Tag: af

Tachycardia

Adult ED Management โ€“ RCUK 2025

Treat the patient, not the rate

Sinus tachycardia is usually compensatory โ€” identify and treat the cause. Do NOT cardiovert sinus tachycardia.

INITIAL ASSESSMENT

ABCDE

Cardiac monitor
BP and SpOโ‚‚
12-lead ECG
IV access
Bloods as clinically indicated: FBC
U&E / Mgยฒโบ / Caยฒโบ
glucose
troponin where indicated
other investigations directed by likely cause
Give oxygenย only if SpOโ‚‚ <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? โ†’ SHOCK

WELL? โ†’ WIDTH + REGULARITY

  • Narrow + regular: Vagal โ†’ Adenosine โ†’ Verapamil / beta-blocker โ†’ Shock
  • Narrow + irregular: AF pathway / rate control
  • Broad + regular: VT until proven otherwise โ†’ Cardioversion / procainamide
  • Broad + irregular: Pre-excited AF / polymorphic VT โ†’ 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 โ†’ Maximum defibrillator output
      > Flutter / SVT โ†’ 70โ€“120 J
      > VT with pulse โ†’ 120โ€“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: 120โ€“150 J initially, escalating if required

      If sedation / anaesthesia presents significant risk

      Drug treatment may be considered:

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

      STOP โ€” HIGH-RISK RHYTHM

      Consider:

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

      Seekย 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: Mgยฒโบ 8 mmol IV over 10 minutes

      Also:

      • Correct Kโบ / Mgยฒโบ 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

      โŒ AVOID AMIODARONE because it may further prolong the QT interval.

      โš ๏ธ PITFALLS

      FAST โ‰  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 โ‰  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 โ€” 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 โ€”ย Guidelines 2025: Adult Advanced Life Support
      • Resuscitation Council UK โ€”ย 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.

      Atrial Fibrillation/Flutter (ECS 2024)

      Before you startย 

      • Whats the cause? – treating the precipitant often sorts the AF (adding B-Blockers to Sepsis can make things worse)
      • Stable or Unstable?ย  – 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 –ย 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. Energyย 
            • 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

      Itโ€™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,ย Glucose
      • Others:ย individualised to the patient.
      STABLE – Rate/Rhythm Control

      Rate Control

      • First line:
        • ฮฒ-Blocker –ย outperforms calcium channel blockers in studies
        • Non-dihydropyridine calcium channel blockers (Diltiazem/Verapamil) – esp. in Severe COPD/Asthma
      • Second Line:Consider adding in
        • Digoxinย – 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)ย – Consider anticoagulation (DOAC) in light of bleed risk
        • ALL (โ‰ฅ2)ย – Anticoagulation recommended (DOAC)-ย Trust DOAC guide,ย  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 willย benefit fromย anticoagulationย – but discuss personalised risk with patients

      Contraindications to Anticoagulation inc:

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

      ย 

      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 mayย start in ED)
          • Hypertension
          • Heart Failure
          • Coronary artery disease
          • Diabetes Mellitus
          • Sleep Apnoea
      STABLE – CARE