ACLS 2000

The Tachycardia Algorithms

 Major New Concepts for the
International Guidelines 2000
• Unstable tachycardias → Cardioversion
• Stable tachycardias
– Making a specific rhythma diagnosis
– Recognizing patients who have significantly
impaired cardiac function ( EF < 40%, overt
signs of heart failure )
Specific Rhythm Diagnosis
Rationale
• Overuse of adenosine has often delayed more appr
opriate treatment
• Unpleasant side effects of adenosine, the possibilit
y of worse rhythms, and a destablilization of heart
rate and blood pressure
• Lidocaine is ineffective for termination of hemody
namically stable sustained VT
Specific Rhythm Diagnosis
• 12-lead ECG
• Esophageal lead

~ Looking for AV dissociation ~

 Specific Rhythm Diagnosis
• History
– CAD, structural heart disease
– accessory pathways, preexisting BBB, rate-
dependent BBB, previous aberrant rhythms
• Physical signs of AV dissociation
– Irregular cannon A waves in the jugular venous
pulse
– Varying intensity of S1
– Beat – to – beat changes in SBP
Antiarrhythmics or Proarrhythmics

• Negative inotropic effects

• Proarrhythmic effects

~ never use more than 1 agent unless absolutely necessary ~

Af/ AF with Normal Cardiac Function
C o n tro l ra te
C a lc iu m b lo c k e r s ( I )
£ ] - B lo c k e r s ( I )
C o n v e rt R h y th m ( < 4 8 h rs )
D C C a r d io v e r s io n
A m id d a r o n e ( I a )
I b u t ilid e ( I I a )
F le c a in id e ( I I a )
P r o c a in a m id e ( I I a )
S o t a lo l ( I I b )
D is o p y r a m id e ( I I b )
Af / AF with Impaired Heart Function
C o n tro l R a te C o n v e rt R h y th m ( < 4 8 h rs )
D ig o x in ( I I b )
D il t ia z e n ( I I b ) D C c a r d io v e r s io n
A m io d a r o n e ( I I b ) A m io d a r o n e ( I I b )
 Af/Af > 48 hrs or unknown duration
• Delayed cardioversion
Anticoagulation x 3 wks
DC cardioversion
Anticoagulation x 4 more weeks
• Early cardiovesion
Begin IV heparin at once
TEE to exclude atrial clot
Cardioversion within 24 hrs
Anticoagulation x 4 more weeks
Af / AF with WPW syndrome (< 48hrs)
Normal Heart

D C c a r d io v e r s io n
A m io d a r o n e ( I I b )
F le c a in id e ( I I b )
P r o c a in a m id e ( I I b )
P ro p afen o n e ( IIb )
S o t a lo l ( I I b )
A d e n o s in e ( I I I )
 - B lo c k e r s ( I I I )
C a lc iu m b lo c k e r s ( I I I )
D ig o x in ( I I I )
Af / AF with WPW syndrome (< 48hrs)
Impaired Heart
• DC cardioversion
• Amiodarone (IIb)
 Af / AF with WPW syndrome
( > 48 hrs or unknown )
• Anticoagulation
• DC cardioversion