Adult advanced life support

Unresponsive and
Maintain
personal not breathing normally
safety

Call resuscitation
team/ambulance

CPR 30:2
Attach defibrillator/monitor

Assess rhythm

SHOCKABLE NON-SHOCKABLE
(VF/Pulseless VT) (PEA/Asystole)
Return of spontaneous
circulation
(ROSC)
1 shock

Immediately resume Immediately resume

CPR for 2 min CPR for 2 min

Give high-quality Identify and treat Consider After ROSC

chest compressions, reversible causes • Coronary angiography/ • Use an ABCDE approach
percutaneous coronary
and: • Hypoxia
intervention
• Aim for SpO2 of 94–98% and
• Hypovolaemia normal PaCO2
• Give oxygen • Mechanical chest
• Use waveform capnography • Hypo-/hyperkalaemia/ compressions to facilitate • 12-lead ECG
• Continuous compressions if metabolic transfer/treatment • Identify and treat cause
advanced airway • Hypo/hyperthermia • Extracorporeal CPR
• Targeted temperature
• Minimise interruptions • Thrombosis – coronary or management
to compressions pulmonary
• Intravenous or intraosseous • Tension pneumothorax
access • Tamponade – cardiac
• Give adrenaline every • Toxins
3–5 min
Consider ultrasound imaging
• Give amiodarone after to identify reversible causes
3 shocks
• Identify and treat reversible
causes
 Adult tachycardia
Assess with Life threatening Synchronised DC
YES
ABCDE approach features? shock
• Give oxygen if SpO2 < 94% up to 3 attempts
1. Shock
• Obtain IV access • Sedation or anaesthesia if
• Monitor ECG, BP, SpO2, 2. Syncope conscious
record 12-lead ECG 3. Myocardial If unsuccessful:
• Identify and treat reversible causes ischaemia • Amiodarone 300 mg IV
e.g. electrolyte abnormalities, over 10–20 min
hypovolaemia causing sinus 4. Severe heart
• Repeat synchronised DC
tachycardia failure shock

UNSTABLE

STABLE
Seek expert help
NO

Is the QRS narrow (< 0.12 s)?

BROAD QRS NARROW QRS

Is QRS regular? Is QRS regular?

IRREGULAR REGULAR REGULAR IRREGULAR

Possibilities If VT (or uncertain Vagal Probable atrial

include: rhythm): manoeuvres fibrillation:
• Atrial fibrillation with • Amiodarone 300 mg IV • Control rate with
bundle branch block over 10–60 min beta-blocker
treat as for irregular If ineffective: • Consider digoxin or
narrow complex If previous certain
diagnosis of SVT with • Give Adenosine amiodarone if evidence
• Polymorphic VT bundle branch block/ (if no pre-excitation) of heart failure
(e.g. torsades de pointes) aberrant conduction: – 6 mg rapid IV bolus • Anticoagulate if
give magnesium 2 g duration > 48 h
over 10 min • Treat as for regular – If unsuccessful,
narrow complex give 12 mg
tachycardia – If unsuccessful,
give 18 mg
• Monitor ECG
continuously

If ineffective:
• Verapamil
or beta-blocker

If ineffective:
• Synchronised DC shock up to 3 attempts
• Sedation or anaesthesia if conscious
 Adult bradycardia

Assess with ABCDE approach

Give oxygen if appropriate and

obtain IV access

Monitor ECG, BP, SpO2,

record 12-lead ECG

Identify and treat reversible causes

e.g. electrolyte abnormalities

Evidence of
life threatening signs?
• Shock
• Syncope
• Myocardial ischaemia
• Heart failure

YES NO

Atropine 500 mcg IV

Satisfactory response? YES Risk of asystole?

• Recent asystole
• Mobitz II AV block
NO • Complete heart block with
broad QRS
• Ventricular pause > 3 s
Interim measures:
• Atropine 500 mcg IV repeat
to maximum of 3 mg YES NO
• Isoprenaline 5 mcg min -1 IV
• Adrenaline 2–10 mcg min -1 IV
• Alternative drugs* Observe
or
Transcutaneous pacing

Seek expert help * Alternatives include:

• Aminophylline
• Dopamine
Arrange transvenous pacing • Glucagon (if beta-blocker or
calcium channel blocker overdose)
• Glycopyrrolate can be used instead
of atropine
 Adult choking

Choking?

Assess severity

SEVERE MILD
Airway obstruction Airway obstruction
(ineffective cough) (effective cough)

Encourage cough
Unconscious Conscious

Continue to check
for deterioration to
Start CPR 5 back blows ineffective cough or until
obstruction relieved

5 abdominal thrusts
 Adult in-hospital resuscitation

Maintain
Collapsed/sick
personal patient
safety

Shout for HELP

and assess patient

Signs of life?
• Check for consciousness and normal breathing
• Experienced ALS providers should simultaneously
check for carotid pulse

NO
YES
(or any doubt)

CARDIAC ARREST MEDICAL EMERGENCY

Call and collect* Call and collect*

CALL resuscitation team CALL resuscitation / medical
COLLECT resuscitation equipment emergency team if needed
COLLECT resuscitation equipment

High-quality CPR*
Give high-quality CPR with oxygen Assess*
and airway adjuncts* ABCDE assessment –
Switch compressor at every recognise and treat
rhythm assessment Give high-flow oxygen
(titrate to SpO2 when able)
Attach monitoring
Defibrillation* Vascular access
Apply pads/turn on defibrillator/AED Consider call for resuscitation/
medical emergency team
Attempt defibrillation if indicated** (if not already called)

Advanced life support Handover

When sufficient skilled personnel Handover to resuscitation/
are present medical emergency team

Handover
Handover to * Undertake actions concurrently
resuscitation team if sufficient staff available
** Use a manual defibrillator if trained
and device available
 Adult
Adultin-hospital
post resuscitation
resuscitation
care
Airway and breathing
IMMEDIATE TREATMENT

• Maintain SpO2 94–98%

• Insert advanced airway
• Waveform capnography
• Ventilate lungs to normocapnia

Circulation
• 12-lead ECG
• Obtain reliable intravenous access
• Aim for SBP >100 mmHg
• Fluid (crystalloid) – restore normovolaemia
• Intra-arterial blood pressure monitoring
• Consider vasopressor/inotrope to maintain SBP

Control temperature
• Constant temperature 32–36°C
• Sedation; control shivering

NO Likely cardiac cause? YES

DIAGNOSIS

YES 12-lead ECG

ST elevation?

NO
Coronary angiography ± PCI

Consider coronary
NO Cause for cardiac arrest identified? angiography ± PCI

Consider CT brain YES

and/or CTPA

Treat non-cardiac cause

of cardiac arrest Admit to ICU
OPTIMISING RECOVERY

ICU management
• Temperature control: constant temperature
32–36°C for ≥ 24 h; prevent fever for at least 72 h
• Maintain normoxia and normocapnia;
protective ventilation
• Avoid hypotension
• Echocardiography
Functional assessments
before hospital
• Maintain normoglycaemia discharge
• Diagnose/treat seizures
(EEG, sedation, anti-epileptic drugs)
• Delay prognostication for at least 72 h
Structured follow-up
after hospital discharge

Secondary prevention
e.g. ICD, screen for inherited disorders, Rehabilitation
risk factor management
 Advanced
Newbornresuscitation
life supportof
the newborn infant

Assess baby with ABC approach

AT ALL TIMES CONSIDER COMMUNICATION AND HUMAN FACTORS

A = Airway B = Breathing C = Circulation

Follow
NEWBORN LIFE SUPPORT ALGORITHM

Worrying or potentially NO
life-threatening features?

