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Cardiac arrhythmia1.ppt3

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Cardiac arrhythmia1.ppt3

  1. 1. Life threatening cardiacarrhythmias- Restoring life Dr. Shankar Hippargi Consultant Dept. of Accident & Emergency Medicine
  2. 2. Objectives• To identify and treat • Tachycardias • Premature ventricular contractions • AV blocks (bradycardias)
  3. 3. Normal conduction
  4. 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. 5. Sinus tachycardia• Regular• Narrow QRS• Always secondary to some cause (anxiety, pain, hypovolumia, fever etc.)• Identify and treat the cause
  6. 6. Atrial fibrillation• Irregularly irregular• Atrial rate >400, ventricular rate 170- 180/min• Narrow QRS complex• No definite P waves• No isoelectric line
  7. 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. 8. Atrial flutterRegularAtrial rate 250-350/minFlutter waves (saw tooth appearance)AV block (2:1, 3:1)
  9. 9. Atrial flutter• This may progress into atrial fibrillation• Treatment is similar to atrial fibrillation
  10. 10. Multifocal atrial tachycardia (MAT)
  11. 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. 12. Re-entry tachycardia (SVT)
  13. 13. Re-entry tachycardia (SVT) • Regular • Narrow QRS • Rate > 150/min • P waves will be either absent, inverted, or seen after QRS
  14. 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. 15. Monomorphic VT
  16. 16. Monomorphic VT• More than 3 consecutive PVC• Regular• Rate >100/min• Broad QRS complex (>3 small squares)• Each QRS similar in shape
  17. 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. 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. 19. Polymorphic VT
  20. 20. Polymorphic VT• Irregularly irregular• QRS wide• Each QRS different from others• May progress to VF• Treatment same as VF
  21. 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. 22. Ventricular fibrillationCoarse Vfib Fine Vfib A&E(SRMC)
  23. 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. 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. 25. Premature ventricular contractions• Occasional PVC• Bigeminy• Trigeminy• Couplet• Triplet
  26. 26. Occasional PVC
  27. 27. Bigeminy Trigeminy
  28. 28. CoupletTriplet
  29. 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. 30. First degree AV block• Regular• Prolonged PR interval (>5 small squares)• Narrow QRS• No treatment required
  31. 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. 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. 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

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