GEMC- Approach to Bradycardias and Tachycardias-for Residents
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GEMC- Approach to Bradycardias and Tachycardias-for Residents

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This is a lecture by Rockefeller Oteng from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the......

This is a lecture by Rockefeller Oteng from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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  • 1. Project: Ghana Emergency Medicine Collaborative Document Title: Approach to Bradycardias and Tachycardias Author(s): Rockefeller Oteng (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1  
  • 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. 2   To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
  • 3. Bradycardia   James Heilman, MD, Wikimedia Commons 3  
  • 4. Brady-­‐   Arrhythmias   BRADYCARDIA Heart Rate <60 bpm and inadequate for clinical condition -  Maintain patient airway; assist breathing as needed -  Give oxygen -  Monitor EKG (id rhythm), blood pressure, oximetry -  Establish IV access REMINDERS -  If pulseless arrest, go to pulseless arrest algorithm -  Search for and treat possible contributing factors: 1 Observe/Monitor Poor perfusion 4A -  Prepare for transvenous pacing -  Treat contributing causes -  Consider expert consultation 5 Hypovolemia - Toxins Hypoxia - Tamponade, cardiac H+ ion (acidosis) - Tension pneumothorax Hypo/hyperkalemia - Thrombosis (coronary/pulmonary) Hypoglycemia - Trauma (hypovolemia/ñICP) Hypothermia 2 Signs or symptoms of poor perfusion caused by the bradycardia? (e.g. acute altered mental status, ongoing chest pain, hypotension, or other signs of shock? Adequate perfusion -  -  -  -  -  -  3 -  Prepare for transcutaneous pacing -  Consider atropine -  Consider epinephrine or dopamine 4 4  
  • 5. Unstable/Poor  Perfusion   Poor perfusion -  Prepare for transcutaneous pacing -  Consider atropine -  Consider epinephrine or dopamine -  Prepare for transvenous pacing -  Treat contributing causes -  Consider expert consultation 4 5 5  
  • 6. Geo Swan, Wikimedia Commons 6  
  • 7. Reminders   •  If  pulseless  arrest  develops,  go  to  pulseless  arrest  algorithm   •  Search  for  and  treat  possible  contribuHng  factors:     Hypovolemia     Toxins  (drugs)   Tamponade  (cardiac)   Hypoxia   Tension  PTX   Hydrogen  ion  (acidosis)   Thrombosis  (coronary  or  pulmonary)   Hypo/hyperkalemia   Trauma  (hypovolemia,  increased  ICP)   Hypoglycemia   Hypothermia   7  
  • 8. Tachy-­‐   Arrhythmias   TACHYCARDIA With Pulses -  -  -  -  NOTE: If patient becomes unstable at any point, go to Box 4 -  Establish IV access -  Obtain 12 lead EKG -  Is QRS narrow (<0.12 sec)? 5 Regular -  Attempt vagal maneuvers -  Give adenosine IV push -  Irregular Narrow Complex Tachycardia -  Likely: A. fib, A. flutter, MAT -  6 Consider: expert consult, Bblockers to control HR 11 Does rhythm convert? Consider: expert consult Converts 8 Does Not Convert -  Likely reentry SVT * Observe for recurrence * Treat recurrence with adenosine, diltiazem, B-blockers 6 Irregular 7 9 1 Treat possible contributing factors: -  Hypovolemia - Toxins -  Hypoxia - Tamponade, cardiac -  H+ ion (acidosis) - Tension pneumothorax -  Hypo/hyperkalemia - Thrombosis (coronary/ pulmonary) -  Hypoglycemia - Trauma (hypovolemia/ñICP) -  Hypothermia Assess and support ABC’s Give oxygen Monitor EKG, blood pressure, oximetry 2 Id and treat reversible causes Symptoms persist Stable Unstable Is patient stable? 3 Wide QRS Narrow QRS NARROW QRS-> is rhythm REGULAR? During evaluation: -  Secure and verify airway and vascular access -  Consider expert consult -  Prepare for cardioversion Perform immediate, synchronized cardioversion WIDE QRS -> is rhythm REGULAR? 12 Regular -  If V. tachycardia or uncertain rhythm: * Amiodarone * Synchronized cardioversion -  If SVT with aberrancy: * Adenosine (Box 7) 13 -  Likely A. flutter, ectopic atrial tachycardia, or junctional tachycardia -  Consider diltiazem and Bblockers to control HR -  Treat underlying cause -  Consider expert consult 10 4 Irregular -  If A. fibrillation with aberrancy: * See Box 11 -  If pre-excited A. fibrillation: * Expert consult advised * Avoid adenosine, digoxin, diltiazem, verapamil * Consider amiodarone -  If recurrent polymorphic VT * Seek expert consult -  If torsades de pointes * Give magnesium 14 8  
  • 9. Stable  or  Unstable?   Narrow  or  Wide?   TACHYCARDIA With Pulses 1 -  Assess and support ABC’s -  Give oxygen -  Monitor EKG, blood pressure, oximetry -  Id and treat reversible causes -  Establish IV access -  Obtain 12 lead EKG -  Is QRS narrow (<0.12 sec)? 5 Narrow QRS 2 Symptoms persist Stable Is patient stable?3 Wide QRS Unstable Perform immediate, synchronized cardioversion WIDE QRS -> is rhythm REGULAR? 4 12 9  