Observe and
YES re-assess as
necessary

Call for HELP

Potentially
Worrying
life-threatening
features
features

Treat potentially life Re-assess ABC

threatening features and
if necessary start CPR Consider DEF
Consider further
diagnostic tests and
Continue definitive treatments
NEWBORN LIFE SUPPORT

Reassess ABCDEF

Treat underlying cause

Assess baby with ABCDEF approach

D = Disability / Drugs / Dextrose E = Exposure / Environment F = Family

Remember thermal care, documentation and debriefing

 Newborn
Newbornlife
lifesupport
support
(Antenatal counselling)
Team briefing and equipment check

Preterm Birth

APPROX 60 SECONDS

MAINTAIN TEMPERATURE

AT ALL TIMES ASK “IS HELP NEEDED”

< 32 weeks Delay cord clamping if possible

Place undried in Start clock / note time

plastic wrap + Dry / wrap, stimulate, keep warm
radiant heat

Assess
Colour, tone, breathing, heart rate

Inspired oxygen
28–31 weeks 21–30% Ensure an open airway
< 28 weeks 30% Preterm: consider CPAP

If gasping / not breathing

If giving inflations, • Give 5 inflations (30 cm H2O) – start in air
start with 25 cm H2O • Apply PEEP 5–6 cm H20, if possible
• Apply SpO2 +/- ECG

Acceptable
Reassess
pre-ductal SpO2
If no increase in heart rate, look for chest movement
2 min 65%
5 min 85%
If the chest is not moving
10 min 90% • Check mask, head and jaw position
• 2 person support
• Consider suction, laryngeal mask/tracheal tube
TITRATE OXYGEN TO ACHIEVE TARGET SATURATIONS

• Repeat inflation breaths

• Consider increasing the inflation pressure

Reassess
If no increase in heart rate, look for chest movement

Once chest is moving continue ventilation breaths

If heart rate is not detectable or < 60 min -1

after 30 seconds of ventilation
• Synchronise 3 chest compressions to 1 ventilation
• Increase oxygen to 100%
• Consider intubation if not already done or laryngeal
mask if not possible

Reassess heart rate and chest movement

every 30 seconds

If the heart rate remains not detectable or < 60 min -1

• Vascular access and drugs
• Consider other factors e.g. pneumothorax,
hypovolaemia, congenital abormality

Update parents and debrief team

Complete records
 Paediatric advanced life support
Recognise cardiac arrest

Call for help 2222

Commence/continue CPR
(5 initial breaths then CV ratio 15:2)
Attach defibrillator/monitor
Minimise interruptions

Assess rhythm

SHOCKABLE NON-SHOCKABLE
VF/Pulseless VT PEA/asystole/brady < 60 min -1

Return of spontaneous
1 shock 4 J kg-1 circulation Immediately resume CPR
for 2 min
(ROSC) Minimise interruptions

Immediately resume CPR

for 2 min Post cardiac arrest care:
Minimise interruptions Give adrenaline IV/IO
• Use an ABCDE approach 10 mcg kg-1
• Aim for SpO2 of 94–98% as soon as possible
and normal PaCO2 and then every 3–5 min
• Avoid hypotension
After 3 shocks give:
• Targeted temp management
• Adrenaline IV/IO 10 mcg kg-1
(and every alternate cycle • Glucose control
thereafter)
AND
• Amiodarone IV/IO 5 mg kg-1
(and repeat 5 mg kg-1 once
more only after 5th shock)

During CPR Identify and treat reversible causes

• Ensure high quality chest compressions are delivered: • Hypoxia
– Correct rate, depth and full recoil • Hypovolaemia
• Provide BMV with 100% oxygen (2 person approach) • Hyperkalaemia, hypercalcaemia,
• Provide continuous chest compressions when a tracheal tube is in place. hypermagnesemia, hypoglycaemia
• Competent providers can consider an advanced airway and capnography, • Hypo-/hyperthermia
and ventilate at a rate (breaths minute -1) of: • Thrombosis – coronary or pulmonary
Infants: 25 1–8 years: 20 8–12 years: 15 > 12 years: 10–12 • Tension pneumothorax
• Tamponade – cardiac
• Vascular access IV/IO
• Toxic agents
• Once started, give Adrenaline every 3-5 min
Adjust algorithm in specific settings
• Maximum single dose Adrenaline 1 mg (e.g. special circumstances)
• Maximum single dose Amiodarone 300 mg
 Paediatric cardiac arrhythmias
Assess with ABCDE approach – recognise and treat reversible causes Follow
ADVANCED
Oxygen if SpO2 < 94%, respiratory rate, heart rate, CRT, Signs of circulation? NO LIFE SUPPORT
cardiac monitoring, blood pressure, vascular access, AVPU
ALGORITHM

Decompensated – seek expert help Compensated

YES
Signs of vital organ perfusion compromise: Normal LOC, +/- respiratory
Reduced LOC, tachypnoea, bradycardia /tachycardia, distress and signs of
BP < 5th centile*, CRT > 2 secs, weak or impalpable circulatory compromise,
peripheral pulses BP > 5th centile*

Monitor for clinical

Bradycardia Tachycardia deterioration and
seek expert help
< 1 year < 80 min -1 Narrow complex Broad complex
> 1 year < 60 min -1
Treat the cause:
Sinus tachycardia SVT VT
Optimal oxygenation with If bradycardia, consider
Infant typically 180–220 min -1 Infant > 220 min -1
Could be VT or SVT,
positive pressure ventilation if oxygenation and vagal tone
Child typically 160–180 min -1 Child > 180 min -1 if unsure treat as VT
required Abrupt onset
Gradual onset If SVT, consider vagal
If unconscious and HR < 60 manoeuvres
min-1 despite oxygenation, Treat the cause: Synchronised cardioversion If conscious:
start chest compressions Reassess
Physiological response: with appropriate sedation Synchronised cardioversion
No response to oxygenation: – Crying + analgesia (e.g. IM/intranasal with appropriate sedation Consider adenosine
If vagal stimulation possible – Exercise ketamine if delay in IV access) + analgesia (e.g. IM/intranasal
cause – atropine – Anxiety/fear Chemical cardioversion may ketamine if delay in IV access,
– Pain be 1st choice if suitable IV do not delay cardioversion).
If no response to oxygenation
or atropine consider Identify precipitant access is in place and delay in If unconscious:
adrenaline Compensatory mechanism: synchronised cardioversion. Immediate synchronised
Pacing – very rarely required – Respiratory/circulatory failure Adenosine cardioversion
and guided by aetiology. – Hypovolaemia Consider amiodarone before Consider amiodarone before
– Sepsis 3rd shock 3rd shock
– Anaemia

Drug Atropine Adrenaline Adenosine Amiodarone Synchronised cardioversion Magnesium Age *Systolic BP
Treatment Up to 11 years: For Up to 1 year: 150 mcg kg -1, increase 50–100 mcg kg -1 5 mg kg -1 – by With appropriate sedation + 25–50 mg kg -1 5th centile
20 mcg kg -1. bradycardia: every 1–2 min. Maximum single dose: Neonates 300 SLOW IV infusion analgesia (e.g. IM/intranasal Maximum per mmHg
10 mcg kg -1 mcg kg -1, Infants 500 mcg kg -1) (> 20 min) before Ketamine if delay in IV access dose 2 g 1 month 50
12–17 years: repeat if 3rd cardioversion + airway management) – IV to be given over
300–600 mcg, 1–11 years: 100 mcg kg -1 increase 50–100 mcg kg -1
necessary. every 1–2 min. Maximum single dose: 500 mcg kg -1 in discussion access attempts must not delay 10–15 min, may 1 year 70
larger doses with paediatric cardioversion be repeated once
may be used in (max. 12 mg) 5 years 75
cardiologist/expert 1st shock: 1 J kg -1 if necessary,
emergency. 12–17 years: 3 mg IV, if required increase to 6 mg in Torsades de 10 years 80
after 1–2 min, then 12 mg after 1–2 min 2nd shock: 2 J kg -1, consider up to pointes VT
4 J kg -1
Paediatric foreign body
airway obstruction
Suspect foreign body
airway obstruction

Shout for HELP

Cough effective? YES

NO Encourage
cough

Call EMS/resuscitation team Continue to

Single rescuer – use speaker function if on mobile phone check for
deterioration

Is the child conscious?

