Resus guidelines

Question 1

In the adult tachycardia (with pulse) algorithm, what are the adverse features that will influence which route to take? (4)

Answer 1

1. Shock
2. Syncope
3. Myocardial ischaemia
4. Heart failure

Question 2

In tachycardia, if there are no adverse features (e.g. shock, heart failure), what do you need to look at on the ECG before choosing the management option?

Answer 2

If the QRS is broad or narrow

Question 3

What constitutes a broad QRS?

Answer 3

> 0.12 seconds

Question 4

If the patient has tachycardia, with a regular rhythm, and a narrow QRS, what is the treatment? (3)

Answer 4

1. Vagal manoeuvres
2. Adenosine 6mg rapid IV bolus (if no effect, give 12mg, and again if no effect)
3. Monitor/record ECG continuously

Question 5

If the patient has tachycardia, with an irregular pulse, and a narrow QRS, what is it most likely going to be?

Answer 5

Atrial fibrillation

Question 6

What is the management of a patient with most likely AF - narrow QRS, tachycardia and irregular pulse? (3)

Answer 6

1. Control rate with beta-blocker or diltiazem
2. If in heart failure, consider digoxin or amiodarone
3. Assess thromboembolic risk and consider anticoagulant

Question 7

In a patient with tachycardia, regular rhythm and narrow QRS, if the treatment of vagal manoeuvres and adenosine don’t work (i.e. no sinus rhythm is achieved), what is the next option?

Answer 7

Seek expert help!

- possible atrial flutter so consider controlling rate e.g. beta blocker

Question 8

What is the most likely cause of someone with tachycardia, regular rhythm, and narrow QRS who does achieve sinus rhythm after the treatment?

Answer 8

Probable re-entry paroxysmal SVT

if SVT recurs, treat again and consider anti-arrhythmic prophylaxis

Question 9

If a patient has no adverse features and has tachycardia with pulse, but has a broad QRS, with a regular pulse, what is the management option?

Answer 9

Amiodarone 300mg IV or 20-60 minutes, then 900mg over 24 hours
(if it is known to be an SVT with bundle branch block, treat as for regular narrow-complex tachycardia)

Question 10

What is the most likely cause of someone having an irregular rhythm tachycardia, with a broad QRS?

Answer 10

1. AF with bundle branch block - treat as for narrow complex

2. Pre-excited AF, consider amiodarone

Question 11

If the patient with tachycardia and a pulse, has got adverse features, e.g. myocardial ischaemia, and therefore is unstable, what is the management plan? (3)

Answer 11

1. Synchronised DC shock - up to 3 attempts
2. GET HELP
3. Amiodarone 300mg IV over 10-20 minutes, repeat shock, then give amiodarone 900mg over 24 hours

Question 12

To summarise, tachycardia in an unstable patient, what is the treatment?

Answer 12

Synchronised DC shock –> amiodarone 300mg IV (10-20 minutes) –> repeat shock –> amiodarone 900mg (24 hours)

Question 13

To summarise, tachycardia, no adverse features, narrow QRS, regular rhythm, what is the treatment? (4)

Answer 13

1. Vagal manoeuvre
2. Adenosine 6mg IV rapid bolus
3. If not worked - 12mg adenosine
4. If not worked again - 12mg adenosine
   - sinus rhythm returned, great, if not, ask for help!

Question 14

To summarise, tachycardia, no adverse features, narrow QRS, irregular rhythm, what is the most likely diagnosis, and what is the treatment? (3)

Answer 14

Most likely atrial fibrillation
Treatment:
1. Beta blocker or diltiazem
2. If in heart failure consider digoxin or amiodarone
3. Assess thromboembolic risk and consider anticoagulation

Question 15

To summarise, tachycardia, no adverse features, broad QRS, regular rhythm, what is the treatment?

Answer 15

If VT (or uncertain rhythm)
- amiodarone 300mg IV (20-60 minutes)
-amiodarone 900mg (24 hours)
If known to be SVT with BBB - treat as for regular narrow complex tachycardia (vagal manoeuvre, adenosine)

Question 16

To summarise, tachycardia, no adverse features, broad QRS, irregular rhythm, what is the treatment?

Answer 16

Ask for help straight away as it depends…, possibilities include AF with BBB or pre-excited AF.

Question 17

Using the adult bradycardia algorithm, what should be given first-line if a patient has bradycardia with adverse features?

Answer 17

Atropine 500 mcg IV

Question 18

If the atropine 500 mcg IV doesn’t work, what is the next option?

Answer 18

Consider interim measures:
Atropine 500mcg IV repeat to maximum of 3mg 
OR
Transcutaneous pacing
OR
Isoprenaline 5mcg min IV
Adrenaline 2-10mcg min IV
Alternative drugs

Question 19

What are the alternative drugs that can be considered when treating someone with bradycardia with adverse features, who is not responding to atropine?

Answer 19

1. Aminophylline
2. Dopamine
   3 Glucagon (if caused by a beta blocker or CCB)
3. Glycopyrrolate

Question 20

If a patient with bradycardia has no adverse features, what is the first part of the management plan?

Answer 20

1. Assess risk of asystole
   - recent asystole
   - Mobitz II AV block
   - Complete heart block with broad QRS
   - Ventricular pause >3s

Question 21

If there is a risk of asystole, what is the management?

Answer 21

Same as if they do have adverse features - give:
1. Atropine 500mcg IV and repeat to maximum of 3mg if necessary
OR
1. Transcutaneous pacing
OR
1. Isoprenaline 5mcg min IV
2. Adrenaline 2-10mcg min IV

Question 22

If the patient with bradcardia has no risk of asystole, what is the management?

Answer 22

Observe

Question 23

To summarise, in a patient with bradycardia and adverse features, what is the first-line management plan?

Answer 23

Give atropine 500mcg IV