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Approach to tachycardia in emergency department
- 1. Approach to tachycardia JeanPaul DUSHIME, MD, MMed EMCC
- 2. Goals To make tachycardia“less scary” To give you an approach to tachycardia Pearls of interpretating
- 3. Case 1 • 30yo M cocaine abuser, chest pain, palpitations and SOB • HR 162 bpm, BP 140/90mmhg, T 37 C,SO2 95% • ECG DX? • What is the treatment ?
- 4. Cardiac Anatomy • Sino-atrialnode (SA Node): origin of physiologic cardiac pacemaker • Atrioventricular Node (AV Node): ONLY pathway between atria and ventricles (AV node delay) • Ventricles: Bundle Branches and His-Purkinje Fibers 4
- 5. Waveforms • P Wave:Atrial depolarization (contraction) • PR Interval: AV node conduction • QRS Complex: ventricular depolarization, conduction through the His-Purkinje system of the ventricles (contraction) • T Wave: ventricular repolarization
- 6. Normal Intervals • PR –0.20 sec (less than one large box) • QRS – 0.08 – 0.10 sec (1-2 small boxes) • QT – 450 ms in men, 460 ms in women – Based on sex / heart rate – Half the R-R interval with normal HR
- 7. What am Ilooking for in the ECG? 7 Stepwise Approach to the Evaluation of Every ECG!!! 1. Ventricular RATE: Fast (>100 beats/min), slow (<60 beats/min) 2. RHYTHM: Is it sinus?? P wave before each QRS complex? 3. RHYTHM: Regular, irregular, regular with occasional irregularities? 4. PR, QRS intervals: PR prolonged? QRS prolonged (>0.12 sec), or normal? 5. ST segments: Dx of Ischemia or Infarction 6. T wave changes: peaked, upright, inverted, biphasic
- 8. Tachycardia Definition – HR > 100bpm Narrowcomplex tachycardia – QRS < 120msec (3 small boxes) Wide complex tachycardia – QRS > 120 msec (3 small boxes)
- 9. Differential Diagnosis ofTachycardia Tachycardia Narrow Complex Wide Complex Regular Sinus Tachycardia SVT (Supra ventricular tachycardia) VT (Ventricular Tachycardia) Irregular A-fib (Atrial fibrillation) VF (Ventricular fibrillation)
- 10. Sinus Tachycardia: • Seekand treat underlying cause • Do NOT treat tachycardia itself Sinus? (p wave before every QRS in II or v1 Wide QRS? (QRS ≥ 120 ms) Ventricular Tachycardia: • Give amiodorone or lidocaine • and/or synchronized cardioversion • If irregular, consider torsades give magnesium Unstable? (Hypotension, altered mental status) Unstable Non-Sinus Tachycardia: • Perform SYNCHRONIZED cardioversion Irregular? Atrial Fibrillation with Rapid Ventricular Response • Rate control: Consider fluids (if hypovolemic), beta blocker if BP OK (IV best), amiodorone or digoxin • Anticoagulation with heparin or LMWH unless contraindication • Suspect and rule out structural heart disease, especially mitral stenosis Supraventricular Tachycardia • Vagal maneuvers • Adenosine YES YES YES YES NO NO NO NO
- 11. Narrow Complex Tachycardia Whatare the questions to ask? Is the rhythm regular or irregular? Is there P with everything QRS or is P > QRS? Regular : ST;SVT Irregular : A fib
- 12. Sinus Tachycardia (100to 180+ beats/min) There is one P with one QRS Regular rhythm
- 13. Sinus Tachycardia Causes • Hypovolemia(blood loss, dehydration) • Fever • Respiratory distress • Heart failure • Hyperthyroidism • Certain drugs (e.g., bronchodilators) • Physiologic states (exercise, excitement, etc.) Treatment • Seek and treat underlying cause • Do NOT treat tachycardia itself
- 14. SVT • Atrial ratebetween 140 and 280 bpm • Regular with narrow QRS unless aberrancy • USUALLY DO NOT SEE P WAVES • May be paroxysmal or be brought on by caffeine, exertion, alcohol, salbutamol, or amphetamines • Women > Men • Young and healthy or people with structural heart disease
- 15. SVT Signs and symptoms •Palpitations • Dizziness or fainting • Shortness of breath • Anxiety Treatment • Try Vagal maneuver • Carotid sinus massage / Valsalva • Adenosine *** • 2nd line= Calcium channel blockers, Beta Blockers, Amiodarone • DC cardioversion rarely needed
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- 17. Atrial Fibrillation • Irregularlyirregular • NO P WAVES • Absence of isoelectric baseline • Variable ventricular rate (therefore irregular) • QRS narrow unless BBB, acc path or aberrancy • May have fibrillatory waves that mimic P waves, they are either fine or course (amplitude)