Unconscious Conscious

Open airway Infant

and try rescue Alternate 5 back blows,
breaths then 5 chest thrusts
Child
Alternate 5 back blows,
then 5 abdominal
Continue with
thrusts
PAEDIATRIC BASIC
LIFE SUPPORT
No repeated or blind
finger sweeps Obstruction
relieved?

YES

Urgent medical
follow-up
 Paediatric out-of-hospital
basic life support
Unresponsive

Second rescuer or
Shout for help single rescuer suspecting
a primary cardiac arrest
• Call EMS on 999
• Collect and apply AED
Open airway if feasible

YES
Breathing normally?

Observe
NO and re-assess as
or any doubt necessary

5 rescue breaths Single rescuer

Infant: mouth to nose/mouth • Call EMS if phone
Child: mouth to mouth available, using speaker
function
If unable/unsafe to ventilate, perform • If no phone available
continuous chest compressions continue with CPR for 1
Add rescue breaths as soon as possible minute before calling EMS

If no signs of life observed

during rescue breaths

30 chest compressions

2 rescue breaths

Clear signs of life? YES

Keep child in safe position,

NO continue to assess and
await EMS

Those trained only in ‘adult’ BLS (may include healthcare providers and lay rescuers) who have no specific knowledge of paediatric
resuscitation, should use the adult sequence they are familiar with, including paediatric modifications.
 Adult post cardiac arrest
functional assessments, follow-up
and rehabilitation

Before hospital discharge

Perform functional assessments

of physical and non-physical impairments

Refer to
rehabilitation
if necessary

At follow up
Within 3 months from hospital discharge
Perform Perform Provide
screening screening for information and
for cognitive emotional support to the
problems problems and survivor and
fatigue their family

Consider referral to
further specialised
care if indicated
 Obstetric Cardiac Arrest
Alterations in maternal physiology and exacerbations of pregnancy related pathologies must be considered. Priorities include calling the appropriate team members, relieving aortocaval
compression, effective cardiopulmonary resuscitation (CPR), consideration of causes and performing a timely emergency hysterotomy (perimortem caesarean section) when ≥ 20 weeks.

START. Box A: POTENTIAL CAUSES 4H’s and 4T’s (specific to obstetrics)

❶ Confirm cardiac arrest and call for help. Declare ‘Obstetric cardiac arrest’ Hypoxia Respiratory – Pulmonary embolus (PE),
 Team for mother and team for neonate if > 20 weeks Failed intubation, aspiration
❷ Lie flat, apply manual uterine displacement to the left Heart failure
 Or left lateral tilt (from head to toe at an angle of 15–30° on a firm surface) Anaphylaxis
Eclampsia / PET – pulmonary oedema, seizure
❸ Commence CPR and request cardiac arrest trolley
Hypovolaemia Haemorrhage – obstetric (remember concealed),
 Standard CPR ratios and hand position apply
abnormal placentation, uterine rupture, atony,
 Evaluate potential causes (Box A)
splenic artery/hepatic rupture, aneurysm rupture
❹ Identify team leader, allocate roles including scribe Cardiac – arrhythmia, myocardial infarction (MI)
 Note time Distributive – sepsis, high regional block,
❺ Apply defibrillation pads and check cardiac rhythm (defibrillation is safe in anaphylaxis
pregnancy and no changes to standard shock energies are required)) Hypo/hyperkalaemia Also consider blood sugar, sodium, calcium and
 if VF / pulseless VT  defibrillation and first adrenaline and amiodarone after magnesium levels
3rd shock Hypothermia
 If PEA / asystole  resume CPR and give first adrenaline immediately Tamponade Aortic dissection, peripartum cardiomyopathy,
 Check rhythm and pulse every 2 minutes trauma
 Repeat adrenaline every 3-5 minutes Thrombosis Amniotic fluid embolus, PE, MI, air embolism
Box B:andIV DRUGS FOR USE DURING CARDIAC ARREST Toxins Local anaesthetic, magnesium, illicit drugs
❻ Maintain airway ventilation Tension
Fluids 500mL IV crystalloid Entonox in pre-existing pneumothorax, trauma
 Give 100% oxygen using bag-valve-mask device bolus pneumothorax
 Insert Adrenaline 1mg
supraglottic airway with IVport
drain every 3-5
–or– minutes
tracheal inifnon-shockable
tube trained to do so
or after
(intubation may be difficult, 3rd shock
and airway pressures may be higher) Box B: IV DRUGS FOR USE DURING CARDIAC ARREST
 Apply Amiodarone
waveform capnography monitoring to airway Fluids 500 mL IV crystalloid bolus
300 mg IV after 3rd shock
 If expired CO2 is absent, presume oesophageal intubation until absolutely Adrenaline 1 mg IV every 3-5 minutes in non-shockable or
Atropine 0.5-1mg IV up to 3mg if vagal tone likely after 3rd shock
excluded
cause Amiodarone 300 mg IV after 3rd shock
❼ Calcium chloride
Circulation 10% 10 mL IV for Mg overdose, low calcium
Atropine 0.5-1 mg IV up to 3 mg if vagal tone likely cause
or hyperkalaemia
 I.V. access above the diaphragm, if fails or impossible use upper limb
Calcium chloride 10% 10 mL IV for Mg overdose, low calcium or
Magnesium
intraosseous (IO) 2 g IV for polymorphic VT / hyperkalaemia
 See Box B for reminders abouthypomagnesaemia,
drugs 4g IV for eclampsia
 Consider extracorporeal CPR (ECPR) if available Magnesium 2 g IV for polymorphic VT / hypomagnesaemia,
Thrombolysis/PCI For suspected massive pulmonary embolus / 4 g IV for eclampsia
❽ MI
Emergency hysterotomy (perimortem caesarean section)
 PerformTranexamic acid
if ≥ 20 weeks 1g iftohaemorrhage
gestation, improve maternal outcome Thrombolysis/PCI For suspected massive pulmonary embolus / MI
 Perform immediately if maternal
Intralipid 1.5mL fatalkginjuries
-1 or prolonged
IV bolus and 15mL pre-hospital
kg-1 hr-1arrest
IV Tranexamic acid 1 g if haemorrhage
 Perform by 5 minutes if no return of
infusion spontaneous circulation
Intralipid 1.5 mL kg-1 IV bolus and 15 mL kg-1 hr-1 IV
❾ Post resuscitation from haemorrhage - activate Massive Haemorrhage Protocol infusion
Consider uterotonic drugs, fibrinogen and tranexamic acid
Uterine tamponage / sutures, aortic compression, hysterectomy
Version 1.1
 Emergency  tracheostomy  management  -­‐  Patent  upper  airway  
Call  for  airway  expert  help  
 Look,  listen  &  feel  at  the  mouth  and  tracheostomy  
A  Mapleson  C  system  (e.g.  ‘Waters  circuit’)  may  help  assessment  if  available  
Use  waveform  capnography  when  available:    exhaled  carbon  dioxide  indicates  a  patent  or  par6ally  patent  airway  

No   Is  the  pa0ent  breathing? Yes  

Call  Resuscita6on  Team   Apply  high  flow  oxygen  to  BOTH  
CPR  if  no  pulse  /  signs  of  life   the  face  and  the  tracheostomy  
 
   Assess  tracheostomy  patency  

Remove  speaking  valve  or  cap  (if  present)  

Remove  inner  tube  
 Some  inner  tubes  need  re-­‐inser6ng  to  connect  to  breathing  circuits  

The  tracheostomy  tube  is  patent  

Can  you  pass  a  suc0on  catheter?   Yes   Perform  tracheal  suc6on    
Consider  par6al  obstruc6on  
No   Ven6late  (via  tracheostomy)  if  
Deflate  the  cuff  (if  present)   not  breathing    
 Look,  listen  &  feel  at  the  mouth  and  tracheostomy   Con6nue  ABCDE  assessment
Use  waveform  capnography  or  Mapleson  C  if  available  
  Tracheostomy  tube  par0ally  

Is  the  pa0ent  stable  or  improving?  

