• Cardiac arrhythmias are relatively common presentations to ED.
  • There are many causes, some more sinister than others.
  • If your patient is not acutely unwell then expert advice may be required.

Resus Council 2021

Assessment (ABCDE) – How sick is your patient?

History (especially any of…)

  • Chest pain suggestive of ischaemia
  • Any collapse or syncope
  • Shortness of breath
  • Swelling of peripheries


  • Signs of shock – pallor, sweating, cold, clammy, confusion
  • Signs of heart failure – Bibasal chest crackles, raised JVP, hepatomegaly, peripheral oedema


  • ECG
  • Observations esp BP
  • IV access – FBC, U&E, Mg2+, Ca2+, Trop, TFT
  • CXR


Any Adverse Features (Unstable) = DC cardioversion

  • Shock
  • Syncope
  • Myocardial ischaemia
  • Heart failure

DC cardioversion – get help as sedation will be required

  • Broad Complex or AF: 120J-150J- 200Jsynchronised shock
  • Narrow Complex or Atrial Flutter: 70-120J- 200J synchronised shock


Stable Narrow Complex (QRS <0.12sec)

Regular  – Sinus Tachycardia, AVNRT (SVT), Atrial flutter with regular block, AVRT (WPW)

  • Sinus Tachycardia – Look for the cause ?infection ?pain ?anaemia ?hypovolaemia ?anxiety ?drugs
  • SVT – Stepwise treatment until NSR regained (ensure cardiac monitoring): –
    • Vagal Manoeuvres – Lie flat and head down, Carotid sinus massage (ensure no bruit 1st), Blow into 50ml syringe
    • Adenosine –  6mg, 12mg, 18mg boluses (not in severe Asthma)
    • Not reverted – call for expert help
  • Atrial Flutter with 2:1 block (150bpm) – consider rate controlling drugs
  • AVRT (WPW) – get expert help (DO NOT give Adenosine)

PDF: Arrhythmia Clinic referral form (Print and Fax OR can email – use fill and sign function to enter details)

PDF: Patient Info

Irregular – likely AF (Follow AF Pathway)


Broad Complex (QRS >0.12sec)

  • Irregular  – likely AF with BBB
    • Get Expert help
  • Regular – VT
    • IV Amiodarone 300mg over 20 mins
    • Consider expert help


DVLA – if caused or likely to cause incapacity



Tachycardia guideline




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