Author: embeds

Tachycardia

Adult ED Management – RCUK 2025

Treat the patient, not the rate

Sinus tachycardia is usually compensatory — identify and treat the cause. Do NOT cardiovert sinus tachycardia.

INITIAL ASSESSMENT

ABCDE

Cardiac monitor
BP and SpO₂
12-lead ECG
IV access
Bloods as clinically indicated: FBC
U&E / Mg²⁺ / Ca²⁺
glucose
troponin where indicated
other investigations directed by likely cause
Give oxygen only if SpO₂ <94%, unless an alternative target is appropriate.

Think WHY the patient is tachycardic?

Sepsis/Hypovolaemia/Haemorrhage
Pain/Anxiety
Hypoxia
Fever
PE
ACS/Heart failure
Thyrotoxicosis
Drugs/Withdrawal
Pregnancy

Do not attempt to normalise an appropriate sinus tachycardia with anti-arrhythmics or electrical cardioversion.

SIMPLE ED RULE

SICK? → SHOCK

WELL? → WIDTH + REGULARITY

  • Narrow + regular: Vagal → Adenosine → Verapamil / beta-blocker → Shock
  • Narrow + irregular: AF pathway / rate control
  • Broad + regular: VT until proven otherwise → Cardioversion / procainamide
  • Broad + irregular: Pre-excited AF / polymorphic VT → expert help

      UNSTABLE?

      LIFE-THREATENING FEATURES

      > SHOCK: Hypotension with evidence of impaired tissue perfusion.
      > SYNCOPE: Especially with severe or ongoing hypotension.
      > MYOCARDIAL ISCHAEMIA: Ongoing chest pain and/or significant ischaemic ECG changes.
      > SEVERE HEART FAILURE: Particularly pulmonary oedema.
      > IMMEDIATELY POST-ROSC

      DC-Cardiversion (SYNC) RCUK 2025

      > AF → Maximum defibrillator output
      > Flutter / SVT → 70–120 J
      > VT with pulse → 120–150 J

      Escalate subsequent shocks where appropriate.

      STABLE

      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/Allergy/Heart transplant)
        • 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)

      Assume VT until proven otherwise

      Particularly in:

      • older patients
      • previous MI
      • structural heart disease
      • cardiomyopathy

      Stable monomorphic VT

      Electrical cardioversion is an appropriate first-line strategy

      • Especially where structural heart disease is present or cannot be excluded.
      • SYNCHRONISED CARDIOVERSION For VT with a pulse: 120–150 J initially, escalating if required

      If sedation / anaesthesia presents significant risk

      Drug treatment may be considered:

      • Procainamide 10–15 mg/kg IV over 20 minutes Maximum 1 g OR
      • Amiodarone 300 mg IV over 10–60 minutes followed by: 900 mg IV over 24 hours
      • If ineffective: SYNCHRONISED CARDIOVERSION WITH EXPERT ADVICE

      STOP — HIGH-RISK RHYTHM

      Consider:

      • 1. AF WITH BUNDLE BRANCH BLOCK
      • 2. PRE-EXCITED AF / WPW
      • 3. POLYMORPHIC VT

      Seek senior / cardiology support early.

      PRE-EXCITED AF

      Think pre-excitation when there is:

      • very rapid irregular broad-complex tachycardia
      • varying QRS morphology
      • ventricular rates sometimes >200 bpm
      • known WPW / previous delta wave

      DO NOT GIVE AV-NODAL BLOCKING DRUGS

      Avoid the following as these may increase conduction through the accessory pathway and precipitate VF:

      • Adenosine
      • Beta-blockers
      • Verapamil
      • Diltiazem
      • Digoxin

      Treatment

      • Procainamide OR
      • Synchronised cardioversion

      If polymorphic VT occurs with QT prolongation:

      Magnesium: Mg²⁺ 8 mmol IV over 10 minutes

      Also:

      • Correct K⁺ / Mg²⁺ abnormalities.
      • Stop QT-prolonging drugs.
      • Treat reversible causes.
      • Seek expert help.

      For recurrent pause-dependent torsades consider increasing the heart rate with:

      • Isoprenaline OR
      • Temporary pacing

      ❌ AVOID AMIODARONE because it may further prolong the QT interval.

      ⚠️ PITFALLS

      FAST ≠ ARRHYTHMIA

      Do not treat physiological sinus tachycardia as an arrhythmia.

      BROAD + REGULAR = VT UNTIL PROVEN OTHERWISE

      Do not delay appropriate treatment while attempting to prove SVT.

      BROAD + IRREGULAR ≠ ROUTINE AF

      Always consider pre-excited AF.

      ADENOSINE IS NOT FOR IRREGULAR BROAD-COMPLEX TACHYCARDIA

      DO NOT GIVE AMIODARONE FOR TORSADES / LONG-QT POLYMORPHIC VT

      Give magnesium and correct the underlying problem.

      CARDIOVERSION REQUIRES SYNC

      Confirm the machine is marking the R waves before delivering the shock.

      Re-check SYNC after each shock — some defibrillators automatically revert out of synchronised mode.

      DISPOSITION

      Consider admission / cardiology assessment for:

      • VT
      • broad-complex tachycardia of uncertain cause
      • syncope associated with tachyarrhythmia
      • significant structural heart disease
      • ACS / myocardial ischaemia
      • heart failure
      • recurrent arrhythmia despite treatment
      • pre-excitation
      • significant electrolyte disturbance
      • drug-induced arrhythmia
      • prolonged QT / torsades
      • haemodynamic instability
      • arrhythmia requiring electrical cardioversion

      Patients with uncomplicated successfully terminated SVT may be suitable for discharge following senior review, appropriate investigation and follow-up depending on the clinical circumstances.

