This document provides an overview of peri-arrest arrhythmias including objectives, ECG interpretation, bradycardia, tachycardia, treatment approaches, and specific arrhythmias like atrial fibrillation, ventricular tachycardia, supraventricular tachycardia, and electrolyte abnormalities. The objectives are ECG interpretation in context of patient assessment, concepts of symptomatic and unstable arrhythmias, basic ECG reading, and treatments for tachycardias and bradycardias. Evaluation of stability and symptoms is emphasized over rhythm alone for treatment decisions.
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Management of peri arrest arrhythmias
1. Management of Peri-arrest
Arrhythmias
Presented: Dr Hesham
Faisal, MD, MRCP, EDIC
Consultant Intensivist SFH-Dammam
2. Objectives
• ECG and rhythm information interpretation
within the context of total patient assessment
• The concept of symptomatic &/or unstable
• Basic ECG interpretation
• Tachy-arrhythmias and Brady-arrhythmias
• ECG strips
3. Symptomatic
Bradycardia and Tachycardia
• ACLS providers treatment decisions
– Should not depend solely on rhythm interpretation and neglect clinical
evaluation.
– must evaluate the patient’s symptoms and clinical signs (ventilation,
oxygenation, HR, BP, level of consciousness, and signs of inadequate
organ perfusion)
– Must define the cause of the patient’s instability in order to properly
direct treatment.
• unstable
– vital organ function is acutely impaired or cardiac arrest is ongoing or
imminent
• Symptomatic
– arrhythmia is causing symptoms (palpitations, lightheadedness, or
dyspnea)
– patient is stable and not in imminent danger
13. Bradycardia
• HR <60 beat/minute
• Symptomatic bradycardia < 50 beat/minute
• hypoxemia is a common cause of bradycardia
• Assessment:
– signs of increased work of breathing (tachypnea, intercostal
retracions, suprasternal retracions, paradoxical abdominal
breathing)
– Hypoxemia as determined by pulse oximetry
• Action:
– provide supplementary oxygen.
– Attach a monitor to the patient,
– evaluate blood pressure
– establish IV access.
– If possible, obtain a 12-lead ECG to better define the rhythm.
14. Dysrhythmias Originating in the SA
Node
Rules of Interpretation
Sinus Bradycardia
Rate Less than 60
Rhythm Regular
Pacemaker Site SA node
P Waves Upright & normal
PRI Normal
QRS Normal
15. Bradycardia
• Signs & Symptoms of poor perfusion
– Hypotension
– acute altered mental status
– ischemic chest discomfort,
– acute heart failure, hypotension, or other signs of
shock,
• the patient should receive immediate
treatment.
16. A first-degree AV block
(generally benign)
Rules of Interpretation
First-Degree AV Block
Depends on underlying
Rate
rhythm
Rhythm Usually regular
Pacemaker Site SA node or atrial
P Waves Normal
PRI > 0.20 Seconds
QRS Usually < 0.12 seconds
17. Second Degree, Mobitz type I block, the
block is at the AV node;
the block is often transient and asymptomatic
Rules of Interpretation
Mobitz Type I Second-Degree AV Block
Atrial, normal; ventricular,
Rate normal to slow
Atrial, regular;
Rhythm
ventricular, irregular
Pacemaker Site SA node or arial
Normal, some P waves not
P Waves followed by QRS
Increases until QRS is
PRI dropped, then repeats
QRS Usually < 0.12 seconds
18. Second Degree Mobitz type II block
block is usually below the AV node
often symptomatic potential to progress to complete AVblock .
Rules of Interpretation
Mobitz Type II Second-Degree AV Block
Atrial, normal;
Rate
ventricular, slow
May be regular or
Rhythm
irregular
Pacemaker Site SA node or atrial
Normal, some P waves not
P Waves followed by QRS
Constant for conducted
PRI beats, may be > 0.21 seconds
QRS Normal or > 0.12 seconds
19. Third Degree AV block
AV node,bundle of His, or bundle branches
Rules of Interpretation
Third-Degree AV Block
Atrial, normal;
Rate
ventricular, 40–60
Both atrial and ventricular
Rhythm are regular
SA node and AV
Pacemaker Site
junction or ventricle
Normal,with no
P Waves
correlation to QRS
PRI No relationship to QRS
QRS 0.12 seconds or greater
20. Treatment of Bradycardia
Atropine:
• first-line drug for acute symptomatic bradycardia
(Class IIa, LOE B)
• Dose: 0.5 mg IV every 3 to 5 minutes to a
maximum total dose of 3 mg
• Use cautiously in the presence of acute coronary
ischemia or MI
• ineffective in cardiac transplant patient
• Avoid in type II second-degree or third degree AV
block with a new wide-QRS complex
21. Treatment of Bradycardia
Transcutaneous pacing (TCP):
• unstable patients who do not respond to
atropine (Class IIa, LOE B)
• patient should be prepared for transvenous
pacing and expert consultation should be
obtained.
