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ECG emergencies

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Including the ACLS protocols of tachycardia, bradycardia ...

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ECG emergencies

  1. 1. ECG EMERGENCIES
  2. 2. Outline Narrow complex tachycardia Wide complex tachycardia Bradycardia Asystole Pulseless Electrical Activity Myocardial Infarction
  3. 3. Answer Sinus Tachycardia – physiologic response to a stressor Stressors include: hypoxia, hypovolemia, fever, anxiety, pain, hyperthyroidism, and exercise. Certain drugs, such as stimulants (eg, nicotine, caffeine), medications (eg, atropine, salbutamol), recreational drugs (eg, cocaine, amphetamines, ecstasy), and hydralazine, can also induce the condition Rx; address the underlying stressor
  4. 4. Answer: Atrial flutter – “sawtooth” pattern Rx – tachycardia algorithm If the patient is hypotensive or unstable, immediate cardioversion with sedation must be performed. If the patient is stable, vagal maneuvers can be used to slow the heart rate and to convert to sinus rhythm. If vagal maneuvers are not successful, adenosine can be used in increasing doses. If adenosine does not work, atrioventricular (AV) nodal blocking agents like calcium channel blockers or beta-blockers should be used, as most patients who present with PSVT have AV nodal reentrant tachycardia (AVNRT) or AV reentrant tachycardia (AVRT). These arrhythmias depend on AV nodal conduction and therefore can be terminated by transiently blocking this conduction Since atrial fibrillation and atrial flutter increase risk of stroke or cerebrovascular accidents, anticoagulation is usually recommended.
  5. 5. Date of download: 2/16/2016 Copyright © The American College of Cardiology. All rights reserved. From: ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias —executive summary: a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee∗ for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) Developed in Collaboration with NASPE-Heart Rhythm Society J Am Coll Cardiol. 2003;42(8):1493-1531. doi:10.1016/j.jacc.2003.08.013 Management of atrial flutter depending on hemodynamic stability. Attempts to electively revert atrial flutter to sinus rhythm should be preceded and followed by anticoagulant precautions, as per AF. AF indicates atrial fibrillation; AV, atrioventricular; CHF, congestive heart failure; DC, direct current; MI, myocardial infarction. Figure Legend:
  6. 6. Vagal maneuvers
  7. 7. Answer Atrial fibrillation - chaotic atrial depolarization Treatment goals include the following: 1.Conversion to normal sinus rhythm 2.Keeping the patient in normal sinus rhythm 3.Control of ventricular rate 4.Preventing thromboembolic disease Beta-blockers and calcium channel blockers are first-line agents for rate control in AF. These drugs can be administered either intravenously or orally. Patients with newly diagnosed AF and patients awaiting electrical cardioversion can be started on intravenous heparin (activated partial thromboplastin time [aPTT] of 45-60 seconds) or low- molecular-weight heparin (1 mg/kg bid).
  8. 8. Answer AVNRT - AVNRT occurs when a reentrant circuit is present within the AV node itself. In this situation, there are two separate conduction pathways within the AV node instead of just one (present in about 5% of the general population). This is sometimes termed “dual AV nodal physiology”. One pathway is slower and has a short refractory period while the other is faster and has a long refractory period. Normal conduction occurs through the faster pathway with the long refractory period. If a premature atrial contraction (PAC) or less commonly a premature ventricular contraction (PVC) occurs at the right time, the normal conduction pathway will still be refractory, so the action potential will conduct through the fast AV nodal pathway with the shorter refractory period instead. After this action potential reaches the ventricles or atrium, it will conduct back through the normal AV nodal conduction pathway since it will no longer be refractory and a reentrant circuit will be created.
  9. 9. Date of download: 2/16/2016 Copyright © The American College of Cardiology. All rights reserved. From: ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias —executive summary: a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of∗ cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) Developed in Collaboration with NASPE-Heart Rhythm Society J Am Coll Cardiol. 2003;42(8):1493-1531. doi:10.1016/j.jacc.2003.08.013 Differential diagnosis for narrow QRS tachycardia. Patients with focal junctional tachycardia may mimic the pattern of slow-fast AVNRT and may show AV dissociation and/or marked irregularity in the junctional rate. AV indicates atrioventricular; AVNRT, atrioventricular nodal reciprocating tachycardia; AVRT, atrioventricular reciprocating tachycardia; MAT, multifocal atrial tachycardia; ms, milliseconds; PJRT, permanent form of junctional reciprocating tachycardia; QRS, ventricular activation on ECG. Figure Legend:
  10. 10. Date of download: 2/16/2016 Copyright © The American College of Cardiology. All rights reserved. From: ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias —executive summary: a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of∗ cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) Developed in Collaboration with NASPE-Heart Rhythm Society J Am Coll Cardiol. 2003;42(8):1493-1531. doi:10.1016/j.jacc.2003.08.013 Responses of narrow complex tachycardias to adenosine. AT indicates atrial tachycardia; AV, atrioventricular; AVNRT, atrioventricular nodal reciprocating tachycardia; AVRT, atrioventricular reciprocating tachycardia; IV, intravenous; QRS, ventricular activation on ECG; VT, ventricular tachycardia. Figure Legend:
  11. 11. Answer Ventricular tachycardia Rx - VT associated with loss of consciousness or hypotension is a medical emergency necessitating immediate cardioversion. In a normal-sized adult, this is typically accomplished with a 100- to 200-J biphasic cardioversion shock administered according to standard Advanced Cardiovascular Life Support (ACLS) protocols Pulseless VT, in contrast to other unstable VT rhythms, is treated with immediate defibrillation. Shock administration should be followed by immediate chest compressions, airway management with supplemental oxygen, and vascular access with administration of vasopressors.
  12. 12. Answer Ventricular Fibrillation Electrical external defibrillation remains the most successful treatment of ventricular fibrillation (VF). A shock is delivered to the heart to uniformly and simultaneously depolarize a critical mass of the excitable myocardium. The objective is to interfere with all reentrant arrhythmia and to allow any intrinsic cardiac pacemakers to assume the role of primary pacemaker AHA algorithm (refer previous slide) Lack of response to standard defibrillation algorithms is challenging. After initial amiodarone bolus, consider continued amiodarone therapy with 1 mg/min IV for 6 hours, then 0.5 mg/min for 18 hours. If ongoing ischemia is the suspected cause of recurrent VF, consider emergent cardiac catheterization and possible angioplasty even in the absence of STEMI, and intra-aortic balloon pump placement. For patients with prolonged and refractory inhospital cardiogenic arrest that included VF/VT, it has been shown that extracorporeal cardiopulmonary resuscitation was associated with improved neurologically intact survival.This study was performed in a large tertiary center with an ongoing protocol for this advanced experimental care.
  13. 13. Date of download: 2/16/2016 Copyright © The American College of Cardiology. All rights reserved. From: ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias —executive summary: a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of∗ cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) Developed in Collaboration with NASPE-Heart Rhythm Society J Am Coll Cardiol. 2003;42(8):1493-1531. doi:10.1016/j.jacc.2003.08.013 Acute management of patients with hemodynamically stable and regular tachycardia. A 12-lead ECG during sinus rhythm must be available for diagnosis. †Adenosine should be used with caution in patients with severe coronary artery disease and may produce AF, which may result in rapid ventricular rates for patients with pre-excitation. Ibutilide is especially effective for patients with atrial∗ ∗∗ flutter but should not be used in patients with EF less than 30% due to increased risk of polymorphic VT. AF indicates atrial fibrillation; AV, atrioventricular; BBB, bundle-branch block; DC, direct current; IV, intravenous; LV, left ventricle; QRS, ventricular activation on ECG; SVT, supraventricular tachycardia; VT, ventricular tachycardia. Figure Legend:
  14. 14. Sinus Bradycardia Rx – depends on the cause ( refer algorithm) Intravenous access, supplemental oxygen, and cardiac monitoring should be initiated In symptomatic patients, intravenous atropine may be used. In rare cases, transcutaneous pacing may need to be initiated.
  15. 15. 2nd Degree AV block – Type II
  16. 16. 3rd Degree Block All patients should be receiving advanced life support (ACLS) with continuous cardiac monitoring, as per local protocols. In all patients, oxygen should be administered and intravenous (IV) access established. Maneuvers likely to increase vagal tone (eg, Valsalva maneuvers, painful stimuli) should be avoided. Atropine can be administered but should be given cautiously The first, and sometimes most important, medical treatment for heart block is the withdrawal of any potentially aggravating or causative medications. Many antihypertensive, antianginal, antiarrhythmic, and heart failure medications cause AV block that resolves after withdrawal of the offending agent. Review patient medication lists upon presentation to help rule out medication-induced or medication-aggravated heart block. Common drugs that induce AV block include beta-blockers, calcium channel blockers, antiarrhythmics, and digoxin.
  17. 17. No Pulse
  18. 18. Finally….
  19. 19. Anterior STEMI Intravenous access, supplemental oxygen, pulse oximetry Immediate administration of aspirin en route Nitroglycerin for active chest pain, given sublingually or by spray If STEMI is present, the decision as to whether the patient will be treated with thrombolysis or primary PCI should be made within the next 10 minutes. Treatment options include the immediate start of IV thrombolysis in the ED or the immediate transfer of the patient to the cardiac catheterization laboratory for primary percutaneous transluminal coronary angioplasty (PTCA). The AHA recommends the initiation of beta-blockers to all patients with STEMI (unless beta- blockers are contraindicated)

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