  • 10. Stable  and  Narrow   Wide QRS Narrow QRS WIDE QRS -> is rhythm REGULAR? 12 NARROW QRS-> is rhythm REGULAR? 6 -  Attempt vagal maneuvers -  Give adenosine IV push 7 Regular Does rhythm convert? Consider: expert consult Converts Irregular 8 -  Irregular Narrow Complex Tachycardia -  Likely: A. fib, A. flutter, MAT -  Consider: expert consult, B-blockers to 11 control HR Does Not Convert 10  
  • 11. SVT  –  Mechanism   Reentry via accessory pathway A) Normal conduction B) PAC C) Orthodromic reentrant pathway 11  
  • 12. SVT  –  Mechanism   •  AV nodal reentrant circuit - 60% •  Atrio-ventricular reentrant circuit w/ accessory pathway - 30% •  Atrial tachycardia – 10% •  Other rare forms: Sinus-node reentrant tachycardia, inappropriate sinus tachycardia, ectopic junctional tachycardia, and non-paroxysmal junctional tachycardia. 12  
  • 13. SVT  -­‐  Treatment   •  •  •  •  Adenosine: –  6 mg - termination in 60-80% –  12 mg - termination in 90-95% –  Contraindicated in heart transplant, COPD/asthma, and wide complex tachycardia (unless 100% certain is SVT w/ aberrancy) –  Avoid with evidence of pre-excitation Beta blockers or Ca++ channel blockers - contraindicated in antidromic WPW Last resort: procainamide, ibutilide, propafenone, or flecainide If unstable - electricity! 13  
  • 14. SVT  -­‐     Treatment  w/  Adenosine   Displaced, Wikimedia Commons 14  
  • 15. Aer  Adenosine   Converts -  Likely A. flutter, ectopic atrial tachycardia, or junctional tachycardia -  Consider diltiazem and Bblockers to control HR -  Treat underlying cause -  Consider expert consult 10 Does Not Convert -  Likely reentry SVT * Observe for recurrence * Treat recurrence with adenosine, diltiazem, B-blockers 9 15  
  • 16. Stable  and  Wide   Regular  or     Irregular?   WIDE QRS -> is rhythm REGULAR? Wide QRS Regular -  If V. tachycardia or uncertain rhythm: * Amiodarone * Synchronized cardioversion -  If SVT with aberrancy: * Adenosine (Box 7) 13 12 Irregular -  If A. fibrillation with aberrancy: * See Box 11 -  If pre-excited A. fibrillation: * Expert consult advised * Avoid adenosine, digoxin, diltiazem, verapamil * Consider amiodarone -  If recurrent polymorphic VT: * Seek expert consult -  If torsades de pointes: * Give magnesium 16   14
  • 17. Wide  Complex  Tachycardia   Steven Fruitsmaak, Wikimedia Commons Afib  with  LBBB   17  
  • 18. Wide  Complex  Tachycardia   •  •  Stable –  Amiodarone 150 mg over 10 min or other anti-arrhythmics –  Prepare for synchronized cardioversion Unstable –  ABC’s/Call for help/Start CPR –  Defibrillate: Biphasic 120-200 J (When in doubt pick 200 J), monophasic 360 J –  Epinephrine 1 mg IV q3-5 min –  Vasopressin 40 Units IV –  May try amiodarone or lidocaine after 3 attempts at defibrillation •  Amiodarone 300 mg, may repeat w/ 150 mg x1 •  Lidocaine 1-1.5 mg/kg, then 0.5-0.75 mg/kg, max is 3 mg/kg 18  
  • 19. H’s  and  T’s   During  EvaluaHon   •  Secure,  verify   airway  and   vascular  access   when  possible   •  Consider  expert   consultaHon   •  Prepare  for   cardioversion     Treat  contribuHng  factors:   Toxins  (drugs)   Tamponade  (cardiac)   Hypoxia   Tension  PTX   Hydrogen  ion  (acidosis)   Thrombosis  (coronary/ pulmonary)   Hypo/hyperkalemia   Trauma   Hypoglycemia   Hypovolemia   Hypothermia     19  
  • 20. Review   20  
  • 21. Bradycardias   Tx  of  Bradycardias   •  Stable   –  MI   –  Adequate  perfusion?   –  Monitor  BP!!     •  Unstable   –  Poor  perfusion   –  Immediate  transcutaneous  pacing   –  Consider  atropine  while  awaiHng  pacer,  0.5-­‐1.0  mg   –  Consider  epi  or  dopamine  if  pacing  ineffecHve   21  
  • 22. Tachycardia’s   Stable  vs.  Unstable   •  Stable   – MI   – 12  lead   – Narrow  complex   – Wide  complex   – Treat  causes   •  Unstable   – Altered  MS   – CP   – Hypotension   – Signs  of  shock   •  H’s  and  T’s   22  
  • 23. Tx  of  Stable  Tachycardias   •  A-­‐fib/fluger   –  DilHazem  (Ca++  channel  blocker)   –  Consider  cardioversion   •  SVT   –  Vagal  maneuvers   –  Adenosine   •  6  mg  then  12  mg  then  12  mg   •  V-­‐Tach  (WITH  PULSE)   –  AnHarrhythmic:  Lidocaine,  Amiodarone,  (Mg+  for   torsades)   23  
  • 24. Tx  of  Unstable  Tachycardias   •  Stable   –  Amiodarone  150  mg  over  10  min  or  other  anH-­‐ arrhythmics   –  Prepare  for  synchronized  cardioversion   •  Perform  immediate  synchronized  cardioversion   –  MI   –  Sedate  if  conscious   –  DO  NOT  DELAY  CARDIOVERSION   24  
  • 25. ContribuHng  Factors     H’s  and  T’s   •  •  •  •  •  •  •  •  •  •  •  Hypovolemia   Hypoxia   Hydrogen  ion  (acidosis)   Hypo/hyperkalemia   Hypoglycemia   Hypothermia   Toxins  (drugs)   Tamponade  (cardiac)   Tension  PTX   Thrombosis  (coronary  or  pulmonary)   Trauma   25