Category: Cardiac

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.

      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.

      Vascular Emergencies (Regional Pathways)

      Intro

      Vascular surgery has been reconfigured across etc region. The vascular oncall will be based at BRI 24/7.

      Multiple pathways have been developed below to help guide appropriate use – full guide HERE

      AAA (Symptomatic)
       
      AAA (Incidental)
       
      Ischaemic Limb (Acute)

      Ischaemic Limb (Critical)

      Ischaemic Limb (Intermittent Claudication)
       
      Uncontrolled Haemorrhage (Interventional Radiology)

      Some patients benefit from control of bleeding using embolization techniques, which is a procedure performed by an Interventional Radiologist.

      Patients should be treated in their receiving hospital to the maximum of that hospital’s capability, where at all possible. When all local treatment options have been exhausted, the patient should be discussed with one of the Arterial Centres (BRI) with a view to transfer for ongoing management by IR techniques.

      Isolated Vascular Trauma

      Diabetic Foot

      Emergency Transfer

      Urgent Vascular Clinic

      Access is very limited to this clinic. It is envisioned by WYVas that access to UVAC for ED patients will be arranged through direct (telephone) referral to either:

      • IN hours: Local (HRI) or ON-Call (BRI)Vascular Consultant
      • OUT of hours: ON-Call (BRI) Vascular Consultant

      LVAD – Resus & Troubleshooting

      LVADs (Left Ventricular Assist Device) are becoming more common and there are patients in our region with them as a bridge to transplant or recovery and in some cases a destination therapy.

      The patient and their family will likely know more about this device than you and should have brought spare parts. Our local LVAD centre is Wythenshaw however, there are other units around the country the patient may direct you to.

      The patient may not have a palpable pulse, the blood pressure will be low and the heart pump sounds like a buzz when you listen.

      If patient is unresponsive or has a history of collapse its important to troubleshoot the device and resusitation may be required

      Read more

      Atrial Fibrillation/Flutter (ECS 2024)

      Before you start 

      • Whats the cause? – treating the precipitant often sorts the AF (adding B-Blockers to Sepsis can make things worse)
      • Stable or Unstable?  – Electricity vs. Drugs
      • Rate/Rhythm control
      • CHADS-VASC vs. ORBIT– Anticoagulation
      • NEW Symptomatic Arrhythmia Clinic [6-8weeks] – referral form attached tho the PDF

      Discharge? – If all of following

        • No compromise
        • HR<110 for 2hr
        • No precipitants requiring admission

      AF/SVT Clinic – AF/SVT clinic Referral form

      • This clinic is only for:
        • Symptomatic patients with new onset AF /SVT (where the presenting symptoms are definitely due to AF /SVT)
        • And patients have fast ventricular rates.
        • ECG shows AF/SVT

      Unstable AF

      Haemodynamically UNSTABLE patients

      Any of:

        • Shock sBP <90mmHg – poor perfusion
        • Reduced level of consciousness – poor brain perfusion
        • Cardiac Ischaemia – poor heart perfusion
        • Pulmonary Oedema – poor lung perfusion

      Emergency DC Cardioversion (DCC) is the mainstay of treatment. Obviously DCC is uncomfortable experience and sedation is preferable, however, if unstable sedation may not be an option.

      DC Cardioversion (SYNCRONISED)

        • Consent (best interest if needed)
        • Sedation if possible (may require anaesthetic assistance)
        • DC Cardiaversion
          1. Syncronise (white dots appear over QRS on monitor)
          2. Energy 
            • 1st shock 70J
            • 2nd shock 120J
            • 3rd shock 200J
          3. Charge & Shock (oxygen away, everyone clear!)
          4. Reassess – repeat for further shocks if required

      Tachycardia Guide line – Resus Council

      Causes/Tests

      Causes

      It’s essential any Modifiable causes are treated, these include:

        • Haemodynamic stress: Valvular disease/Hypertension/LVD/Thrombus
        • Atrial ischemia: Ischaemic Heart Disease
        • Inflammation: Sepsis/Myocarditis/pericarditis
        • Noncardiovascular respiratory causes: PE/Pneumonia/Lung Cancer
        • Alcohol and drug use: Alcohol/Cocaine/Amphetamine
        • Endocrine disorders: Hyperthyroid/Diabetes/Phaeochromacytoma/Electrolyte prob.
        • Neurologic disorders: Subarachnoid Haemorrhage/Stroke
        • Genetic factors
        • Advancing age

      Tests (NEW AF)

      • 12 Lead ECG
      • Bloods: FBC, U&E, Bone profile, Magnesium, LFT, TFT, Clotting, Glucose
      • Others: individualised to the patient.
      STABLE – Rate/Rhythm Control

      Rate Control

      • First line:
        • β-Blocker – outperforms calcium channel blockers in studies
        • Non-dihydropyridine calcium channel blockers (Diltiazem/Verapamil) – esp. in Severe COPD/Asthma
      • Second Line:Consider adding in
        • Digoxin – however, digoxin alone is not effective in patients with increased sympathetic drive. Observational studies have associated digoxin use with excess mortality in AF patients)
        • Amiodarone can be useful as a last resort when heart rate cannot be controlled with combination therapy in patients who do not qualify for non-pharmacological rate control

      Rhythm control in ED

      “Early cardioversion is not recommended without appropriate anticoagulation or transoesophageal echocardiography if AF duration is longer than 24 h, or there is scope to wait for spontaneous cardioversion.”

      In reality risks increase beyond 12hrs from onset, and those reverted in ED will often return to AF by the time they get to AF clinic follow up.