Yes   obstructed  or  displaced  
Con6nue  ABCDE  assessment  
   
No  
REMOVE  THE  TRACHEOSTOMY  TUBE    
 Look,  listen  &  feel  at  the  mouth  and  tracheostomy.  Ensure  oxygen  re-­‐applied  to  face  and  stoma  
Use  waveform  capnography  or  Mapleson  C  if  available  

Call  Resuscita6on  team   No   Is  the  pa0ent  breathing?

Yes   Con6nue  ABCDE  
CPR  if  no  pulse  /  signs  of  life   assessment  

 Primary  emergency  oxygena6on   Secondary  emergency  oxygena6on    

Standard  ORAL  airway  manoeuvres   AEempt  ORAL  intuba0on

Cover  the  stoma  (swabs  /  hand).  Use:     Prepare  for  difficult  intuba0on  
         Bag-­‐valve-­‐mask   Uncut  tube,  advanced  beyond  stoma
         Oral  or  nasal  airway  adjuncts  
         SupragloWc  airway  device  e.g.  LMA

AEempt  intuba0on  of  STOMA  

Tracheostomy  STOMA  ven6la6on   Small  tracheostomy  tube  /  6.0  cuffed  ETT  
         Paediatric  face  mask  applied  to  stoma   Consider  Aintree  catheter  and  fibreop6c  
         LMA  applied  to  stoma ‘scope  /  Bougie  /  Airway  exchange  catheter

National Tracheostomy Safety Project. Review date 1/4/16. Feedback & resources at www.tracheostomy.org.uk
 Emergency  laryngectomy  management  
Call  for  airway  expert  help  
 Look,  listen  &  feel  at  the  mouth  and  laryngectomy  stoma  
A  Mapleson  C  system  (e.g.  ‘Waters  circuit’)  may  help  assessment  if  available  
Use  waveform  capnography  whenever  available:    exhaled  carbon  dioxide  indicates  a  patent  or  par/ally  patent  airway  

No   Is  the  pa5ent  breathing? Yes  

Apply  high  flow  oxygen  to  laryngectomy  stoma  
Call  Resuscita/on  Team   If  any  doubt  whether  pa/ent  has  a  
CPR  if  no  pulse  /  signs  of  life   laryngectomy,  apply  oxygen  to  face  also*  

   Assess  laryngectomy  stoma  patency        

Most  laryngectomy  stomas  will  NOT  have  a  tube  in  situ  

Remove  stoma  cover  (if  present)  

Remove  inner  tube  (if  present  )  
 Some  inner  tubes  need  re-­‐inser/ng  to  connect  to  breathing  circuits  
Do  not  remove  a  tracheoesophageal  puncture  (TEP)  prosthesis
The  laryngectomy  stoma  is  patent  
Yes   Perform  tracheal  suc/on    
Can  you  pass  a  suc5on  catheter?   Consider  par/al  obstruc/on  
Ven/late  via  stoma  if  not  breathing  
No   Con/nue  ABCDE  assessment
Deflate  the  cuff  (if  present)  
 Look,  listen  &  feel  at  the  laryngectomy  stoma  or  tube  
 Use  waveform  capnography  or  Mapleson  C  if  available  
 

Is  the  pa5ent  stable  or  improving?  

Yes   Con/nue  ABCDE  assessment  

No  
REMOVE  THE  TUBE  FROM  THE  LARYNGECTOMY  STOMA  if  present  
 Look,  listen  &  feel  at  the  laryngectomy  stoma.  Ensure  oxygen  is  re-­‐applied  to  stoma  
 Use  waveform  capnography  or  Mapleson  C  if  available  

Call  Resuscita/on  Team  

No   Yes   Con/nue  ABCDE  
Is  the  pa5ent  breathing?
CPR  if  no  pulse  /  signs  of  life   assessment  

 Primary  emergency  oxygena/on   Secondary  emergency  oxygena/on    

Laryngectomy  stoma  ven/la/on  via  either   AAempt  intuba5on  of  laryngectomy  stoma  
 Paediatric  face  mask  applied  to  stoma   Small  tracheostomy  tube  /  6.0  cuffed  ETT  
 LMA  applied  to  stoma Consider  Aintree  catheter  and  fibreop/c  
‘scope  /  Bougie  /  Airway  exchange  catheter

Laryngectomy  pa/ents  have  an  end  stoma  and  cannot  be  oxygenated  via  the  mouth  or  nose
*Applying  oxygen  to  the  face  and  stoma  is  the  default  emergency  ac/on  for  all  pa/ents  with  a  tracheostomy  
National Tracheostomy Safety Project. Review date 1/1/20 Feedback & resources at www.tracheostomy.org.uk
Cardiac rehabilitation and secondary prevention

Cardiac rehabilitation and secondary prevention

Cardiac rehabilitation Drug therapy for secondary prevention

• Start cardiac rehabilitation before hospital discharge • ACE inhibitor and continue indefinitely (an ARB if intolerant)
• Assessment appointment to take place in 10 days of discharge • Dual antiplatelet therapy (aspirin plus a second antiplatelet) for up to 12
months. Continue therapy started in acute stage unless a separate indication
for anticoagulation (see below)
• Beta-blocker (consider diltiazem or verapamil if beta-blockers contraindicated
and no pulmonary congestion or reduced left ventricular ejection fraction).
Cardiac rehabilitation programme Continue beta-blocker indefinitely if reduced left ventricular ejection fraction.
Otherwise consider continuing for at least 12 months
• Physical activity (adapted to clinical condition and ability) • Statin
• Lifestyle advice, including advice on driving, flying and sex
• Stress management
• Health education Drug titration

• ACE inhibitors - titrate upwards (with monitoring) every 12 to 24 hours.

