1) A 30-year-old male presented with palpitations that had occurred intermittently over the past 10-15 years. His heart rate was elevated between 230-250 bpm. 2) The document discusses approaches to evaluating and treating different types of arrhythmias based on characteristics like rhythm (regular vs irregular), QRS width (narrow vs wide), and presence of P waves. 3) Arrhythmias are categorized into four main groups: narrow regular, narrow irregular, wide regular, and wide irregular. Specific treatments are suggested based on the category, and unstable rhythms may require electrical cardioversion.

1. Case
Malignant Arrythmia?

2. 30 year old Male
● PC Palpitations
● HPC Awoke at 6 am with palpitations
Sensation in chest, flutters, irregular with the
occassional heavy beat
No Chest pain, dizziness or sob but felt
slightly ill at ease
Otherwise well

3. Further Questioning
● Previous episodes over 10 – 15 years
● Spontaneous in onset and offset, usually short
lived
● One episode lead to visit to A and E spontaneous
resolution ? Sensitive to caffeine
● No episodes for a few years
● No ppt factors
● No tricks for termination

4. Past Medical History
● Nil of Note
● Non Smoker
● No illlicit drugs
● Alcohol – Occasional binges
Last binge 2 /52 prior
● No Meds
● No FHx

5. Examination
● Alert, orientated amd comfortable
● HR 230 – 250. BP 145/88. sats 98. rr 14
● Jvp – large 'a waves'
● Apyrexial slightly flushed
● Chest clear

6. Approach to Arrythmias
● IV, O2, Monitor,Defib, airway equipment
● Stable or unstable
● P waves?
● Regular or irregular
● Narrow or wide
● All antiarrythmixs are pro-arrythmic
● Drug with shortest half-life and short term effects =
electricity

7. Stable or Unstable
● Not dichotomous
● Altered Mental Status
● Pulmonary oedema
● Chest Pain
● Hypotension
● Grey v Pink

8. P waves
● Not necessarily sinus
● ?normal p wave axis ( pos in 11, neg in AVR)
● Multiple morphology
● Retrograde
● Fusion
● Saw toothed
● 1:1. 1:2 etc

9. Regular or Irregular
●
Regular ≠ Sinus
● SVT = exquisitly regular
● Irregular = above the AV Node
= block AV Node
= not VT

10. Narrow or Wide Complexes
● Narrow = supraventricular
= not Ventricular tachycardia (very rare)
= Regular or irregular
= block the AV node
= 0.12 secs (3 small squares) 0.08 in kids
● Wide = supraventricular or ventricular
= Regular or irregular

11. 4 Arrythmia Groups
● Narrow Regular
● Narrow Irregular
● Wide Regular
● Wide Irregular

12. Narrow, Regular
● PSVT
● Atrial Flutter with consistent non variable block
● Orthodromic WPW
● Very rarely narrow complex VT
● Rx Adenosine, verapamil
(others esmolol, diltiazem, magnesium,
● Unstable = adenosine, sync dc shock 50j aliquots

13. Narrow, Irregular
● Atrial Fibrillation
● Atrial Flutter with variable block
● Multifocal atrial tachycardia
● Rx rate or rhythmn control
● Calcium channel blockers (diltiazem), digoxin,
amiodarone, magnesium, BBlockers

14. Wide, Regular
● Ventricular Tachycardia
● Ventricular Tachycardia
● Ventricular Tachycardia
● Supraventricular Tachycardia with aberrancy/rate
related block
● Antidromic WPW

15. Ventricular Tachycardia
● Predictors of VT – old age, CAD, ECG Criteria
● Brugada's criteria for VT on ECG, rsR' in v1
● Fusion beats, Capture Beats
● Rx Magnesium, Procainamide, Amiodarone,
DC Cardioversion

16. Wide, Irregular, no P waves
● AF with bundle branch block
● Atrial Flutter variable block and bundle branch
block
● WPW antidromic and atrial fibrillation