1) Cardiac arrhythmias are common in the ICU and represent a major source of morbidity and potential increased mortality. Arrhythmias may be the primary reason for admission or develop during critical illness. 2) Factors that increase the risk of life-threatening arrhythmias in ICU patients include their underlying critical illnesses, drugs, electrolyte imbalances, hypoxia, sepsis and other metabolic disturbances, and fluctuations in intravascular volume. 3) Arrhythmias can be life-threatening if the heart rate is too fast or slow resulting in hemodynamic instability, if it degenerates to ventricular fibrillation, or if associated with severe hypokalemia/hypomagnesemia or underlying

1. Life-threatening Arrhythmias In the ICU
By
Khaled Hussein, MD
Professor of Critical Care Medicine
Cairo University
Consultant Electrophysiologist
2017

2. Cardiac arrhythmias are a common problem encountered in the
intensive care unit (ICU) and represent a major source of
morbidity and may have associated with increased mortality.
Arrhythmia may be Primary cause of admission or Contingency
in critical illness
Tasdemir G et al . Crit Care. 2015; 19(Suppl 1): P156.
Reisinget al. Journal of IntensiveCare Medicine.2007

3. What places the patients admitted to ICU at risk of
life-threatening arrhythmia?

4. • The critical nature of their underlying disease>>(ACSs, CMs)
• Drugs >>pro-arrhythmia
• Electrolyte imbalance, hypoxia ,sepsis and other metabolic
derangements
• Flactuation in the intravascular volume
• Surgical procedures
• Autonomic nervous system>>QT interval ,HR variability, BR
sensitivity

5. At what point can arrhythmia be life
threatening?
• If the heart rate is too fast to be tolerated>> hemodynamic
instability
• If the heart rate is t00 slow>> syncope or asystole
• If degenerates to VF
• If associated with severe hypokalemia or hypomagnesemia
• If associated with SHD like ACS,CMs, stenotic VHD
• If associated with inherited ADs or CMs >>SCD

6. Sustained arrhythmia commonly seen in ICU
Tachyarrhythmias (common)
• Narrow complex ( QRS <120 ms)
• Wide complex (QRS >120 ms)
Bradyarrhythmias
• Sinus arrest
• Atrio-Ventricular conduction
block (CHBwith very slow or
unstable ventricular escape
Reising et al. J intensive Care Med 2007;22:3-13
Cynthia Tracy, Ali B0ushahri.Critical Care Clinic,2014

7. Tachyarrhythmias(types)
Rhythm and morphology
Reising et al. J intensive Care Med 2007;22:3-13
AF with pre-excitation

8. Approach to deal with life-threatening arrhythmias:
• Recognize and identify the rhythm disturbance (12-lead ECG)
except in lethal arrhythmia
• Acute management based on the hemodynamic state
• Treating the underlying SHD as protocol
• Drug list
• Correction of the underlying metabolic derangements,
hypoxia ,electrolyte abnormalities and hypovolemia.

9. Identifythe rhythm disturbance
• Rapid, irregular and sudden onset
• Chaotic baseline
• N0 identifiedP waves

10. AF-Types

11. AF-Integrated management

12. AF-Rate control

13. AF-Acute rhythm management
SHD

14. Pill-in-the-pocket
Approach to AF
Propafenone is a potent inhibitor of the metabolism of
warfarin, which is used for stroke prevention in the
majority of patients with atrial fibrillation, and also reduces
the non renal clearance of digoxin
Alboniet al, 2004

15. Identifythe rhythm disturbance

16. General treatment goals for symptomaticatrial
flutter
Similar to those for atrial fibrillation and include the following:
• Control of the ventricular rate
• Restoration of sinus rhythm
• Prevention of recurrent episodes or reduction of their
frequency or duration
• Prevention of thromboembolic complications
• Minimization of adverse effects from therapy (ibutilide,
sotalol and dofetilide)
• Consider catheter-based ablation as first-line therapy in
patients with type I typical atrial flutter if they are reasonable
candidates.
AHA,Acc guidelines,2015

17. Regular SVT-Howto identify?

18. Identify the rhythm disturbance

19. Identifythe rhythm disturbance

20. Identifyrhythm disturbance

21. SVT-Acute management

22. Wide complextachycardia (WCT)
• Regular>> (MMVT , SVT with BB aberration , with
preexisting BBB ,with rate dependent BBB )
• Irregular>> ( PMVT, AF with pre-excitation)

23. MMVT-ECG diagnosis
Brugada 1991 Other diagnostic criteria
• VT usually occurs in
patients with structural
heart disease
• Josephson's sign
• Wide QRS complex (>140-
160 ms)
• Dominant R in aVR
(Vereckei )
• Extreme axis deviation

24. VT-ECG diagnosis
Fusion beatCapture beat
Lt Rabbit ear Brugada sign, Josephson's sign
AV-dissociation

25. Identifythe Rhythm disturbance
1
2
3

26. VT-Acute management
PULSELESS:
• ACLS protocol
• Immediate unsynchronised defibrillation>> if no
response
• CPR with minimal interruption (30:2, with 2 minute
cycles)
• Intubation
• O2
• IV access
• Adrenaline 1mg Q3min
• Amiodarone 300mg (following 3rd shock)
• Exclude reversible causes

27. VT-acute treatment
European Heart Journal (2015) 36, 2793–2867
doi:10.1093/eurheartj/ehv316
No SHD

29. Identifyrhythm disturbance

30. Torsade-Acute treatment
• In an otherwise stable patient, DC cardioversion is kept as a
last resort
• Magnesium can be given at 1-2 g IV initially in 30-60 seconds,
which then can be repeated in 5-15 minutes
• K supplementation to keep K level at high normal
• Isoproterenol can be used in bradycardia-dependent torsade
• TemporaryPM
• Consult an electrophysiologist

31. Identifythe rhythm disturbance
What wouldyou recommendfor this patient?
A. Repeat direct current cardioversion(DCCV)
B. StartCardizem drip
C. Refer for catheter ablation of ventricular tachyardia
D. Start intravenous ibutilide
E. Give adenosinebolus

32. Pre-excited AF-acute management
• IV ibutilide >>increased refractoriness of both AVN and AP
• If not available>>IV procainamide or amiodarone
• In case of hemodynamic instability >> DC shock
• Avoid AVN blocking agents>>hemodynamic collapse and VF
• Send for catheter ablation to avoid SD
ACC guidelines2014

33. Bradyarrhythmias
• Problems with impulse generation>>severe SB, SA
• Problems with AV conduction>>HB

34. Bradycardia managementalgorithm

35. Take-home message
• Diagnosis of life threatening arrhythmia is challenging. It
should be fast and accurate
• In case of tachyarrhythmia+ hemodynamic compromise >>
electric CV
• In case of tachyarrhythmia with hemodynamic stability
manage with AADs >>if failed CV
• In case of severe bradyarrhythmia >> manage as protocol
• Correct the underlying electrolyte metabolic disturbance
• Manage the underlying SHD as protocol
• For long term management >>consult an electrophysiologist

36. Thank you for attention