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Tachyarrhythmias

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Tachyarrhythmias

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Tachyarrhythmias

  1. 1. Tachy Rhythms Candice Hanson
  2. 2. Tacky rhythm quiz…
  3. 3. Now the hard stuff:
  4. 4. Regular & Narrow Complex
  5. 5. Sinus tachycardia
  6. 6. Atrial Flutter  Atrial rates 250-350. Slower ventricular rate e.g. 150 = 2:1 block
  7. 7. Supraventicular Tachycardias  Generally used to mean any tachyarrythmia with abrupt onset and offset involving a re-entrant pathway:  Atrioventricular nodal re-entrant tachycardia (AVNRT)  Atrioventricular re-entry tachycardia (AVRT) – orthodromic, antidromic  AVNRT  Anatomy of the AV node: fast & slow fibres. Results in a functional re-entrant circuit within the AV node.  Narrow complex, rates of 140-280. Heart is structurally normal. More common in women. Sudden onset / offset. May respond to vagal manoeuvres.
  8. 8. AVNRT  Typically initiated by a PAC.  Different subtypes (google LITFL…)  ECG findings – narrow complex tachy, QRS alternans, retrograde conduction of P waves  Management: vagal manoeuvres, adenosine, other anti-arrythmics (CCB, BB, amiodarone). Rarely requires DCCV*
  9. 9. ECG in AVNRT
  10. 10. AVRT  Pre-excitation syndromes seen on ECG when patient in sinus rhythm (WPW changes). These are lost when AVRT is established  Short PR, delta wave, widened QRS  Anatomical re-entrant pathway (Bundle of Kent). Circus movement between the AV node and accessory pathway.  May be triggered by PAC or PVC  Circus movement may by orthodromic or antidromic
  11. 11. Pre-excitation
  12. 12. Orthodromic vs Antidromic Conduction
  13. 13. Orthodromic AVRT  ECG features: rate 200-300 bpm; buried or retrograde P waves, narrow complex*, QRS alternans, TWI, ST depression.  Treatment – is pt stable? Can try vagal, adenosine, CCB. If pt compromised  DCCV!
  14. 14. Antidromic AVRT  Antegrade conduction via the accessory pathway, retrograde conduction via AV node.  ECG features: rate 200-300, wide QRS (abnormal depolarisation of ventricles)  Likely to be mistaken for VT. Treatment: DCCV
  15. 15. Technically broad complex…
  16. 16. Summing up the SVTs  AVNRT – most common  Narrow complex*, rate up to 240, regular, responds to adenosine  Structurally normal heart – functional re-entrant pathway  AVRT – seen in pre-excitation syndromes (WPW)  Anatomical re-entrant pathway due to presence of accessory bundle  Orthodromic  via AV node and back up (retrograde) via the bundle. Results in narrow complex tachy up to 300bpm, regular  Antidromic  via accessory pathway and retrograde via the AV node. Results in broad complex tachy up to 300bpm, regular.
  17. 17. Tacky rhythm quiz #2
  18. 18. Regular & Broad Complex
  19. 19. Ventricular Tachycardia  Ventricular tachycardia, rates up to 300bpm  Sustained / non-sustained; monomorphic, polymorphic  VT should be regular (sustained irregularity think SVT w BBB e.g. AF)  SVT with aberrancy vs VT  Pt can be stable or unstable  Features more suggestive of VT:  Age > 35  Pre-existing ischaemic heart disease  Previous VT  Absence normal BBB morphology  Hx structural disease, CCF, cardiomyopathy  FHx sudden cardiac death
  20. 20. SVT with aberrancy  Looks like VT!  Broad complex tachycardia originating above Bundle of His. Becomes broad due to pre-existing BBB. This will be seen on the baseline ECG!  Some clues to distinguish  North west axis  Concordance of QRS complexes in praecordial leads  Left rabbit ear > right in V1 (very specific for VT)  Fusion & capture beats; AV dissociation  Brugada & Josephson’s signs  Q wave in V6  Very broad complex  http://lifeinthefastlane.com/ecg-library/basics/vt_vs_svt/ for examples of above
  21. 21. VT or SVT?
  22. 22. VT or SVT?
  23. 23. Ventricular Flutter  Regular sine wave, rate >200.  Absence of P waves, QRS complex, T waves  Lethal (deteriorates to VF) unless abruptly terminated.
  24. 24. Tacky rhythm quiz #3 - Australiana
  25. 25. Irregular & Narrow Complex
  26. 26. Atrial Fibrillation
  27. 27. Atrial Flutter, Variable Block
  28. 28. Multi Focal Atrial Tachycardia Associated w severe respiratory disease, hypoxia High mortality – survival at 1 yr is 20% Treat the underlying condition, not the tachycardia Must have 3 P wave morphologies Baseline is isoelectric!!!
  29. 29. Tacky rhythm quiz #4
  30. 30. Irregular & Broad Complex
  31. 31. Polymorphic VT - torsades  Requires polymorphic appearance AND QT prolongation  PVC causes ‘R on T’ phenomenon  May be self terminating, or degrade into VF  Treatment – magnesium, overdrive pacing, isoprenaline
  32. 32. Ventricular Fibrillation
  33. 33. AF / flutter in pre-excitation
  34. 34. Other causes of broad complex tachys  Don’t forget  Metabolic derangements e.g. hyperkalaemia  Toxidromes e.g. TCA poisoning  Pacemaker related
  35. 35. Tachyarrhythmia Treatment Algorithm
  36. 36. Summing it up…  Tachyarrhythmias can be regular, irregular, narrow or broad complex  May be the result of functional or anatomical re-entrant circuits, or increase automaticity  Treatment may depend on underlying cause and on whether the patient is haemodynamically stable  VT and SVT with aberrancy can be difficult to distinguish, when in doubt, cardioversion
  37. 37. The ED Doctor’s Most Important ‘Tacky Rhythm’…

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