Complete titration in 4 to 6 weeks of hospital discharge. Measure renal
Lifestyle changes function, serum electrolytes and blood pressure before starting an ACE
inhibitor or ARB and after 1 to 2 weeks
• Healthy eating - Mediterranean diet (more bread, fruit, vegetables, fish and • Beta-blockers - titrate to the maximum tolerated or target dose
products based on plant oils)
• Alcohol - low-risk drinking (no more than 14 units a week)
• Regular physical activity - 20 to 30 minutes a day to point of slight
Antiplatelet therapy with an indication for anticoagulation
breathlessness (increase duration and intensity gradually while gaining fitness)
Do not routinely offer prasugrel or ticagrelor with an anticoagulant needed for a
• Stop smoking
separate indication
• Reaching and maintaining a healthy weight
If already on anticoagulation:
• continue and offer clopidogrel (to replace prasugrel or ticagrelor) for up to 12
months if the person has PCI
Aldosterone antagonist for heart failure with reduced left ventricular • continue and consider continuing aspirin for up to 12 months (clopidogrel if
ejection fraction aspirin contraindicated) if no PCI and not at high bleeding risk

For a new indication for anticoagulation, offer oral anticoagulant and:

• Start 3 to 14 days after MI, preferably after ACE inhibitor
• clopidogrel (to replace prasugrel or ticagrelor) for up to 12 months if the
• Monitor renal function and serum potassium before and during treatment. If
person has had PCI
hyperkalaemia is a problem, halve dose or stop drug
• aspirin (clopidogrel if aspirin contraindicated) for up to 12 months if no PCI

This is a summary of the recommendations on cardiac rehabilitation and secondary prevention from NICE’s guideline on acute coronary syndromes. See the guideline at www.nice.org.uk/
© NICE 2020. All rights reserved. Subject to Notice of rights.
guidance/NG185
NSTEMI/unstable angina: early management
Initial antiplatelet therapy - Offer a 300-mg loading dose of aspirin and continue aspirin indefinitely unless contraindicated
Initial antithrombin therapy - Offer fondaparinux unless high bleeding risk or immediate angiography. Think about choice and dose of antithrombin if high
bleeding risk (advancing age, bleeding complications, renal impairment, low body weight). Consider unfractionated heparin with dose adjusted to clotting
function if creatinine above 265 micromoles/litre

Use established risk scoring system, such as GRACE, to predict 6-month mortality and risk of cardiovascular events. Include in the risk
assessment clinical history, physical examination, resting 12-lead ECG and blood tests (troponin I or T, creatinine, glucose, haemoglobin).
Balance possible benefits of treatment against bleeding risk.

Low risk Intermediate or higher risk

(predicted 6-month mortality ≤ 3%) (predicted 6-month mortality > 3%)

Consider conservative management without Offer immediate angiography if clinical condition unstable
angiography but be aware that some younger people Otherwise, consider angiography (with follow-on PCI if indicated) within 72 hours if no
may benefit from early angiography contraindications such as comorbidity or active bleeding

Offer ticagrelor with aspirin unless high bleeding risk If no separate indication for oral anticoagulation, offer prasugrel* or ticagrelor with aspirin. If a
Consider clopidogrel with aspirin, or aspirin alone, for person has a separate indication for oral anticoagulation, offer clopidogrel with aspirin. Only give
high bleeding risk prasugrel once PCI intended
Consider ischaemia testing before discharge Offer systemic unfractionated heparin in catheter laboratory if having PCI
Offer a drug-eluting stent if stenting indicated

*For people aged 75 and over, think about whether bleeding risk with prasugrel outweighs its
Consider angiography (with follow-on PCI if indicated) if
effectiveness
ischaemia develops or shown on testing

If follow-on PCI not done, consider angiography findings,

Assess left ventricular function for NSTEMI comorbidities and risks and benefits when discussing management
strategy with the interventional cardiologist, cardiac surgeon and
Consider assessing for unstable angina
the patient

Cardiac rehabilitation and secondary prevention

This is a summary of the recommendations on early management of unstable angina and NSTEMI from NICE’s guideline on acute coronary syndromes. See the guideline at www.nice.org.uk/
guidance/NG185 © NICE 2020. All rights reserved. Subject to Notice of rights.
STEMI: early management
Offer a 300-mg loading dose of aspirin as soon as possible and continue aspirin indefinitely unless contraindicated
Do not offer routine GPIs or fibrinolytic drugs before arrival at the catheter laboratory if primary PCI planned

Immediately assess eligibility (irrespective of age, ethnicity, sex or level of consciousness) for reperfusion therapy
If eligible, offer reperfusion therapy as soon as possible. Otherwise offer medical management

Medical management Reperfusion therapy (primary PCI or fibrinolysis)

Angiography with follow-on primary PCI Fibrinolysis

• Offer if presenting in 12 hours of symptoms and PCI can be delivered in • Offer if presenting in 12 hours of symptoms and PCI
• Offer ticagrelor with 120 mins not possible in 120 mins
aspirin unless high • Consider if presenting more than 12 hours after symptoms and continuing • Give an antithrombin at the same time
bleeding risk myocardial ischaemia or cardiogenic shock • Offer ECG 60-90 mins after fibrinolysis
• Consider clopidogrel • Consider radial in preference to femoral access
with aspirin, or aspirin
alone, for high bleeding
risk
Drug therapy for primary PCI • Offer ticagrelor with aspirin unless high bleeding risk
• Offer prasugrel* with aspirin if not already taking oral anticoagulant • Consider clopidogrel with aspirin, or aspirin alone, for
• Offer clopidogrel with aspirin if taking an oral anticoagulant high bleeding risk
• Offer unfractionated heparin with bailout GPI for radial access
• Consider bivalirudin with bailout GPI if femoral access needed

Offer cardiology assessment *For people aged 75 and over, think about whether risk of bleeding with • Do not repeat fibrinolysis; offer immediate
prasugrel outweighs its effectiveness ; if so offer ticagrelor or clopidogrel as angiography with follow-on PCI if indicated by ECG
alternatives • Seek specialist advice for recurrent myocardial
ischaemia and offer angiography with follow-on PCI if
Stenting and revascularisation appropriate
• If stenting indicated, offer a drug-eluting stent • Consider angiography during same admission if stable
• Offer complete revascularisation (consider doing this in the index after successful fibrinolysis
Assess left ventricular admission) if multivessel coronary artery disease and no cardiogenic shock, • Assess left ventricular function
function but consider culprit only during the index procedure for cardiogenic shock

Cardiac rehabilitation and secondary prevention

This is a summary of the recommendations on early management of STEMI from NICE’s guideline on acute coronary syndromes. See the guideline at www.nice.org.uk/guidance/NG185 © NICE 2020. All rights reserved. Subject to Notice of rights.
Atrial fibrillation: diagnosis and management
Diagnosis
• Perform manual pulse palpation if atrial fibrillation (AF) is suspected
• Perform a 12-lead ECG in people with an irregular pulse, with or without symptoms, to diagnose AF
• If paroxysmal AF is suspected and not detected on ECG, use a 24-hour ambulatory ECG monitor if episodes
<24 hours apart or an ambulatory ECG monitor, event recorder or other ECG technology for an appropriate
period if episodes >24 hours apart

Assessment
• Assess stroke risk using the person’s CHA2DS2-VASc score
• Assess bleeding risk using the person’s ORBIT score. The ORBIT bleeding risk tool has a higher accuracy in
predicting absolute bleeding risk than other tools
• Discuss the results and offer monitoring and support to modify risk factors for bleeding
• Perform transthoracic echocardiography (TTE) if a baseline echocardiogram is important for long-term
management, cardioversion is being considered, underlying heart disease is suspected or if refinement of

Sup p o r t with s h ared d ecis io n makin g an d ad h eren ce

clinical risk stratification for antithrombotic therapy is needed
• Do not routinely perform TTE solely for further stroke risk stratification if anticoagulation has already been

Pers o n alis ed p ackage of care an d info rm at io n

agreed
• Perform transoesophageal echocardiography (TOE) if TTE shows an abnormality needing further assessment,
or if TTE is technically unsuitable and cardiac abnormalities need to be excluded, or if TOE-guided
cardioversion is being considered

Stroke prevention

CHA2DS2-VASc ≥ 2 CHA2DS2-VASc = 1 in men CHA2DS2-VASc ≤ 1 in women or

offer oral anticoagulant consider oral anticoagulant CHA2DS2-VASc = 0 in men
do not offer an anticoagulant

