. 1971:12z7e-og the ECG in different ernheim A. Fatio R Kiowski w, weilenmann D, Rickli H, Rocca HP. the following circumstances with expert consultation: after cardiac transplantation: an unpredictable and dose-independent phe- nomenon. Transplantation. 2004: 77: 1181-1185 To control rhythm in atrial fibrillation or atrial flutter in 10. Love JN. Sachdeva DK, Bessman ES, Curtis LA. Howell JM. A potential patients with pre-excitation (WPw) syndrome and pre role for glucagon in the treatment of drug-induced symptomatic brady- served ventricular function when the duration of the ar- cardia. Chest. 1998: 114: 323-3 rhythmia is <48 hours. But the intervention of choice for I1. Lown B. Electrical reversion of cardiac arrhythmias. Br Heart J, 1967; 29:469-489 this indication is dc cardioversion 12. Kerber RE, Martins JB, Kienzle MG, Constantin L, Olshansky B, Hopse · For monomorphic VT R, Charbonnier F. Energy, current, and success in defibrillation and method of energy adjustment. Circulation. 1988: 77: 1038-1046 sec cardioversion: clinical st mg/kg body weight, then infused at a rate of 10 mg/min Side Kerber RE Kienzle MG, Olshansky B, Waldo AL, Wilber D,Carlson effects include bradycardia, hypotension, and arrhythmia. achycardia rate and morphology determine energy and current The incidence of torsades de pointes following a single dose equirements for transthoracic cardioversion. Circulation. 1992: 85 of sotalol for treatment of VT is reportedly 0. 1%0.45 Use of IV 14. Lim SH, Anantharaman V, Teo WS, Goh PP, Tan AT. Comparison of sotalol is limited by the need to infuse it relatively slowl treatment of supraventricular tachycardia by Valsalva maneuver and carotid sinus massage. Ann Emerg Med. 1998: 31: 30-35 Summary 5. Omato JP, Hallagan LF, Reese WA, Clark RF, Tayal Vs, Gamett AR The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically the emergency department by clinical decision analysis [published cor- Am J Emerg Med. 1990: 8: 85]. Am J Emerg Med unstable. Pacing or drugs, or both, may be used to control 988:6:555-560 symptomatic bradycardia. Cardioversion or drugs, or both, 16. DiMarco JP. Miles w, Akhtar M, Milstein S. Sharma AD. Platia E. may be used to control symptomatic tachycardia. ALS McGovern B. Scheinman MM. Govier wC. providers should closely monitor stable patients pending amil: assessment in placebo-controlled, multicenter trials. The Adenosine expert consultation and should be prepared to aggressively for PSVT Study Group published correction appears in Ann Intern Med. treat those who develop decompensation 990:113:996]. Ann Intern med.1990;113:104-110. 17. Brady WJ Jr. DeBehnke DJ, wickman LL, Lindbeck G. Treatment of References It-of-hospital supraventricular tachycardia: adenosine vs verapamil. 1. Chiriboga D, Yarzebski J. Goldberg R, Gore JM, Alpert JS. Tempo 8. Furlong R, Gerhardt RT, Farber P, Schrank K, Willig R, Pittaluga J In trends(1975 through 1990) in the incidence and case-fatality rates of travenous adenosine as first-line prehospital management of narrow-with known pre-excitation (WPW) syndrome and pre￾served ventricular function ● One of several drugs that can be used for AV reentrant, narrow-complex tachycardias such as reentry SVT if rhythm is uncontrolled by adenosine and vagal maneuvers in patients with preserved ventricular function Procainamide hydrochloride for non-VF/VT arrest may be given in an infusion of 20 mg/min until the arrhythmia is suppressed, hypotension ensues, the QRS complex is pro￾longed by 50% from its original duration, or a total of 17 mg/kg (1.2 g for a 70-kg patient) of the drug has been given. Bolus administration of the drug can result in toxic concen￾trations and significant hypotension. The maintenance infu￾sion rate of procainamide hydrochloride is 1 to 4 mg/min, diluted in D5W or normal saline. This should be reduced in the presence of renal failure. Procainamide should be used cautiously in patients with preexisting QT prolongation. In general it should be used with caution if at all in combination with other drugs that prolong the QT interval (consider obtaining expert consulta￾tion). Monitor the ECG and blood pressure continuously during administration of procainamide. Sotalol Sotalol is not a first-line antiarrhythmic. Sotalol hydrochlo￾ride is an antiarrhythmic agent that, like amiodarone, pro￾longs action potential duration and increases cardiac tissue refractoriness. It also has nonselective -blocking properties. One randomized controlled trial (LOE 1)48 indicated that sotalol is significantly more effective than lidocaine for terminating acute sustained VT. This agent may be used in the following circumstances with expert consultation: ● To control rhythm in atrial fibrillation or atrial flutter in patients with pre-excitation (WPW) syndrome and pre￾served ventricular function when the duration of the ar￾rhythmia is 48 hours. But the intervention of choice for this indication is DC cardioversion. ● For monomorphic VT. IV sotalol is usually administered at a dose of 1 to 1.5 mg/kg body weight, then infused at a rate of 10 mg/min. Side effects include