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UDK   616.12-008.318-083.98                                           

ISSN 2466-2992 (Online) (2015) br.2, p.25-29

COBISS.SR-ID 221119756


Goran Živković

Emergency Medical Service Nis, Serbia


Introduction: The correct identification and treatment of arrhythmias in the critically ill patient may prevent primary or secondary cardiac arrest. In periarrest situations should be distinguished arrhythmias that can lead to a further deterioration of the patient's condition and ultimately cardiac arrest than those who do not require immediate treatment.

The initial assessment and treatment of a patient with anarrhythmia should follow the ABCDE approach. Key elements in this process include assessing for adverse signs, oxygen if indicated, obtaining intravenous access, and establishing monitoring (ECG, blood pressure, SpO2), recording a 12-lead ECG, identifying and treating reversible causes (eg. electrolyte abnormalities). The presence of the following adverse signs indicates the unfavorable situation of instability of the patient as a result of arrhythmia: shock, syncope, heart failure and myocardial ischemia. Generally, drugs are used as first-line therapy for stable patients without adverse signs, and electrical cardioversion is the safest and most effective way of treatment for unstable patients with adverse signs.

Treatment of tachycardia: If the patient is unstable or deteriorating immediately attempt synchronised cardioversion. If cardioversion is unsuccessful, give amiodarone 300 mg IV over 10-20 min. and retry cardioversion. If the patient is stable and not in clinical deterioration analyze of 12-lead ECG and determine whether the tachycardia with a narrow (<0,12ms) or broad QRS complexes (≥12ms). Broad-complex tachycardia may be regular - usually ventricular tachycardia (VT) (treat with amiodarone iv) or supraventricular tachycardia (SVT) with bundle branch block (treat as SVT with normal conduction) or irregular. In case of irregular broad-complex tachycardia usually comes atrial fibrillation (AF) with bundle branch block (treated as AF without conduction abnormalities), or AF with ventricular pre-excitation (never give drugs that slow AV conduction) or polymorphic VT (eg. torsade de pointes - treat with magnesium iv). Narrow-complex tachycardia may be regular (usually a benign AV nodal re-entry tachycardia or AV re-entry tachycardia - in 90-95% of cases is converted with vagal maneuvers and adenosine iv) and irregular (usually a AF with treatment options: rate control, rhythm control and prevention of complications).

Treatment of bradycardia: If adverse signs are present, give atropine iv and, if necessary, repeat every 3–5 min. If treatment with atropine is ineffective, consider alternative drugs (epinephrine, dopamine, isoprenaline, theophylline, glucagon, glycopyrrolate) or transcutaneous pacing. Furthermore, if necessary, seek advice from cardiologists and assess the need for temporary transvenous pacing.

Conclusion: A doctor who provides care for critically ill patient should be able to quickly assess the ECG recording (in the context of clinical assessment), and as soon as possible treat malignant arrhythmias (physical methods, drugs, electroconversion, electrostimulation) with constant monitoring of vital functions.

Keywords: peri-arrest arrhythmia, adverse signs, antiarrhythmics, cardioversion, electrostimulation.


Goran Živković, MD

Emergency Medical Service Nis, Serbia

E mail:

Rad primljen:    18.12.2015

Rad prihvaćen:   26.12.2015.

Elektronska verzija objavljena:  01.02.2016.

Issue 2015-2 / article 4