Review at age 65 or if the

person develops diabetes or
cardiovascular comorbidities

Discuss risks and benefits of anticoagulation, including that for most people the benefit of anticoagulation
outweighs the bleeding risk.
Direct-acting anticoagulants (DOACs)
• Offer a DOAC as first-choice anticoagulant
• Discuss choice of DOAC, taking into account clinical features, contraindications and the person’s preference.
Follow guidance in the BNF and the MHRA advice on direct-acting oral anticoagulants
• For people already stable on a vitamin K antagonist, discuss switching at their next routine appointment,
taking into account time in therapeutic range (TTR)
Vitamin K antagonists
• Use a vitamin K antagonist if DOACs are contraindicated or not tolerated
• Calculate the person’s TTR at each visit. Reassess anticoagulation if poorly controlled (2 INR values >5 or
1 INR value >8 or 2 INR values <1.5 in past 6 months or TTR <65%)
• Take into account and address factors that may contribute to poor control
• Discuss the risks and benefits of alternative stroke prevention strategies with the person
Left atrial appendage occlusion
• If anticoagulation is contraindicated or not tolerated consider left atrial appendage occlusion

• Review anticoagulation at least annually for people taking an anticoagulant and follow the MHRA advice on
direct-acting oral anticoagulants
• Review people who are not taking an anticoagulant because of bleeding risk at least annually
Published date: April 2021. This is a summary of the advice on diagnosis and
management in NICE’s guideline on atrial fibrillation. Pages 1 and 3 are new, based on
the updated 2021 guidance. Page 2 is taken from the algorithms in the 2014 guideline.
1
 Rate control strategies (non-acute presentation)

Offer rate control as first-line treatment strategy, unless:

• AF has a reversible cause
• the person has heart failure thought to be caused by AF
• the person has new-onset AF Offer rhythm control
• the person has atrial flutter and their condition is suitable for ablation strategy if suitable for
• a rhythm control strategy is more suitable based on clinical judgement first-line treatment

• Offer a standard beta-blocker (not sotalol) or a rate-limiting calcium-

channel blocker as initial monotherapy unless the person is sedentary or
cannot use other rate-limiting options
• Base drug choice on symptoms, heart rate, comorbidities and preferences

Sup p o r t wi t h s h a red d ecis io n makin g an d ad h e re n ce

• Consider digoxin monotherapy for non-paroxysmal AF only for people
who are sedentary or cannot use other rate-limiting options

Pers o n a l i s ed p ackage of care an d info rmati o n

• Do not offer amiodarone for long-term rate control
• Consider rhythm
• For people with AF and chronic heart failure follow the recommendations
control strategy
in NICE’s guideline on chronic heart failure on beta-blockers and avoiding
if symptoms are
calcium-channel blockers
not controlled with
If monotherapy does not control symptoms and symptoms are thought to be rate control
due to poor ventricular rate control, consider any 2 of the following: • If ineligible for
• a beta-blocker rhythm control see
• diltiazem ablation strategies
• digoxin (page 3)

Rhythm control strategies

Persistent AF Paroxysmal AF

Assess the need for drug therapy for

Duration long-term rhythm control
Duration >48 hours
<48 hours, see
people presenting
acutely with AF Consider a standard beta-blocker (not sotalol)
on page 3 Consider a ‘no drug treatment’ or a ‘pill-in-the-
pocket’ strategy for infrequent paroxysms and
few symptoms, or symptoms induced by known
precipitants
Already on Consider other drugs taking into account
Not on therapeutic
therapeutic comorbidities:
anticoagulants
anticoagulants • amiodarone for people with left ventricular
impairment or heart failure
• dronedarone in line with NICE’s technology
Consider Electrical appraisal guidance on dronedarone for non-
transoesophageal cardioversion permanent AF
echocardiography- (consider Do not offer class 1c antiarrhythmic drugs such as
guided cardioversion amiodarone therapy flecainide or propafenone to people with known
and/or therapeutic 4 weeks before and ischaemic or structural heart disease
anticoagulation for up to 12 months
at least 3 weeks after electrical
before cardioversion cardioversion) If treatment fails, see ablation strategies (page 3)

Refer people promptly (within 4 weeks) at any stage if treatment does not control symptoms
2
 Left atrial ablation and pace and ablate strategies

Symptomatic AF and drug treatment unsuccessful, unsuitable or not tolerated

Left atrial ablation Pace and ablate

• Consider radiofrequency point-by-point ablation • Consider pacing and atrioventricular node ablation
• If radiofrequency point-by-point ablation is for symptomatic permanent AF or left ventricular
unsuitable, consider cryoballoon ablation or laser dysfunction caused by high ventricular rates
balloon ablation • Reassess symptoms and the need for ablation
• Consider left atrial catheter ablation before after pacing and optimising drug treatment
pacing and atrioventricular node ablation for
people with paroxysmal AF or heart failure caused
by non-permanent AF
• Discuss the risks and benefits and take into

Sup p o r t wi t h s h ared d ecis io n makin g an d ad h e re nce

account the person’s preferences. Explain that
ablation is not always effective or long lasting

Pers o n a l i s ed p ackage of care an d info rmati o n

• If other cardiac surgery is planned, consider
carrying out ablation at the same time
• Consider antiarrhythmic drug treatment (see
page 2) after ablation and reassess at 3 months

People presenting acutely with AF

New onset AF with

New onset AF without life-threatening
life-threatening haemodynamic
haemodynamic instability
instability

Carry out emergency electrical If onset <48 hours offer If onset >48 hours or uncertain
cardioversion without delaying to anticoagulation (see below) and offer anticoagulation (see below)
achieve anticoagulation either rate or rhythm control and rate control

If rhythm control is agreed, consider either pharmacological or electrical

cardioversion If acute decompensated heart
failure is suspected, seek senior
If pharmacological cardioversion is agreed, offer: specialist input on using
• a choice of flecainide or amiodarone if no evidence of structural or beta-blockers and do not use
ischaemic heart disease calcium-channel blockers
• amiodarone if evidence of structural heart disease

Anticoagulation for acute presentation of AF

In people with new onset AF who are receiving no or subtherapeutic anticoagulation therapy, offer heparin at
initial presentation and continue until stroke and bleeding risk are assessed (see page 1)
If onset <48 hours, offer oral anticoagulation if:
• stable sinus rhythm is not successfully restored within the same 48 hours after onset or
• there are factors indicating a high risk of recurrence or
• it is recommended after assessment of stroke and bleeding risks (see page 1)
If onset >48 hours and long-term rhythm control is being considered, delay cardioversion until maintained on
therapeutic anticoagulation for at least 3 weeks and offer rate control during this time
If there is uncertainty over the time since onset, offer oral anticoagulation (see page 1)

Refer people promptly (within 4 weeks) at any stage if treatment does not control symptoms
© NICE 2021. All rights reserved. Subject to Notice of rights.
3
Venous thromboembolism: diagnosis and anticoagulation treatment