bradycardia, hypotension, and arrhythmia. The incidence of torsades de pointes following a single dose of sotalol for treatment of VT is reportedly 0.1%.45 Use of IV sotalol is limited by the need to infuse it relatively slowly. Summary The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable. Pacing or drugs, or both, may be used to control symptomatic bradycardia. Cardioversion or drugs, or both, may be used to control symptomatic tachycardia. ALS providers should closely monitor stable patients pending expert consultation and should be prepared to aggressively treat those who develop decompensation. References 1. Chiriboga D, Yarzebski J, Goldberg RJ, Gore JM, Alpert JS. Temporal trends (1975 through 1990) in the incidence and case-fatality rates of primary ventricular fibrillation complicating acute myocardial infarction: a communitywide perspective. Circulation. 1994;89:998 –1003. 2. American Heart Association in collaboration with International Liaison Committee on Resuscitation. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2000; 102(suppl):I1–I384. 3. Blomstrom-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ, Campbell WB, Haines DE, Kuck KH, Lerman BB, Miller DD, Shaeffer CW Jr, Stevenson WG, Tomaselli GF, Antman EM, Smith SC Jr, Alpert JS, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Hiratzka LF, Hunt SA, Jacobs AK, Russell RO Jr, Priori SG, Blanc JJ, Budaj A, Burgos EF, Cowie M, Deckers JW, Garcia MA, Klein WW, Lekakis J, Lindahl B, Mazzotta G, Morais JC, Oto A, Smiseth O, Trappe HJ; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; European Society of Cardiology Com￾mittee for Practice Guidelines, Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias. ACC/AHA/ESC guidelines for the management of patients with supraventricular tachycardias— executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Com￾mittee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias). Circulation. 2003;108:1871–1909. 4. Cummins RO, Field JM, Hazinski MF, eds. ACLS: Principles and Practice. Dallas, Tex: American Heart Association; 2003:239 –375. 5. Smith I, Monk TG, White PF. Comparison of transesophageal atrial pacing with anticholinergic drugs for the treatment of intraoperative bradycardia. Anesth Analg. 1994;78:245–252. 6. Brady WJ, Swart G, DeBehnke DJ, Ma OJ, Aufderheide TP. The efficacy of atropine in the treatment of hemodynamically unstable bradycardia and atrioventricular block: prehospital and emergency department consider￾ations. Resuscitation. 1999;41:47–55. 7. Chadda KD, Lichstein E, Gupta PK, Kourtesis P. Effects of atropine in patients with bradyarrhythmia complicating myocardial infarction: use￾fulness of an optimum dose for overdrive. Am J Med. 1977;63:503–510. 8. Dauchot P, Gravenstein JS. Effects of atropine on the ECG in different age groups. Clin Pharmacol Ther. 1971;12:272–280. 9. Bernheim A, Fatio R, Kiowski W, Weilenmann D, Rickli H, Rocca HP. Atropine often results in complete atrioventricular block or sinus arrest after cardiac transplantation: an unpredictable and dose-independent phe￾nomenon. Transplantation. 2004;77:1181–1185. 10. Love JN, Sachdeva DK, Bessman ES, Curtis LA, Howell JM. A potential role for glucagon in the treatment of drug-induced symptomatic brady￾cardia. Chest. 1998;114:323–326. 11. Lown B. Electrical reversion of cardiac arrhythmias. Br Heart J. 1967; 29:469 – 489. 12. Kerber RE, Martins JB, Kienzle MG, Constantin L, Olshansky B, Hopson R, Charbonnier F. Energy, current, and success in defibrillation and cardioversion: clinical studies using an automated impedance-based method of energy adjustment. Circulation. 1988;77:1038 –1046. 13. Kerber RE, Kienzle MG, Olshansky B, Waldo AL, Wilber D, Carlson MD, Aschoff AM, Birger S, Fugatt L, Walsh S, et al. Ventricular tachycardia rate and morphology determine energy and current requirements for transthoracic cardioversion. Circulation. 1992;85: 158 –163. 14. Lim SH, Anantharaman V, Teo WS, Goh PP, Tan AT. Comparison of treatment of supraventricular tachycardia by Valsalva maneuver and carotid sinus massage. Ann Emerg Med. 1998;31:30 –35. 15. Ornato JP, Hallagan LF, Reese WA, Clark RF, Tayal VS, Garnett AR, Gonzalez ER. Treatment of paroxysmal supraventricular tachycardia in the emergency department by clinical decision analysis [published cor￾rection appears in Am J Emerg Med. 1990;8:85]. Am J Emerg Med. 1988;6:555–560. 16. DiMarco JP, Miles W, Akhtar M, Milstein S, Sharma AD, Platia E, McGovern B, Scheinman MM, Govier WC. Adenosine for paroxysmal supraventricular tachycardia: dose ranging and comparison with verap￾amil: assessment in placebo-controlled, multicenter trials. The Adenosine for PSVT Study Group [published correction appears in Ann Intern Med. 1990;113:996]. Ann Intern Med. 1990;113:104 –110. 17. Brady WJ Jr, DeBehnke DJ, Wickman LL, Lindbeck G. Treatment of out-of-hospital supraventricular tachycardia: adenosine vs verapamil. Acad Emerg Med. 1996;3:574 –585. 18. Furlong R, Gerhardt RT, Farber P, Schrank K, Willig R, Pittaluga J. In￾travenous adenosine as first-line prehospital management of narrow￾IV-76 Circulation December 13, 2005