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Bradycardia
Assessment and Management
Callum Addison
● Narrow Complex:
● Wide Complex
Classifying Bradydysrhythmias
Regular Irregular
Sinus bradycardia Sinus arrhythmia
Comple...
ECG 1
● Type II
ECG 2
ECG 3
Classification (cont)
● Sinus Bradycardia
● Sinus node dysfunction
Sinoatrial exit block
Sinus arrest – pause > 3 seconds
...
Causes
● Physiological
● Medications – AV nodal blockade, cholinergic crisis
● Cardiac disease – Ischaemia, myocarditis, c...
Sinus Bradycardia
● Physiological
Athletes
Respiratory Sinus Arrhythmia
Sleep:
Medications
● AV nodal blocking drugs
(Class II, Class IV, Digoxin, Amiodarone)
● Organophosphates
● Clonidine
● Spot Quiz...
Kim Jong-nam - VX
Ischaemia
● Up to 30% of patient with inferior STEMI will
develop second or third degree AV block.
● Associated with an in...
Raised ICP
● Cushing response.
● Raised BP, Bradycardia, Irregular breathing.
● Bradycardia is due to the baroreceptor res...
Symptomatic
Dizziness, light headedness, palpitations, fatigue,
exercise intolerance.
Unstable
● Neuro: GCS, Syncope
● Res...
Treatment Algorithm
● ABC Management
● IV Access/O2/Vitals/ECG
● Assess for and treat underlying causes
● As per ACLS
ACLS Algorithm
ncreases firing of the SA Node by blocking the action of the vagus nerv
APLS algorithm
Atropine
● Competitive muscarinic antagonist -
Anticholinesterase inhibitor
● Increases firing of the SA Node by blocking ...
Spot Quiz – Who Am I
● Invasive Pest
● Solanaceae family
● Contains Tropane alkaloids
Transcutaneous Pacing
● Non-invasive pacing is used on a temporary basis
until the patient is stabilized and either an ade...
Apple of Sodom
Alternative Agents
● Adrenaline (second line agent).
Non-selective A/B agonist.
2-10mcg/min
Titrated to maintain a satisfa...
Transcutaneous Pacing
● Indications
Patient with symptomatic bradycardia and a palpable pulse
who has not responded to pha...
Transcutaneous Pacing
● For pacing readiness (i.e. standby mode) in the
setting of acute myocardial infarction (AMI) with
...
Transcutaneous Pacing - Procedure
● O2 and IV Access.
● Sedation unless contraindicated.
● Placement of pads on clean, dry...
Classification of Bradycardia
● Absolute or Relative
● Functional or relative bradycardia occurs when a patient may have a...
Case 1
● 68 year old female.
● Presents with an episode of syncope on a
background of 1 week of vomiting and poor oral
int...
Case 1 (cont)
● K+ of 7.8
● Responded to IV calcium gluconate, IV insulin
dextrose and inhaled salbutamol.
● Always consid...
Case 1 (cont)
Case 1 (cont)
● Severe bradycardia (HR ~ 30 bpm)
● Symmetrically peaked T waves in V2-5
● Flattening, broadening and near-...
Case 2
● 48 year old presents with sharp pleuritic
chest pain after playing a game of squash
today.
● PMHx: BPH, Meningiom...
Athlete's Heart
● Regular physical activity leads to physiological
adaptions in cardiac dimensions. Primarily LV wall
thic...
Case 2
Athlete's heart.
● Electrocardiographic findings that are common,
training-related, normalize with exercise and that do
no...
Athlete's Heart (cont)
● With voltage criteria for LVH, pathological
hypertrophy should be suspected in any of the
followi...
Proceed with caution.
Case 3
● 74 year old lady with sudden onset 30 minute
episode of crushing central chest pain, radiating to
neck and associ...
Case 3 (cont)
Case 3 (cont)
● Regular, narrow complex bradycardia.
● Ventricular rate of 43 BPM.
● Complete AV block.
● Likely junctiona...
Case 3 (cont)
● Inferior STEMI with RV infarction was diagnosed.
● IV fluids were given.
● Aspirin, Ticagrelor and Heparin...
Summary
● Remember ABC'ss
● Assess and treat underlying causes
● Reassess regularly for changes in rhythm.
● Decision to t...
LIFEPAK 20/20E Defibrillator/Monitor
Noninvasive (Transcutaneous) Pacing
Demonstration video (4 minutes).
● https://www.yo...
References/Further Reading
● ACLS/APLS Australia
● Australian Resuscitation Council
● Textbook of Cardiology.org
● Family ...