Suspected DVT: diagnosis and initial management

DVT
suspected Determine 2-level DVT Wells score

Wells score ≥ 2 points Wells score ≤ 1 point 2-level DVT Wells score
DVT likely DVT unlikely Clinical feature Points
Active cancer (treatment ongoing, 1
within 6 months, or palliative)
Paralysis, paresis or recent plaster 1
Quantitative D-dimer test1 with result in 4 hours
immobilisation of lower extremities
Proximal leg vein ultrasound scan within 4 hours or
Recently bedridden for 3 days 1
or Interim therapeutic anticoagulation3-5 while awaiting test result
or more, or major surgery within
• Quantitative D-dimer test if not already done1,2, then 12 weeks requiring general or
• Interim therapeutic anticoagulation3-5 and regional anaesthesia
• Scan within 24 hours D-dimer positive D-dimer negative Localised tenderness along the 1
distribution of the deep venous
system
Entire leg swollen 1
Scan positive Scan negative
Calf swelling at least 3 cm larger 1
than asymptomatic side
Pitting oedema confined to the 1
Diagnose DVT and offer Quantitative D-dimer test if not already done1,2 symptomatic leg
or continue treatment Collateral superficial veins 1
(non-varicose)
D-dimer positive D-dimer negative Stop interim Previously documented DVT 1
anticoagulation6 and An alternative diagnosis is at least -2
think about other as likely as DVT
Stop interim anticoagulation6 and repeat scan 6 to 8 days later diagnoses DVT likely: 2 points or more
DVT unlikely: 1 point or less
Adapted with permission from Wells et al.
(2003)
Second scan positive Second scan negative

1Laboratory or point-of-care test. Consider age-adjusted threshold for people over 50

2Note that only one D-dimer test is needed during diagnosis
3
Measure baseline blood count, renal and hepatic function, PT and APTT but start anticoagulation before results available and review within 24 hours
This is a summary of the recommendations on diagnosis and
4
If possible, choose an anticoagulant that can be continued if DVT confirmed
management from NICE’s guideline on venous thromboembolic diseases.
5
Direct-acting anticoagulants and some LMWHs are off label for use in suspected DVT. Follow GMC guidance on prescribing unlicensed medicines See the original guidance at www.nice.org.uk/guidance/NG158
6
This refers to interim therapeutic anticoagulation only. Do not stop long-term anticoagulation for secondary prevention.
 Suspected PE: diagnosis and initial management

PE
suspected Determine 2-level PE Wells score

Wells score > 4 points Wells score ≤ 4 points 2-level PE Wells score
PE likely PE unlikely Clinical feature Points

Clinical signs and symptoms of DVT 3

(minimum of leg swelling and pain
with palpation of the deep veins)
Quantitative D-dimer test1 and result in 4 hours
An alternative diagnosis is less likely 3
or than PE
Interim therapeutic anticoagulation3-5 while awaiting test result
Heart rate more than 100 beats per 1.5
Immediate CTPA2 (CT pulmonary angiogram) minute
or Immobilisation for more than 3 days 1.5
Interim therapeutic anticoagulation3-5 while awaiting CTPA D-dimer positive D-dimer negative or surgery in previous 4 weeks
Previous DVT/PE 1.5
Haemoptysis 1
CTPA positive CTPA negative Malignancy (on treatment, treated in 1
the last 6 months, or palliative)
PE likely: More than 4 points
Diagnose PE and offer DVT suspected DVT not suspected PE unlikely: 4 points or less
or continue treatment Adapted with permission from Wells et al.
(2000)

Consider proximal leg

Stop interim anticoagulation6 and think about other diagnoses
vein ultrasound scan

Consider outpatient treatment for low-risk PE

1
Laboratory or point-of-care test. Consider age-adjusted threshold for people over 50
2
CT pulmonary angiogram. Assess suitability of V/Q SPECT or V/Q planar scan for allergy, severe renal impairment (CrCl <30 ml/min estimated using the Cockcroft and
Gault formula; see the BNF) or high irradiation risk
3
Measure baseline blood count, renal and hepatic function, PT and APTT but start anticoagulation before results are available and review within 24 hours
4
If possible, choose an anticoagulant that can be continued if PE is confirmed
5
Direct-acting anticoagulants and some LMWHs are off label for use in suspected DVT. Follow GMC guidance on prescribing unlicensed medicines
6
This refers to interim therapeutic anticoagulation only. Do not stop long-term anticoagulation for secondary prevention.
 DVT or PE: anticoagulation

• Measure baseline full blood count, renal and hepatic function, PT and APTT but start anticoagulation before results available.
PE with haemodynamic instability Review and if necessary act on results within 24 hours
Offer continuous UFH infusion and • Offer anticoagulation for at least 3 months. Take into account contraindications, comorbidities and the person’s preferences
consider thrombolytic therapy • After 3 months (3 to 6 months for active cancer) assess and discuss the benefits and risks of continuing, stopping or changing
the anticoagulant with the person. See long-term anticoagulation for secondary prevention in the guideline
Body weight
If body weight <50 kg or >120 kg No renal impairment, active Renal impairment Active cancer Antiphospholipid syndrome
consider anticoagulant with cancer, antiphospholipid (CrCl estimated using the (receiving antimitotic (triple positive, established
monitoring of therapeutic levels. syndrome or haemodynamic Cockcroft and Gault formula; treatment, diagnosed in diagnosis)
Note cautions and requirements for instability see the BNF) past 6 months, recurrent,
dose adjustments and monitoring metastatic or inoperable)
in SPCs. Follow local protocols, or
specialist or MDT advice Offer apixaban or rivaroxaban CrCl 15 to 50 ml/min, offer Consider a DOAC Offer LMWH and a VKA for
one of: at least 5 days or until INR
If neither suitable, offer one of: If a DOAC is not suitable,
• apixaban at least 2.0 on 2 consecutive
• LMWH for at least 5 days consider one of:
INR monitoring • rivaroxaban readings, then a VKA alone
followed by dabigatran or • LMWH
Do not routinely offer • LMWH for at least 5 days then
edoxaban • LMWH and a VKA for at
self-management or self-monitoring – edoxaban or
• LMWH and a VKA for at least 5 days or until INR at
of INR – dabigatran if CrCl
least 5 days, or until INR at least 2.0 on 2 consecutive
≥ 30 ml/min
least 2.0 on 2 consecutive readings, then a VKA alone
• LMWH or UFH and a VKA for
readings, then a VKA alone
Prescribing in renal impairment and at least 5 days, or until INR
Offer anticoagulation for
active cancer at least 2.0 on 2 consecutive
3 to 6 months
Some LMWHs are off label in renal readings, then a VKA alone
Take into account tumour
impairment, and most anticoagulants CrCl < 15 ml/min, offer one of:
site, drug interactions
are off label in active cancer. • LMWH including cancer drugs,
Follow GMC guidance on prescribing • UFH and bleeding risk
unlicensed medicines • LMWH or UFH and a VKA for
at least 5 days, or until INR
at least 2.0 on 2 consecutive
Treatment failure
readings, then a VKA alone
If anticoagulation treatment fails:
• check adherence Note cautions and
• address other sources of requirements for
hypercoagulability dose adjustments and
• increase the dose or change to monitoring in SPCs.
an anticoagulant with a different Follow local protocols, or
mode of action specialist or MDT advice

© NICE 2020. All rights reserved. Subject to Notice of rights.

