1. Ventricular Fibrillation and Tachycardia:
-If unstable (see ACLS protocol): Defibrillate with
unsynchronized 200 J, then 300 J.
-Oxygen 100% by mask.
-Lidocaine (Xylocaine) loading dose 75-100 mg IV,
then 2-4 mg/min IV OR
-Amiodarone (Cordarone) 300 mg in 100 mL of D5W,
IV infusion over 10 min, then 900 mg in 500 mL of
D5W, at 1 mg/min for 6 hrs, then at 0.5 mg/min
thereafter; or 400 mg PO q8h x 14 days, then 200-
400 mg qd.
-Also see "other antiarrhythmics" below.
2. Torsades De Pointes Ventricular Tachycardia:
-Correct underlying cause and consider discontinuing
quinidine, procainamide, disopyramide, moricizine,
amiodarone, sotalol, Ibutilide, phenothiazine,
haloperidol, tricyclic and tetracyclic antidepressants,
ketoconazole, itraconazole, bepridil,
hypokalemia, and hypomagnesemia.
-Magnesium sulfate 1-4 gm in IV bolus over 5-15 min
or infuse 3-20 mg/min for 7-48h until QTc interval
<440 msec.
-Isoproterenol (Isuprel), 2-20 mcg/min (2 mg in 500 mL
D5W, 4 mcg/mL).
-Consider ventricular pacing and/or cardioversion.
3. Other Antiarrhythmics:
Class I:
-Moricizine (Ethmozine) 200-300 mg PO q8h, max 900
mg/d [200, 250, 300 mg].
Class Ia:
-Quinidine gluconate (Quinaglute) 324-648 mg PO q8-
12h [324 mg].
-Procainamide (Procan, Procanbid)
IV: 15 mg/kg IV loading dose at 20 mg/min, followed
by 2-4 mg/min continuous IV infusion.
PO: 500 mg (nonsustained release) PO q2h x 2
doses, then Procanbid 1-2 gm PO q12h [500, 1000
mg].
-Disopyramide (Nor-pace, Norpace CR) 100-300 mg
PO q6-8h [100, 150, mg] or disopyramide CR 100-
150 mg PO bid [100, 150 mg].
Class Ib:
-Lidocaine (Xylocaine) 75-100 mg IV, then 2-4 mg/min
IV
-Mexiletine (Mexitil) 100-200 mg PO q8h, max 1200
mg/d [150, 200, 250 mg].
-Tocainide (Tonocard) loading 400-600 mg PO, then
400-600 mg PO q8-12h (1200-1800 mg/d) PO in
divided doses q8-12h [400, 600 mg].
-Phenytoin (Dilantin), loading dose 100-300 mg IV
given as 50 mg in NS over 10 min IV q5min, then
100 mg IV q5min prn.
Class Ic:
-Flecainide (Tambocor) 50-100 mg PO q12h, max 400
mg/d [50, 100, 150 mg].
-Propafenone (Rythmol) 150-300 mg PO q8h, max
1200 mg/d [150, 225, 300 mg].
Class II:
-Propranolol (Inderal) 1-3 mg IV in NS (max 0.15
mg/kg) or 20-80 mg PO tid-qid [10, 20, 40, 60, 80
mg]; propranolol-LA (Inderal-LA), 80-120 mg PO qd
[60, 80, 120, 160 mg]
-Esmolol (Brevibloc) loading dose 500 mcg/kg over 1
min, then 50-200 mcg/kg/min IV infusion
-Atenolol (Tenormin) 50-100 mg/d PO [25, 50, 100
mg].
-Nadolol (Corgard) 40-100 mg PO qd-bid [20, 40, 80,
120, 160 mg].
-Metoprolol (Lopressor) 50-100 mg PO bid-tid [50, 100
mg], or metoprolol XL (Toprol-XL) 50-200 mg PO
qd [50, 100, 200 mg].
Class III:
-Amiodarone (Cordarone), PO loading 400-1200 mg/d
in divided doses for 2-4 weeks, then 200-400 mg
PO qd (5-10 mg/kg) [200 mg] or amiodarone
(Cordarone) 300 mg in 100 mL of D5W, IV infusion
over 10-20 min, then 900 mg in 500 mL of D5W, at
1 mg/min for 6 hrs, then at 0.5 mg/min thereafter.
-Sotalol (Betapace) 40-80 mg PO bid, max 320 mg/d
in 2-3 divided doses [80, 160 mg].
4. Extras: CXR, ECG, Holter monitor, signal averaged
ECG, cardiology consult.
5. Labs: SMA 7&12, Mg, calcium, CBC, drug levels. UA.