      GUIDANCE

      Based primarily on:

      • Resuscitation Council UK — Guidelines 2025: Adult Advanced Life Support
      • Resuscitation Council UK — Adult Tachyarrhythmia Algorithm, current version March 2026
      • Current atrial fibrillation guidance

      EMbeds clinical quick guide

      Last evidence review: September 2026
      Suggested next review: September 2027

      This is a clinical support guide and does not replace clinical judgement, current CHFT medicines guidance or specialist advice.

      Early Pregnancy Pain & Bleeding

      <16 WEEKS  (ED ALGORITHM)

      1    INITIAL ASSESSMENT

      Pain • bleeding • collapse • shoulder-tip pain • GI symptoms  →  THINK ECTOPIC
      Complete: Urine pregnancy test  •  observations  •  stability  •  brief history + ectopic risk factors

      2 ASSESS STABILITY

      UNSTABLE

      ABCDE
      2 x IV cannulas
      FBC/U&E/LFT/G&S ± crossmatch & serum β-hCG
      Fluids/blood
      URGENT GYNAE REVIEW
      DO NOT transfer to EPAU before stabilisation.

      STABLE

      Discuss with EPAU – SAME DAY.
      Then apply traffic-light triage below.

      3    TRAFFIC-LIGHT TRIAGE

      4   ED RULES

      ✓ DO

      Urine pregnancy test
      Assess stability
      Consider ectopic
      Discuss symptomatic patients with EPAU
      Safety net

      ✕ DO NOT

      Routinely request serum β-hCG in stable patients
      Use β-hCG to decide scans
      Promise scan times
      Exclude ectopic because observations are normal

      5   SAFETY NET

      RETURN IMMEDIATELY to CRH

      If: collapse, worsening pain, shoulder-tip pain, heavy bleeding, new symptoms, feeling unwell

      KEY MESSAGE

      Positive pregnancy test + pain/bleeding + NO confirmed intrauterine pregnancy
      = ECTOPIC PREGNANCY REMAINS POSSIBLE UNTIL PROVEN OTHERWISE

      Acute Coronary Syndrome (ACS) – 2025

      First take a good history, not ALL chest pain needs to be investigated as ACS. However, its worth noting older patients and women are more likely to have atypical presentations. Be wary that some patients with negative troponin give a history of Unstable Angina and therefore require admission.

      Read more: Acute Coronary Syndrome (ACS) – 2025

      ACS Treatment (Not STEMI going for PPCI)

      • Aspirin 300mg stat
      • Ticagrelor 180mg stat
      • Fondaparinux 2.5mg sc stat. 

      Anticoagulated with a DOAC, or with Warfarin (with a therapeutic INR),

      • Aspirin 300mg stat
      • Clopidogrel 300mg stat

      ACS &Aspirin Allergy

      • If the history suggests intolerance (GI upset, dyspepsia, nausea etc) rather than allergy, aspirin rechallenge is justifiable.
      • In TRUE allergy aspirin should be avoided. > Give Ticagrelor 180mg + Fondaparinux 2.5mg (unless contraindicated)
      • Any doubts contact Cardiology on-call Con

      Treatment STEMI going for PPCI

      • Aspirin 300mg stat
      • Plus Either:
        • Ticagrelor 180mg stat (Hx of CVA)
        • Prasugrel 60mg stat (NO Hx of CVA)

      Direct admissions to CCU

      Patients with ST Elevation (if not accepted for primary PCI) or those with CP + new ST Depression should be discussed with a local Cardiologist and come directly to CCU.

      As it is difficult to be prescriptive for every other circumstance, a discussion with a senior/cardiologist may be worthwhile in order to best manage and place your patient within the hospital.

      Patients where MI is excluded

      If patients do exit the pathway (no new symptoms, no new ECG ischemia and troponins that meet the exit criteria to exclude an MI), two other important possibilities still require consideration:

      1. Is the history in keeping with unstable angina? (This is still an ACS). If so the patient will require an acute inpatient admission with telemetry and IP cardiology review.
      2. Is the chest pain due to a significant alternative diagnosis? If so this still needs to be actively considered/ investigated/ treated.

      Asthma – Adult

      • Severity – Severe or Life threatening – think RESUS
      • Treatment within 30 min – bronchodilators and steroids should bee given within 30min
      • 1hrs Observation after Neb – better after a neb don’t just send home they may deteriorate when it wears off.
      • PEFR – must be >75% expected prior to discharge (at least 1hr after treatment finished)
      • Discharge advice sheet – can print off from this guide, remember to check inhaler technique and consider a spacer

      Read more

      Non-Major Trauma Pelvic Fractures in Older Adults

      The vast majority of non-major trauma pelvic fractures presenting to Calderdale & Huddersfield A&E will be fragility fractures in elderly patients — almost exclusively:

      • Isolated pubic rami fractures (anterior ring, FFP-I)
      • Pubic rami fractures with concurrent non-displaced sacral fracture (FFP-II)

      These represent 84% of all elderly pelvic fractures nationally, and virtually all are non-operative injuries by definition. The remaining cases are a small minority and are addressed in the referral criteria below.

      Read more