Atrial fibrillation: diagnosis and management
Diagnosis
• Perform manual pulse palpation if atrial fibrillation (AF) is suspected
• Perform a 12-lead ECG in people with an irregular pulse, with or without symptoms, to diagnose AF
• If paroxysmal AF is suspected and not detected on ECG, use a 24-hour ambulatory ECG monitor if episodes
<24 hours apart or an ambulatory ECG monitor, event recorder or other ECG technology for an appropriate
period if episodes >24 hours apart

Assessment
• Assess stroke risk using the person’s CHA2DS2-VASc score
• Assess bleeding risk using the person’s ORBIT score. The ORBIT bleeding risk tool has a higher accuracy in
predicting absolute bleeding risk than other tools
• Discuss the results and offer monitoring and support to modify risk factors for bleeding
• Perform transthoracic echocardiography (TTE) if a baseline echocardiogram is important for long-term
management, cardioversion is being considered, underlying heart disease is suspected or if refinement of

Sup p o r t with s h ared d ecis io n makin g an d ad h eren ce

clinical risk stratification for antithrombotic therapy is needed
• Do not routinely perform TTE solely for further stroke risk stratification if anticoagulation has already been

Pers o n alis ed p ackage of care an d info rm at io n

agreed
• Perform transoesophageal echocardiography (TOE) if TTE shows an abnormality needing further assessment,
or if TTE is technically unsuitable and cardiac abnormalities need to be excluded, or if TOE-guided
cardioversion is being considered

Stroke prevention

CHA2DS2-VASc ≥ 2 CHA2DS2-VASc = 1 in men CHA2DS2-VASc ≤ 1 in women or

offer oral anticoagulant consider oral anticoagulant CHA2DS2-VASc = 0 in men
do not offer an anticoagulant

Review at age 65 or if the

person develops diabetes or
cardiovascular comorbidities

Discuss risks and benefits of anticoagulation, including that for most people the benefit of anticoagulation
outweighs the bleeding risk.
Direct-acting anticoagulants (DOACs)
• Offer a DOAC as first-choice anticoagulant
• Discuss choice of DOAC, taking into account clinical features, contraindications and the person’s preference.
Follow guidance in the BNF and the MHRA advice on direct-acting oral anticoagulants
• For people already stable on a vitamin K antagonist, discuss switching at their next routine appointment,
taking into account time in therapeutic range (TTR)
Vitamin K antagonists
• Use a vitamin K antagonist if DOACs are contraindicated or not tolerated
• Calculate the person’s TTR at each visit. Reassess anticoagulation if poorly controlled (2 INR values >5 or
1 INR value >8 or 2 INR values <1.5 in past 6 months or TTR <65%)
• Take into account and address factors that may contribute to poor control
• Discuss the risks and benefits of alternative stroke prevention strategies with the person
Left atrial appendage occlusion
• If anticoagulation is contraindicated or not tolerated consider left atrial appendage occlusion

• Review anticoagulation at least annually for people taking an anticoagulant and follow the MHRA advice on
direct-acting oral anticoagulants
• Review people who are not taking an anticoagulant because of bleeding risk at least annually
Published date: April 2021. This is a summary of the advice on diagnosis and
management in NICE’s guideline on atrial fibrillation. Pages 1 and 3 are new, based on
the updated 2021 guidance. Page 2 is taken from the algorithms in the 2014 guideline.
1
 Rate control strategies (non-acute presentation)

Offer rate control as first-line treatment strategy, unless:

• AF has a reversible cause
• the person has heart failure thought to be caused by AF
• the person has new-onset AF Offer rhythm control
• the person has atrial flutter and their condition is suitable for ablation strategy if suitable for
• a rhythm control strategy is more suitable based on clinical judgement first-line treatment

• Offer a standard beta-blocker (not sotalol) or a rate-limiting calcium-

channel blocker as initial monotherapy unless the person is sedentary or
cannot use other rate-limiting options
• Base drug choice on symptoms, heart rate, comorbidities and preferences

Sup p o r t wi t h s h a red d ecis io n makin g an d ad h e re n ce

• Consider digoxin monotherapy for non-paroxysmal AF only for people
who are sedentary or cannot use other rate-limiting options

Pers o n a l i s ed p ackage of care an d info rmati o n

• Do not offer amiodarone for long-term rate control
• Consider rhythm
• For people with AF and chronic heart failure follow the recommendations
control strategy
in NICE’s guideline on chronic heart failure on beta-blockers and avoiding
if symptoms are
calcium-channel blockers
not controlled with
If monotherapy does not control symptoms and symptoms are thought to be rate control
due to poor ventricular rate control, consider any 2 of the following: • If ineligible for
• a beta-blocker rhythm control see
• diltiazem ablation strategies
• digoxin (page 3)

Rhythm control strategies

Persistent AF Paroxysmal AF

Assess the need for drug therapy for

Duration long-term rhythm control
Duration >48 hours
<48 hours, see
people presenting
acutely with AF Consider a standard beta-blocker (not sotalol)
on page 3 Consider a ‘no drug treatment’ or a ‘pill-in-the-
pocket’ strategy for infrequent paroxysms and
few symptoms, or symptoms induced by known
precipitants
Already on Consider other drugs taking into account
Not on therapeutic
therapeutic comorbidities:
anticoagulants
anticoagulants • amiodarone for people with left ventricular
impairment or heart failure
• dronedarone in line with NICE’s technology
Consider Electrical appraisal guidance on dronedarone for non-
transoesophageal cardioversion permanent AF
echocardiography- (consider Do not offer class 1c antiarrhythmic drugs such as
guided cardioversion amiodarone therapy flecainide or propafenone to people with known
and/or therapeutic 4 weeks before and ischaemic or structural heart disease
anticoagulation for up to 12 months
at least 3 weeks after electrical
before cardioversion cardioversion) If treatment fails, see ablation strategies (page 3)

Refer people promptly (within 4 weeks) at any stage if treatment does not control symptoms
2
 Left atrial ablation and pace and ablate strategies

Symptomatic AF and drug treatment unsuccessful, unsuitable or not tolerated

Left atrial ablation Pace and ablate

• Consider radiofrequency point-by-point ablation • Consider pacing and atrioventricular node ablation
• If radiofrequency point-by-point ablation is for symptomatic permanent AF or left ventricular
unsuitable, consider cryoballoon ablation or laser dysfunction caused by high ventricular rates
balloon ablation • Reassess symptoms and the need for ablation
• Consider left atrial catheter ablation before after pacing and optimising drug treatment
pacing and atrioventricular node ablation for
people with paroxysmal AF or heart failure caused
by non-permanent AF
• Discuss the risks and benefits and take into

Sup p o r t wi t h s h ared d ecis io n makin g an d ad h e re nce

account the person’s preferences. Explain that
ablation is not always effective or long lasting

Pers o n a l i s ed p ackage of care an d info rmati o n

• If other cardiac surgery is planned, consider
carrying out ablation at the same time
• Consider antiarrhythmic drug treatment (see
page 2) after ablation and reassess at 3 months

People presenting acutely with AF

New onset AF with

New onset AF without life-threatening
life-threatening haemodynamic
haemodynamic instability
instability

Carry out emergency electrical If onset <48 hours offer If onset >48 hours or uncertain
cardioversion without delaying to anticoagulation (see below) and offer anticoagulation (see below)
achieve anticoagulation either rate or rhythm control and rate control

If rhythm control is agreed, consider either pharmacological or electrical

cardioversion If acute decompensated heart
failure is suspected, seek senior
If pharmacological cardioversion is agreed, offer: specialist input on using
• a choice of flecainide or amiodarone if no evidence of structural or beta-blockers and do not use
ischaemic heart disease calcium-channel blockers
• amiodarone if evidence of structural heart disease

Anticoagulation for acute presentation of AF

In people with new onset AF who are receiving no or subtherapeutic anticoagulation therapy, offer heparin at
initial presentation and continue until stroke and bleeding risk are assessed (see page 1)
If onset <48 hours, offer oral anticoagulation if:
• stable sinus rhythm is not successfully restored within the same 48 hours after onset or
• there are factors indicating a high risk of recurrence or
• it is recommended after assessment of stroke and bleeding risks (see page 1)
If onset >48 hours and long-term rhythm control is being considered, delay cardioversion until maintained on
therapeutic anticoagulation for at least 3 weeks and offer rate control during this time
If there is uncertainty over the time since onset, offer oral anticoagulation (see page 1)

Refer people promptly (within 4 weeks) at any stage if treatment does not control symptoms
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