      STABLE – Stroke Prevention

      Anticoagulation

      AF increases the chance of Stroke by 5x (and those recently diagnosed are least likely be on any form of protection)

      • ESC/NICE recommends using the CHADS-VASc to assess stroke risk and ORBIT to assess bleeding risk
      • There are currently significant delays getting to “New AF” clinic as well as to GP’s, making assessment of Stroke risk in ED more important than ever

      CHADS-VASc outcome recommendations

        • Males (0), Female (1) – No anticoagulation recommended
        • Males (1) – Consider anticoagulation (DOAC) in light of bleed risk
        • ALL (≥2) – Anticoagulation recommended (DOAC)- Trust DOAC guide,  NICE/CKS
        • Use Apixaban where first line, significantly cheaper. If using alternative please document reasons.

      ORBIT outcome recommendations

        • Modifiable risks – Address ALL modifiable risk factors
        • Most will benefit from anticoagulation – but discuss personalised risk with patients

      Contraindications to Anticoagulation inc:

        • Active serious bleeding (where the source should be identified and treated)
        • Associated comorbidities (e.g. severe thrombocytopenia <50 platelets/lL, severe anaemia under investigation, etc.)
        • Recent high-risk bleeding event such as intracranial haemorrhage (ICH).

       

      STABLE – Comorbidities

      Cardiovascular risk factors

        • Life Style
          • Obesity: Risk of AF, Recurrence of AF and Stoke all increase with BMI
          • Alcohol: Alcohol excess both increases the risk of AF and of Bleeding, so patient should support to reduce aldol intake is recommended
          • Caffeine: It is unlikely caffeine consumption causes AF. Habitual caffeine use may reduce the risk of developing AF. But increases the symptoms
          • Exercise: Moderate cardiavasclar exercise is protective, however higher rates of AF are seen in elite athletes and vigorous physical activity
        • Specific conditions- patient should follow up with GP/Clinic (treatment may start in ED)
          • Hypertension
          • Heart Failure
          • Coronary artery disease
          • Diabetes Mellitus
          • Sleep Apnoea
      STABLE – CARE

      Pulmonary Embolism in Pregnancy

      Unfortunately the the normal pathway for investigation of PE performs poorly in pregnancy RCOG have the following pathway

      1. Investigation – of suspected PE

      • Clinical assessment – its all on the history and exam scoring doesn’t work
      • Perform the following tests:
        • CXR – sheilding can protect the baby and may avoid further radiation
        • ECG
        • Bloods: FBC, U&E, LFTs, Clotting
      • Commence Tinzaparin (unless treatment is contraindicated – use booking weight to calculate dose) –[BNF]

       

      Malignant/Accelerated Hypertension

      There are several terms commonly used “Accelerated Hypertension”, “Hypertensive Emergency”, “Malignant Hypertension”. They all have a very similar definition (ESC/ESH, NICE, ACEP)

      Patient has both:

      1. Blood pressure: Systolic ≥180mmHg OR Diastolic ≥110mmHg (often >220/120mmHg)
      2. End-Organ Damage: Retinal Changes, Encephalopathy, Heart Failure, Acute Kidney Injury, etc.

      Mortality has improved in recent years with 5yr survival of 80% if treated. However, untreated average life expectancy is 24 months.

      Read more

      Acute Heart Failure (AHF) – ESC

      Patients presenting with AHF have a high mortality 4-10% in-hospital and 25-30% at 1yr, and 45% if re-admitted. So rapid diagnosis a treat is essential.

      AHF Triggers

      there are many triggers for AHF, which if recognized and treated with help improve outcomes

      • Cardiac: ACS, Arrhythmia, Aortic Dissection, Acute Valve Incompetence, VSD, Malignant Hypertension
      • Respiratory: PE, COPD
      • Infection: Pneumonia, Sepsis, Infective endocarditis
      • Toxins/Drugs: Alcohol, Recreational drugs, NSAIDs, Steroids, Cardiotoxic meds
      • Increased Sympathetic Drive: Stress
      • Metabolic: DKA, Thyroid dysfunction, Pregnancy, Adrenal Dysfunction
      • Cerebrovascular Insult

      ESC Guide – 2021 Heart Failure

      Presentations

      Decompensated Heart Failure

      Isolated Right Vent-Failure

      Pulmonary Oedema

      Cardiogenic Shock

      Managment

      Treatment – Time Matters!!!

      • Mortality increased by 1%/hour IV treatment not started

      Treat The Cause!: If you can identify the trigger treat it it will in turn improve the AHF. (e.g. AMI, Arrythmia(Tachy/Brady), Massive PE)

      Oxygen
      • Not all patients should be given Oxygen ESC suggest maintain SaO2 >90%
      • Early NIV is suggested if any of:
        • RR >25bpm or SaO2 <90% despit oxygen
        • Signs type 2 respiratory failure

      Metanalysis suggests early NIV may reduce need for intubation and improve mortality

      NIV Guide-HERE

      Diuretic

      Vasodilator

      Inotropes

      Hypomagnesaemia

      Classification

      • Normal: 1.1-0.7
      • Mild: 0.69-0.5 – No symptoms or non-specific symptoms, such as lethargy, muscle cramps, or muscle weakness
      • Severe: <0.5 – Severe neurologic symptoms such as nystagmus, tetany, seizures, and cardiac arrhythmias

      Signs/Symps (normally <0.5)

      • MSK: Muscle Twitch, Tremor, Tetany, Cramps
      • CNS: Apathy, Depression, Hallucination, Agitation, Confusion, Seizure
      • CVS: Tachycardia, Hypertension, Arrhythmia, Digoxin Toxicity
      • BioChem: Hypokalaemia, Hypocalcaemia, Hypophosphataemia, Hyponatraemia

      Read more