Case History of an unusual arrythmia

1. Case
Malignant Arrythmia?

2. 30 year old Male
● PC Palpitations
● HPC Awoke at 6 am with palpitations
Sensation in chest, flutters, irregular with the
occassional heavy beat
No Chest pain, dizziness or sob but felt
slightly ill at ease
Otherwise well

3. Further Questioning
● Previous episodes over 10 – 15 years
● Spontaneous in onset and offset, usually short
lived
● One episode lead to visit to A and E spontaneous
resolution ? Sensitive to caffeine
● No episodes for a few years
● No ppt factors
● No tricks for termination

4. Past Medical History
● Nil of Note
● Non Smoker
● No illlicit drugs
● Alcohol – Occasional binges
Last binge 2 /52 prior
● No Meds
● No FHx

5. Examination
● Alert, orientated amd comfortable
● HR 230 – 250. BP 145/88. sats 98. rr 14
● Jvp – large 'a waves'
● Apyrexial slightly flushed
● Chest clear

6. Approach to Arrythmias
● IV, O2, Monitor,Defib, airway equipment
● Stable or unstable
● P waves?
● Regular or irregular
● Narrow or wide
● All antiarrythmixs are pro-arrythmic
● Drug with shortest half-life and short term effects =
electricity

7. Stable or Unstable
● Not dichotomous
● Altered Mental Status
● Pulmonary oedema
● Chest Pain
● Hypotension
● Grey v Pink

8. P waves
● Not necessarily sinus
● ?normal p wave axis ( pos in 11, neg in AVR)
● Multiple morphology
● Retrograde
● Fusion
● Saw toothed
● 1:1. 1:2 etc

9. Regular or Irregular
●
Regular ≠ Sinus
● SVT = exquisitly regular
● Irregular = above the AV Node
= block AV Node
= not VT

10. Narrow or Wide Complexes
● Narrow = supraventricular
= not Ventricular tachycardia (very rare)
= Regular or irregular
= block the AV node
= 0.12 secs (3 small squares) 0.08 in kids
● Wide = supraventricular or ventricular
= Regular or irregular

11. 4 Arrythmia Groups
● Narrow Regular
● Narrow Irregular
● Wide Regular
● Wide Irregular

12. Narrow, Regular
● PSVT
● Atrial Flutter with consistent non variable block
● Orthodromic WPW
● Very rarely narrow complex VT
● Rx Adenosine, verapamil
(others esmolol, diltiazem, magnesium,
● Unstable = adenosine, sync dc shock 50j aliquots

13. Narrow, Irregular
● Atrial Fibrillation
● Atrial Flutter with variable block
● Multifocal atrial tachycardia
● Rx rate or rhythmn control
● Calcium channel blockers (diltiazem), digoxin,
amiodarone, magnesium, BBlockers

14. Wide, Regular
● Ventricular Tachycardia
● Ventricular Tachycardia
● Ventricular Tachycardia
● Supraventricular Tachycardia with aberrancy/rate
related block
● Antidromic WPW

15. Ventricular Tachycardia
● Predictors of VT – old age, CAD, ECG Criteria
● Brugada's criteria for VT on ECG, rsR' in v1
● Fusion beats, Capture Beats
● Rx Magnesium, Procainamide, Amiodarone,
DC Cardioversion

16. Wide, Irregular, no P waves
● AF with bundle branch block
● Atrial Flutter variable block and bundle branch
block
● WPW antidromic and atrial fibrillation