22. Treatment of Bradycardia
Alternative Drugs:
• unresponsive for atropine
• Temporizing measure awaiting TCP
• overdose of a β blocker or Ca channel blocker.
Dopamine
• 2-10 mcg/kg/minute and titrate to patient response
Epinephrine
• 2 -10 mcg/min and titrate to patient response
Isoproterenol
• 2 to 10 mcg/min by IV infusion, titrated according to
heart rate and
23.
24. Tachycardia
• Heart rate > 100 beats/minute
• clinical significance ≥ 150 beats/minute
• hypoxemia is a common cause of tachycardia,
Assessment:
– signs of increased work of breathing (tachypnea, intercostal retracions,
suprasternal retracions, paradoxical abdominal breathing)
– Hypoxemia as determined by pulse oximetry
Action:
– provide supplementary oxygen.
– Attach a monitor to the patient,
– evaluate blood pressure
– establish IV access.
– If possible, obtain a 12-lead ECG to better define the rhythm
immediate cardioversion should not be delayed if the patient is
unstable
25. Unstable tachycardia
Evaluate
• unstable tachycardia
• with severe signs and symptoms related to a suspected
arrhythmia
– acute altered mental status,
– ischemic chest discomfort,
– acute heart failure,
– hypotension, or other signs of shock
Treat:
• Immediate Cardioversion
• Selected cases of regular narrow complex tachycardia:
Adenosine
26. Synchronized Cardioversion
• establish IV access before cardioversion
• sedation if the patient is conscious
• shock delivery that is timed (synchronized) with the
QRS complex
• avoids shock delivery during the relative refractory
period of the cardiac cycle when a shock could produce
VF
• recommended to treat
1. unstable atrial fibrillation →120 - 200 J
2. unstable SVT → 50 - 100 J
3. Unstable atrial flutter → 50 - 100 J
4. unstable monomorphic (regular) VT → 100 J.
28. Stable tachycardia
Evaluate:
• narrow-complex or wide-complex tachycardia
• rhythm is regular or irregular
• Wide complexes QRS morphology is
– monomorphic
– Polymorphic
Treat:
• Tailored accordingly
29. Narrow–QRS-complex (SVT)
tachycardias
QRS< 0.12 second in order of frequency
• Sinus tachycardia
• Atrial fibrillation
• Atrial flutter
• AV nodal reentry
• Accessory pathway–mediated tachycardia
• Atrial tachycardia (including automatic and reentry
• forms)
• Multifocal atrial tachycardia (MAT)
• Junctional tachycardia (rare in adults)
30. Sinus Tachycardia
physiologic compensation rather than the cause of instability
Rules of Interpretation
Sinus Tachycardia
Rate >100 (220-age )
Rhythm Regular
Pacemaker Site SA node
P Waves Upright & normal
PRI Normal
QRS Normal
31. Supraventricular Tachycardia
(Re-entry SVT)
Rules of Interpretation
Paroxysmal Supraventricular
Tachycardia
Rate 150–250
Rhythm Regular
Pacemaker
Atrial (outside SA Node)
Site
Often buried in
P Waves
preceding T wave
PRI Usually normal
QRS Usually normal
32. Treatment of stable PSVT
Vagal Maneuvers
• Valsalva maneuver or carotid sinus massage
• preferred initial therapeutic choices for the termination
of stable PSVT
• may transiently slow the ventricular rate & assist
rhythm diagnosis
Adenosine (Class I, LOE B)
• 6 mg rapid IV push followed by a 20 mL saline flush
• 12 mg rapid IV push
• Defibrillator should be available
• Side effects: flushing, dyspnea & chest discomfort
33. Treatment of stable PSVT
calcium channel blockers (Class IIa, LOE B)
• verapamil
– 2.5 mg to 5 mg IV bolus over 2 minutes
– repeated doses of 5 -10 mg q 15-30 minutes to a total dose
of 20 mg
– Contraindicated in impaired LV function or heart failure
• Diltiazem
– 15 -20 mg IV over 2 minutes
– maintenance infusion dose is 5-15 mg/hour
IV β-blockers (Class IIa, LOE C)
• metoprolol,atenolol, propranolol, esmolol
• used with caution in patients with COPD or CCF
35. Wide-Complex Tachycardia
Evaluation
1. Stable or unstable patient
– Unstable → immediate cardioversion
2. 12 lead ECG
3. Regular or irregular
a. Regular VT or SVT with aberrancy
b. Irregular atrial fibrillation with aberrancy or
polymorphic VT/torsades de pointes
36. Therapy for Regular stable Wide-
Complex Tachycardias
IV adenosine
• safe for both treatment and diagnosis (Class IIb, LOE B).
