2020 ACLS Guidelines on Medications for Management of Specific Arrhythmias

Jan 23, 21
2020 ACLS Guidelines on Medications for Management of Specific Arrhythmias

ACLS 2020 arrhythmias

The 2020 ACLS guidelines provide recommendations on the medication-specific management for arrhythmias including wide-complex tachycardia, regular narrow-complex tachycardia, atrial fibrillation/flutter, and bradycardia [1]. There are also our 2020 ACLS guideline summaries on vasopressor and non-vasopressor medications used during cardiac arrest and toxicology-related conditions.

Wide-complex tachycardia (WCT)

Wide-complex tachycardia Medication(s) Evidence
Hemodynamically stable Adenosine COR 2b, LOE B-NR
Amiodarone, procainamide, or sotalol COR 2b, LOE B-R
NOTE: Verapamil is harmful COR 3, LOE B-NR
Polymorphic VT with long QT (torsades de points) Magnesium COR 2b, LOE C-LD
Polymorphic VT without long QT Lidocaine or amiodarone COR 2b, LOE C-LD

Regular narrow-complex tachycardia

  1. Vagal maneuvers (COR 1, LOE B-R)
  2. Adenosine (COR 1, LOE B-R)
  3. Diltiazem or verapamil (COR 2a, LOE B-R)
  4. Beta-blockers (COR 2a, LOE C-LD)

Atrial fibrillation/flutter with rapid ventricular rate

  1. Beta-blocker or diltiazem or verapamil (COR 1, LOE B-NR)
  2. Amiodarone (COR 2a, LOE B-NR)

Note that medications can be harmful in these settings:

  1. Preexcitation: Digoxin, non-dihydropyridine calcium channel blockers, beta-blockers, or amiodarone (COR 3, LOE C-LD)
  2. LV systolic dysfunction and decompensated heart failure: Non-dihydropyridine calcium channel blockers or beta-blockers (COR 3, LOE C-EO)

Bradycardia

  1. Treat reversible causes (COE 1, LOE C-EO)
  2. Atropine if hemodynamic compromise (COR 2a, LOE B-NR)
  3. Epinephrine or transcutaneous pacing if unresponsive to atropine (COR 2b, LOE C-LD)

Reference

Panchal AR, Bartos JA, Cabañas JG, et al; Adult Basic and Advanced Life Support Writing Group. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142(16_suppl_2):S366-S468. doi: 10.1161/CIR.0000000000000916. Epub 2020 Oct 21. PMID: 33081529.

Author information

Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP

Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP

Leadership Team, ALiEM
Creator and Lead Editor, Capsules and EM Pharm Pearls Series
Attending Pharmacist, EM and Toxicology, MGH
Associate Professor of EM, Division of Medical Toxicology, Harvard Medical School

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