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- 20. Atrial Fibrillation Causes • Ischemicheart disease • HTN • Valvular heart disease- RWANDA (MS) • Acute infections • Electrolyte disturbance (hypokalemia, hypomagnesaemia) • Thyrotoxicosis • Drugs • PE • Pericardial disease • Cardiomyopathies: Dilated or hypertrophic • Pheochromocytoma
- 21. Atrial Fibrillation Management • Firstdiagnose it! Do an EKG. • Stable or Unstable? • Rate or rhythm control? • Assessment of Duration Less than 48 hours or greater than 48 hours as this determines who is safe for cardioversion • Assessment for anticoagulation- CHADS 2 Score • Treatment of underlying disease
- 22. Atrial Fibrillation Unstable • Shock(120-200J) – Might not work! • A heart that has been in afib can get used to it • Consider IVF – Dehydration is a common cause driving rapid heart rates in afib – May be in heart failure so carefully! • Load with amiodorone, digoxin Stable Rate Control • Atenolol (not in acute heart failure) • Calcium Channel Blocker • Digoxin oral load- better if LVD Arrythmias, Rhythm control • Amiodarone Load 150mg IV
- 23. Wide ComplexTachycardias 23 What arethe questions to ask? Is the rhythm regular or irregular? Regular :VT (monomorphic and polymorphic) Irregular :VF
- 24. Ventricular tachycardia • Wide complextachycardia • May be monomorphic or polymorphic • Originates from single focus within the ventricles • Produces uniform QRS complexes
- 25. Monomorphic Ventricular Tachycardia CAUSES •Dilated Cardiomyopathy • Hypertrophic Cardiomyopathy • Ischemic Heart disease • Chaga’s Disease TREATMENT • STABLE = Give drugs or DC Cardioversion • Presence or absence of Left Ventricular Dysfunction determines choice of pharmacologic therapy – Amiodarone 150 mg I.V. over 10 minutes may be RX of choice maximum 2.2 gm/24 hours • UNSTABLE? (hypotension, chest pain, cardiac failure, ALOC) • = DC Cardioversion (Biphasic 100-200 J with sedation)
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- 27. Polymorphic VT/Torsade dePointes • Classic pattern of “twisting” of QRS in an axis • Can be seen with electrolyte abnormalities- Hypo K, Hypo Mg
- 28. Polymorphic VT • Requiresimmediate defibrillation as does VF • Drug of choice I.V. Lidocaine , Amiodarone • Usually result of severe metabolic disturbance or Cardiac ischemia. • Rarely when associated with prolonged QT known as Torsades de Pointes • Magnesium replacement therapy/replete potassium (even if normal) 28
- 29. “Torsade de Pointes”(PolymorphicVT Associated with Prolonged Repolarization) • Occurs in the context of QT prolongation • QRS “twists” around isoelectric line • Must have PVT + QT prolongation • Can be short lived and self terminating but CAN progress into ventricular fibrillation • Bigeminy in someone with prolonged QT may give a warning they will go into Torsades 29
- 30. Torsades de Points •QTC is prolonged if > 440ms in men or >460ms in women • QTC >500 is associated with increased risk of Torsades Must Ask Why QT prolongation? Will help treatment • Drugs effects? • Electrolyte Abnormalities: Hypokalemia, Hypomagnesaemia, Hypocalcemia • Hypothermia • Raised increased intracranial pressure • Congenital • Myocardial Ischemia • TREATMENT: CARDIOVERSION + MAGNESIUM 2-4G IV
- 31. Ventricular Fibrillation • Disorganized,non-perfusing ventricular rhythm • Not consistent with life • Requires immediate defibrillation • VT 250 beats/min, without clear isoelectric line 31
- 32. Ventricular Fibrillation 32 • CardiopulmonaryResuscitation (CPR): High quality compressions!!! Limit interruptions in CPR • Success decrease 10% per minute in VF • Defibrillate: adults: biphasic: 200 J once – 5 cycles of CPR • Administer epinephrine 1 mg every 3–5 minutes • Administer amiodarone 300 mg IV/IO once, then consider administering an additional 150 mg once • Consider lidocaine if no response
- 33. Case 2 • 24yo EKG tech p/w heart palpitations, shortness of breath. Appears anxious. • What is the DDx/approach to narrow complex tachycardia? 81
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Editor's Notes
- #21 CHF HTN AGE >75 DIABETES STROKE/ TIA