• should not be given for unstable or irregular or
polymorphic widecomplex tachycardias
• 6 mg rapid IV push → 12 mg → 12 mg
• defibrillator should be available
Stable likely VT
• IV antiarrhythmic (procainamide, amiodarone or
sotalol)
• Or elective cardioversion
37. Dysrhythmias Originating in the
Ventricles
Rules of Interpretation
Ventricular Tachycardia
Rate 100–250
Rhythm Usually regular
Pacemaker Site Ventricle
If present, not
P Waves
associated with QRS
PRI None
QRS >0.12 seconds, bizarre
38. Irregular Tachycardias
Irregular narrow-complex or wide-complex
tachycardia:
1. atrial fibrillation (with or without aberrant
conduction)
2. MAT
3. sinus rhythm/tachycardia with frequent atrial
premature beats
39. AF
Rules of Interpretation
Atrial Fibrillation
Atrial rate 350–50
Rate Ventricular rate varies
Rhythm Irregularly irregular
Pacemaker Site Atrial (outside SA Node)
P Waves None discernible
PRI None
QRS Normal
40. Treatment of AF
Rate control
• >48 hours are at increased risk for cardioembolic
events
• Avoid Electric or pharmacologic cardioversion unless
the patient is unstable
• IV β –blockers or calcium channel blockers such as
diltiazem
• Digoxin and amiodarone
– Congestive heart failure
• wide-complex irregular rhythm (AF with pre-excitation)
– Avoid AV nodal blocking agents such as adenosine, calcium
channel, β blockers, digoxin
41. MAT
Rules of Interpretation
Multifocal Atrial Tachycardia
Rate More than 100
Rhythm Irregular
Pacemaker Site Ectopic sites in atria
Organized, nonsinus P
P Waves waves; at least 3 forms
Varies depending on
PRI
source of impulse
QRS Variable
42. PACs
Rules of Interpretation
Premature Atrial Contractions
Depends on underlying
Rate
rhythm
Usually regular except
Rhythm
for the PAC
Pacemaker Site Ectopic sites in atria
Occurs earlier than
P Waves
expected
Varies dependent on
PRI
foci of impulse
QRS Usually normal
43. Dysrhythmias Originating in the Atria
Rules of Interpretation
Atrial Flutter
Atrial rate 250–350
Rate Ventricular rate varies
Rhythm Usually regular
Pacemaker Site Atrial (outside SA node)
P Waves F waves are present
PRI Usually normal
QRS Usually normal
44. Dysrhythmias Originating in the
Ventricles
• Torsade de Pointes
– Polymorphic VT.
– Caused by the use of certain
antidysrhythmic drugs.
– Exacerbated by
coadministration of
antihistamines, azole antifungal
agents and macrolide
antibiotics, erythromycin,
azithromycin, and
clarithramycin.
45. Polymorphic (Irregular) VT
torsades de pointes
• requires immediate defibrillation with the same
strategy used for VF
– stop medications known to prolong the QT interval
– Correct electrolyte imbalance
• magnesium is commonly used
– Polymorphic VT associated with familial long QT syndrome
• isoproterenol or ventricular pacing
– Polymorphic VT with bradycardia and drug-induced QT
prolongation
• IV amiodarone and β–blockers
– myocardial ischemia induced Polymorphic VT
46.
47. Dysrhythmias Originating in the
Ventricles
Rules of Interpretation
Artificial Pacemaker Rhythm
Varies with
Rate
pacemaker
May be regular or
Rhythm
irregular
Depends upon
Pacemaker Site
electrode placement
None produced by
P Waves ventricular pacemakers;
pacemaker spike
PRI If present, varies
QRS >0.12 seconds, bizarre
48. Dysrhythmias Resulting from
Disorders of Conduction
• Pre-excitation
Syndromes
– Excitation by an impulse
that bypasses the AV node
• Wolff-Parkinson-
White Syndrome
(WPW)
– Short PRI and long
QRS duration
– Delta waves
– Treat underlying rhythm.
49. ECG Changes Due to Electrolyte
Abnormalities and Hypothermia
• Hyperkalemia
– Tall Ts
• Suspect in patients with a
history of renal failure.
• Hypokalemia
– Prominent U waves
• Hypothermia
– Osborn wave (“J” wave)
– T wave inversion, sinus
bradycardia, atrial fibrillation
or flutter, AV blocks, PVCs, VF,
asystole
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74. Summary
• The goal of therapy for bradycardia or tachycardia is to
– rapidly identify and treat patients who are
hemodynamically unstable or symptomatic due to the
arrhythmia
• Drugs or when appropriate, pacing may be used to control
unstable or symptomatic bradycardia
• Cardioversion or drugs or both may be used to control
unstable or symptomatic tachycardia
• ACLS providers
– should closely monitor stable patients pending expert
consultation and
– should be prepared to aggressively treat those with
evidence of decompensation