Peri-arrest arrhythmias refer to rhythm abnormalities occurring before or after cardiac arrest. They fall into two categories:Arrhythmias leading to cardiac arrest – May occur in acute myocardial infa…
Peri-arrest arrhythmias refer to rhythm abnormalities occurring before or after cardiac arrest. They fall into two categories:
Recognising and treating these arrhythmias promptly is critical for preventing deterioration or cardiac arrest recurrence.
All patients with suspected arrhythmias should be assessed using the ABCDE approach:
Key Steps in Assessment:
✔ Record a 12-lead ECG as early as possible.
✔ Look for adverse features, including shock, syncope, heart failure, and myocardial ischaemia.
✔ Insert intravenous (IV) access and correct hypoxia (oxygen saturation target: 94-98% or 88-92% in COPD).
✔ Identify whether the arrhythmia is a bradyarrhythmia or tachyarrhythmia, as this determines management.
Immediate intervention is required if the patient has:
If adverse features are present → Urgent treatment is required.
Management follows specific treatment algorithms for tachyarrhythmias and bradyarrhythmias.
Classified as:
Treatment for Tachyarrhythmias:
If Adverse Features are Present (Unstable Patient) → Immediate synchronised cardioversion
✔ If unsuccessful, give IV amiodarone (300 mg over 10-20 min), followed by another shock.
✔ If still refractory, continue amiodarone infusion (900 mg over 24 hours).
If No Adverse Features (Stable Patient):
✔ Assess ECG (QRS width and rhythm regularity).
✔ Regular narrow-complex tachycardia → Consider vagal manoeuvres, adenosine 6 mg IV (increase dose if ineffective).
✔ Irregular narrow-complex tachycardia → Likely atrial fibrillation; use rate control (beta-blockers or diltiazem).
✔ Regular broad-complex tachycardia → Assume ventricular tachycardia (VT) and treat with amiodarone.
✔ Irregular broad-complex tachycardia → Consider Torsades de Pointes (TdP) and give IV magnesium sulfate.
Causes include sinoatrial node disease, AV block, drugs (beta-blockers, digoxin), and metabolic disorders.
🔹 Treatment for Bradyarrhythmias:
If Adverse Features are Present (Unstable Patient)
✔ First-line: Give atropine 500 mcg IV, repeat every 3-5 minutes up to 3 mg.
✔ If atropine is ineffective: Consider transcutaneous pacing or drugs:
If No Adverse Features (Stable Patient)
✔ Monitor closely and identify the underlying cause (e.g., drug-induced, metabolic disorder).
✔ Seek expert help if the patient has Mobitz Type II or complete heart block.
Torsades de Pointes (TdP) – Associated with prolonged QT interval.
✔ Give IV magnesium sulfate (2g over 10 min).
✔ Consider overdrive pacing if recurrent.
✔ Avoid QT-prolonging drugs (e.g., amiodarone).
Pulseless Electrical Activity (PEA) – Any electrical activity without a pulse.
✔ Search for reversible causes (4 H’s & 4 T’s):
Atrial Fibrillation (AF) in ACS
✔ Use beta-blockers or calcium-channel blockers for rate control.
✔ Avoid amiodarone in pre-excited AF (e.g., WPW syndrome).
Post-Resuscitation Arrhythmias
✔ Common after return of spontaneous circulation (ROSC).
✔ Requires ECG monitoring and cardiology review for potential ICD placement.
✔ Peri-arrest arrhythmias can lead to or follow cardiac arrest and require prompt recognition and treatment.
✔ ABCDE assessment + 12-lead ECG are critical to identify adverse features and initiate appropriate treatment.
✔ Tachyarrhythmias (HR >100 bpm) require cardioversion or anti-arrhythmic drugs, depending on stability and ECG findings.
✔ Bradyarrhythmias (HR <60 bpm) require atropine or pacing if they cause haemodynamic instability.
✔ Reversible causes (e.g., electrolyte imbalance, hypoxia, drug toxicity) must always be considered.
✔ Seek expert help if advanced interventions (transvenous pacing, ICD placement) are required.
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