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Cardiac arrhythmia1.ppt3

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  • 1. Life threatening cardiacarrhythmias- Restoring life Dr. Shankar Hippargi Consultant Dept. of Accident & Emergency Medicine
  • 2. Objectives• To identify and treat • Tachycardias • Premature ventricular contractions • AV blocks (bradycardias)
  • 3. Normal conduction
  • 4. Tachycardia• Narrow complex • Broad complex – Sinus tachycardia – Ventricular tachycardia – Atrial fibrillation – Ventricular fibrillation – Atrial flutter – Torsades de pointes – Multifocal atrial tachycardia – Re-entry tachycardia (SVT)
  • 5. Sinus tachycardia• Regular• Narrow QRS• Always secondary to some cause (anxiety, pain, hypovolumia, fever etc.)• Identify and treat the cause
  • 6. Atrial fibrillation• Irregularly irregular• Atrial rate >400, ventricular rate 170- 180/min• Narrow QRS complex• No definite P waves• No isoelectric line
  • 7. Atrial Fibrillation- Treatment• If acute or patient is unstable do synchronized cardioversion with 50J• Control ventricular rate with Diltiazem 0.25mg/kg, Verapamil 5mg, Metaprolol 25mg, Digoxin 0.5mg• If >2 days (onset not known) do ECHO to R/O thrombus in atrium• If no clot Cardioversion with 50J• If there is a clot anti coagulate for 1-3 weeks
  • 8. Atrial flutterRegularAtrial rate 250-350/minFlutter waves (saw tooth appearance)AV block (2:1, 3:1)
  • 9. Atrial flutter• This may progress into atrial fibrillation• Treatment is similar to atrial fibrillation
  • 10. Multifocal atrial tachycardia (MAT)
  • 11. Multifocal atrial tachycardia (MAT)• Wandering pacemaker• Irregularly irregular• Each P-wave is different in morphology• Narrow QRS complex• Standard anti arrhythmic agents ineffective• Cardioversion has no effect• Magnesium sulfate 2gm iv over 1 min, and infusion at 1-2gm/hr• Maintain K+ level above 4mEq/lt• Verapamil 5-10mg to control ventricular rate
  • 12. Re-entry tachycardia (SVT)
  • 13. Re-entry tachycardia (SVT) • Regular • Narrow QRS • Rate > 150/min • P waves will be either absent, inverted, or seen after QRS
  • 14. Re-entry tachycardia (SVT)• Carotid massage 10 sec (caution)• Valsalva maneuver• Facial immersion in cold water 6-7 sec• Adenosine 6mg rapid IV push (ultra short acting), repeat dose 12mg• Verapamil 5mg slow IV• Diltiazem 0.25mg/kg slow IV• Synchronized cardioversion with 50J
  • 15. Monomorphic VT
  • 16. Monomorphic VT• More than 3 consecutive PVC• Regular• Rate >100/min• Broad QRS complex (>3 small squares)• Each QRS similar in shape
  • 17. Monomorphic VT• If unstable (pulseless) A&E(SRMC) – Start CPR, defibrillate with 200J biphasic or 360J monophasic, resume CPR for 2 min, reassess the rhythm – Adrenaline 1mg, Amiodarone 300mg or Lidocaine 50-75mg and re attempt defibrillation – Defibrillation can be continued as long as there is shockable rhythm
  • 18. Monomorphic VT• Stable VT (with pulse) – Amiodarone 150mg slow iv over 10min, followed by infusion at 1mg/min for 6 hours and 0.5mg/min for next 18 hours – Alternatively Lidocaine 1-1.5mg/kg bolus and infusion at 1-4mg/min – Synchronized Cardioversion with 100J
  • 19. Polymorphic VT
  • 20. Polymorphic VT• Irregularly irregular• QRS wide• Each QRS different from others• May progress to VF• Treatment same as VF
  • 21. Torsades de pointes• Twisting of points• Special variant of polymorphic VT• Magnesium sulfate 2gm in 10ml DNS over 2-3 min, followed by infusion at 1-2gm/hr• Temporary pacing may abolish TdP
  • 22. Ventricular fibrillationCoarse Vfib Fine Vfib A&E(SRMC)
  • 23. Ventricular fibrillation• Irregularly irregular• Wide and varying QRS• Disorganized• Incompatible with life (cannot produce CO)• Its important to differentiate fine Vfib from asystole
  • 24. Ventricular fibrillation• Start CPR immediately, shock with 200J biphasic or 360J monophasic• Resume CPR for 2 min (don’t look at monitor)• Adrenaline 1mg, Amiodarone 300mg or Lidocaine 75mg• Assess rhythm, if Vfib persists shock and resume CPR for 2 min (repeat the cycle)
  • 25. Premature ventricular contractions• Occasional PVC• Bigeminy• Trigeminy• Couplet• Triplet
  • 26. Occasional PVC
  • 27. Bigeminy Trigeminy
  • 28. CoupletTriplet
  • 29. AV blocks• First degree AV block• Second degree AV block – Mobitz type 1 (Wenckebach) – Mobitz type 2• Third degree AV block (complete heart block)
  • 30. First degree AV block• Regular• Prolonged PR interval (>5 small squares)• Narrow QRS• No treatment required
  • 31. Second degree Type 1(wenckebach) • Regularly Irregular • Progressively increasing PR interval until 1 QRS is dropped, and the cycle repeats • QRS narrow • Reversible • No treatment if asymptomatic • If symptomatic give atropine 0.5mg, repeat every 3 min (max 3mg) • Temporary pacing
  • 32. Second degree Type 2• Irregularly irregularly• Constant PR interval, narrow/wide QRS• QRS dropped irregularly• Irreversible• May progress to complete block• Atropine 0.5mg repeated every 3min (max 3mg), may not be effective• Permanent pacing
  • 33. Third degree (complete) AV block• Regular P-P interval and R-R interval• More P waves than QRS• QRS usually wide, but may be narrow• Atropine not effective• Permanent pacing