Bradycardia Assessment and Management
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Bradycardia Assessment and Management

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Bradycardia Assessment and Management

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Bradycardia Assessment and Management

  1. 1. Bradycardia Assessment and Management Callum Addison
  2. 2. ● Narrow Complex: ● Wide Complex Classifying Bradydysrhythmias Regular Irregular Sinus bradycardia Sinus arrhythmia Complete AV Block (junctional escape) Mobitz Type I+2 Atrial flutter with high degree block Atrial flutter with variable block. Regular Irregular Sinoventricular rhythm Sinoatrial exit block with BBB Complete AV Block (ventricular escape) Mobitz Type I+2 Atrial flutter with high degree block Irregular bradycardias with BBB
  3. 3. ECG 1 ● Type II
  4. 4. ECG 2
  5. 5. ECG 3
  6. 6. Classification (cont) ● Sinus Bradycardia ● Sinus node dysfunction Sinoatrial exit block Sinus arrest – pause > 3 seconds ● Sick sinus syndrome. ● AV 1st degree HB 2nd degree HB – Mobitz I + II 3rd degree HB Junctional escape ● Ventricular escape rhythm
  7. 7. Causes ● Physiological ● Medications – AV nodal blockade, cholinergic crisis ● Cardiac disease – Ischaemia, myocarditis, cardiomyopathies, HIS- purkinje fibre degeneration ● Metabolic/Endocrine – Anorexia, hyperkalaemia, hypothyroidism ● Neurological ● Autoimmune – SLE, sarcoidosis, amyloidosis ● Infections – Lyme disease, diptheria, typhoid fever ● Hypoxia/Hypothermia ● Surgery
  8. 8. Sinus Bradycardia ● Physiological Athletes Respiratory Sinus Arrhythmia Sleep:
  9. 9. Medications ● AV nodal blocking drugs (Class II, Class IV, Digoxin, Amiodarone) ● Organophosphates ● Clonidine ● Spot Quiz – Which organophosphate was recently used to assassinate the step-brother of a well known political figure.
  10. 10. Kim Jong-nam - VX
  11. 11. Ischaemia ● Up to 30% of patient with inferior STEMI will develop second or third degree AV block. ● Associated with an increased in-hospital mortality. ● Inferior myocardial wall and the SA/AV nodes are usually all supplied by the right coronary artery
  12. 12. Raised ICP ● Cushing response. ● Raised BP, Bradycardia, Irregular breathing. ● Bradycardia is due to the baroreceptor response to the sympathetic efforts to increase cerebral perfusion – or mechanical distortion of the vagus nerve
  13. 13. Symptomatic Dizziness, light headedness, palpitations, fatigue, exercise intolerance. Unstable ● Neuro: GCS, Syncope ● Respiratory: SOB, Pulmonary congestion ● CVS: Hypotension, shock, CHF, ACS. Symptoms
  14. 14. Treatment Algorithm ● ABC Management ● IV Access/O2/Vitals/ECG ● Assess for and treat underlying causes ● As per ACLS
  15. 15. ACLS Algorithm ncreases firing of the SA Node by blocking the action of the vagus nerv
  16. 16. APLS algorithm
  17. 17. Atropine ● Competitive muscarinic antagonist - Anticholinesterase inhibitor ● Increases firing of the SA Node by blocking the action of the vagus nerve. ● Onset of action ~ 1 minute ● Duration of action 30 – 60 minutes. ● The first drug of choice for symptomatic bradycardia. ● Dose in the Bradycardia ACLS algorithm is 0.5mg IV push and may repeat up to a total dose of 3mg.
  18. 18. Spot Quiz – Who Am I ● Invasive Pest ● Solanaceae family ● Contains Tropane alkaloids
  19. 19. Transcutaneous Pacing ● Non-invasive pacing is used on a temporary basis until the patient is stabilized and either an adequate intrinsic rhythm has returned or a transvenous pacemaker is inserted, whether temporary or permanent.
  20. 20. Apple of Sodom
  21. 21. Alternative Agents ● Adrenaline (second line agent). Non-selective A/B agonist. 2-10mcg/min Titrated to maintain a satisfactory HR. ● Dopamine – 2-10mcg/kg/min ● Isoprenaline – 2.5mcg/min
  22. 22. Transcutaneous Pacing ● Indications Patient with symptomatic bradycardia and a palpable pulse who has not responded to pharmacological therapy (or no IV access able to be established). High-grade AV blockade (3rd degree heart block or unstable mobitz type II. Cardiac arrest with ventricular standstill, but atrial activity present. ● Recent asystole. ● Contraindication Asystolic cardiac arrest
  23. 23. Transcutaneous Pacing ● For pacing readiness (i.e. standby mode) in the setting of acute myocardial infarction (AMI) with the following: Symptomatic sinus bradycardia Mobitz type II second-degree AV block Third-degree AV block New left, right or alternating bundle branch block or bifascicular block
  24. 24. Transcutaneous Pacing - Procedure ● O2 and IV Access. ● Sedation unless contraindicated. ● Placement of pads on clean, dry, shaven skin. ● Pacing mode with rate 60-80 bpm. ● Begin pacing at 5mA amp, increase amperage in 5mA increments until visible electrical capture- (QRS-T complexes after each pacing spike). ● Check pulse for mechanical capture. ● Increase by a further 5mA after capture.
  25. 25. Classification of Bradycardia ● Absolute or Relative ● Functional or relative bradycardia occurs when a patient may have a heart rate within normal sinus range, but the heart rate is insufficient for the patients condition. An example would be a patient with an heart rate of 80 bpm when they are experiencing septic shock. ● Narrow or Wide Complex ● Regular or irregular ● Sinus vs Sick Sinus vs AV nodal vs Ventricular
  26. 26. Case 1 ● 68 year old female. ● Presents with an episode of syncope on a background of 1 week of vomiting and poor oral intake. ● GCS 14 on arrival, HR 34, BP 80/53 ● PMHx: HTN, CHF ● Medx: Spironolactone, Bisoprolol.
  27. 27. Case 1 (cont) ● K+ of 7.8 ● Responded to IV calcium gluconate, IV insulin dextrose and inhaled salbutamol. ● Always consider the diagnosis of hyperkalaemia in patients presenting with bradycardia or complete heart block. ).
  28. 28. Case 1 (cont)
  29. 29. Case 1 (cont) ● Severe bradycardia (HR ~ 30 bpm) ● Symmetrically peaked T waves in V2-5 ● Flattening, broadening and near-disappearance of P waves (still barely visible in V1-3) ● Prolongation of the PR interval ● Broad QRS complexes (~120 ms)
  30. 30. Case 2 ● 48 year old presents with sharp pleuritic chest pain after playing a game of squash today. ● PMHx: BPH, Meningioma. ● Fhx: CAD. ● No recent immobilization or surgical history. ● O/E Haemodynamically stable WNL. 3rd heart sound heard.
  31. 31. Athlete's Heart ● Regular physical activity leads to physiological adaptions in cardiac dimensions. Primarily LV wall thickness and cavity size. ● Enhanced diastolic filling with increased stroke volume and cardiac output. ● Subsequent bradycardia, repolarization abnormalities and voltage criteria for chamber enlargement. ● Accentuated antagonism.
  32. 32. Case 2
  33. 33. Athlete's heart. ● Electrocardiographic findings that are common, training-related, normalize with exercise and that do not require additional evaluation are: ● Sinus bradycardia ● 1° atrioventricular block or mobitz 1 are common. ● Incomplete right bundle branch block (BBB) ● Early repolarization. ● Isolated voltage criteria for left ventricular hypertrophy (LVH).
  34. 34. Athlete's Heart (cont) ● With voltage criteria for LVH, pathological hypertrophy should be suspected in any of the following: ● Left atrial enlargement, ● Left-axis deviation, ● Repolarization abnormalities, ● Pathological Q waves. ● T-wave inversion ≥2 mm in ≥2 adjacent leads.
  35. 35. Proceed with caution.
  36. 36. Case 3 ● 74 year old lady with sudden onset 30 minute episode of crushing central chest pain, radiating to neck and associated with diaphoresis and palpitations. ● Previous similar episodes for the last 6 months on exertion however only mild in severity. ● PMHx: Diabetic, HTN, Hypercholesterolaemia. ● Shx: Smoker ● O/E – HR 42, BP 102/60, Sats 97% on RA.
  37. 37. Case 3 (cont)
  38. 38. Case 3 (cont) ● Regular, narrow complex bradycardia. ● Ventricular rate of 43 BPM. ● Complete AV block. ● Likely junctional escape rhythm. ● Significant ST elevation in leads II, III, and AVF, with reciprocal ST depression in leads I and AVL, all suggestive of an inferior STEMI.
  39. 39. Case 3 (cont) ● Inferior STEMI with RV infarction was diagnosed. ● IV fluids were given. ● Aspirin, Ticagrelor and Heparin were given ● Patient taken to cath lab: ● Coronary angiography revealed an acute thrombus with 100% occlusion of the proximal Right Coronary Artery (proximal to the right ventricular marginal branch), successfully stented and reduced.
  40. 40. Summary ● Remember ABC'ss ● Assess and treat underlying causes ● Reassess regularly for changes in rhythm. ● Decision to treat largely based on haemodynamic stability and risk of asystole. ● Clear algorithms provided by APLS/ACLS available for treatment.
  41. 41. LIFEPAK 20/20E Defibrillator/Monitor Noninvasive (Transcutaneous) Pacing Demonstration video (4 minutes). ● https://www.youtube.com/watch? v=Nb0fDABC6UY
  42. 42. References/Further Reading ● ACLS/APLS Australia ● Australian Resuscitation Council ● Textbook of Cardiology.org ● Family Practice Notebook ● LITFL ● Dr Smith's ECG Blog ● Dr Venkatesan.com ● Department of Agriculture and Food.

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