Perioperative arrhythmias are common and can be caused by patient factors, anesthesia, or surgery. The document defines and classifies different types of arrhythmias including sinus, atrial, junctional, and ventricular rhythms. It describes the characteristic electrocardiogram patterns of normal sinus rhythm as well as abnormal rhythms like sinus bradycardia, premature atrial contractions, atrial fibrillation, and premature ventricular contractions. Perioperative management strategies are discussed for select arrhythmias depending on their stability and symptoms. Continuous ECG monitoring is important for arrhythmia detection during the perioperative period.
Ropivacaine is a recently launched local anesthetic in Iran. Because of its more safety profile, it would be an appropriate substitution for routinely used LA, Bupivacaine.
A patient with pacemaker presents a complex challenge to the attending anaesthesiologist. The mode of management will be according to the type of pacemaker implanted. This presentation discusses in brief the peri-operative consideration in a patient with pacemaker.
Ropivacaine is a recently launched local anesthetic in Iran. Because of its more safety profile, it would be an appropriate substitution for routinely used LA, Bupivacaine.
A patient with pacemaker presents a complex challenge to the attending anaesthesiologist. The mode of management will be according to the type of pacemaker implanted. This presentation discusses in brief the peri-operative consideration in a patient with pacemaker.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
2. • Definition: Arrhythmia is defined as
"Abnormality of cardiac rate, rhythm or
conduction.
• Cardiac arrhythmias are the most frequent
perioperative cardiovascular abnormalities
in patients undergoing both cardiac and
non-cardiac surgery.
• The occurrence of arrhythmias have been
reported in 70% of patients subjected to
general anaesthesia for various surgical
procedures.
3. Mechanisms of Arrhythmia
Production
• Re-entry (refractory tissue reactivated due to conduction
block, causes abnormal continuous circuit. eg accessory
pathways linking atria and ventricles in Wolff-Parkinson-
White syndrome)
• Injury or damage (pathology) to the cardiac conduction
systems
• Abnormal pacemaker activity/ automaticity in non-
conducting/conducting tissue (eg. ischaemia)
• Delayed after-depolarisation (automatic depolarisation of
cardiac cell triggers ectopic beats, can be caused by drugs
eg digoxin)
4. Contributing factors and causes
1. Patient related factors-
• preexisting cardiac disease
• central nervous system disease
• Old age
2.Anaesthesia related factors
• Tracheal intubation
• general anaesthetics
• regional anaesthesia
• Electrolyte imbalance and abnormal arterial
blood gases
• Central venous cannulation
9. Anaesthetic considerations
• All patients undergoing anaesthesia and
surgery should have ECG monitoring.
• Lead II and V 5 are superior for arrhythmia
detection and diagnosis before the
appearance of physical signs.
10.
11. Waveform Analysis
– For each strip it is necessary to go through steps
to correctly identify the rhythm
1. Is there a P-wave for every QRS?
• P-waves are upright and uniform
• One P-wave preceding each QRS
2. Is the rhythm regular?
• Verify by assessing R-R interval
• Confirm by assessing P-P interval
3. What is the rate?
• Count the number of beats occuring in one minute
• Counting the p-waves will give the atrial rate
• Counting QRS will give ventricular rate
12. • Normal
– Heart rate = 60 – 100 bpm
– PR interval = 0.12 – 0.20 sec
– QRS interval <0.12
– SA Node discharge = 60 – 100 / min
– AV Node discharge = 40 – 60 min
– Ventricular Tissue discharge = 20 – 40 min
13. • Cardiac cycle
– P wave = atrial depolarization
– PR interval = pause between atrial and
ventricular depolarization
– QRS = ventricular depolarization
– T wave = ventricular depolarization
15. • Normal Sinus Rhythm
– Sinus Node is the primary pacemaker
– One upright uniform p-wave for every QRS
– Rhythm is regular
– Rate is between 60-100 beats per minute
Sinus Rhythms
17. • Sinus Bradycardia
– One upright uniform p-wave for every QRS
– Rhythm is regular
– Rate less than 60 beats per minute
• SA node firing slower than normal
• Normal for many individuals
• Identify what is normal heart rate for patient
Sinus Rhythms
18. Perioperative causes of Sinus Bradycardia-:
1. Vagal stimulation- Oculocardiac reflex, Celiac
plexus stimulation(traction on mesentry),
laryngoscopy, Abdominal insufflation, Nausea
and ECT
2. Drugs- Beat blocker, Cal channel blocker, opioids
(fentanyl/sufentanyl)
3. Succinylcholine 4.Hypothermia
5. Hypothyroidism 6. Atheletic heart syndrome
7. SA node disease or ischemia
19. Perioperative T/T-
- In asymptomatic pt no t/t requires
- In Mildly symptomatic pts, underlying factors
should be eleminated
- In severly symptomatic pts, those with chest pain
or syncope, immediate
transcutaneous/transvenous pacing is required.
- Atropine 0.5 mg Iv every 3-5 min(max 3mg) may
be given. It should be noted dose of atropine
(<0.5mg) can cause further slowing of HR.
- An epinephrine or dopamine infusion may be
titrated while awaiting cardiac pacing.
21. • Sinus Tachycardia
– One upright uniform p-wave for every QRS
– Rhythm is regular
– Rate is greater than 100 beats per minute due to
increased SA node discharge sec. to sympathetic
stimulation (physiological/pathological
/pharmacological response)
• Usually between 100-160 (>160 SVT)
• Can be high due to anxiety, stress, fever, medications
(anything that increases oxygen consumption)
Sinus Rhythms
22. Treatment-:
-correcting underlying cause of symp. Stimulation.
-Beta blockers may be employed to lower heart rate
and decrease myocardial o2 demand(if pt is not
hypovolemic).
-supplemental O2 to increase supply in response to
increase demand.
-Avoidance of vagolytic drug (pancuronium)
intraoperatively
24. • Sinus Arrhythmia
– One upright uniform p-wave for every QRS
– Rhythm is irregular
• Rate increases as the patient breathes in
• Rate decreases as the patient breathes out
– Rate is usually 60-100 (may be slower)
– Variation of normal, not life threatening
Sinus Rhythms
25. Premature Atrial Contraction (PAC)
Heart
Rate
Rhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
NA Irregular
Premature &
abnormal or
hidden
.12 - .20 <.12
Atrial Rhythms
26. – Premature Atrial Contraction (PAC)
• One P-wave for every QRS
– P-wave may have different morphology on ectopic beat,
but it will be present
• Single ectopic beat will disrupt regularity of
underlying rhythm
• Rate will depend on underlying rhythm
• Underlying rhythm must be identified
• Classified as rare, occasional, or frequent PAC’s
based on frequency
Atrial Rhythms
27. • Sign and symptoms
-PACs arises from ectopic foci in atria. Typical
symptoms include an awareness of a fluttering
or a heavy heart beat.
-Precipitated by excessive caffeine, stress,
alcohol, nicotine and hyperthyroidism.
-Often occur at rest and become less frequent
by exercise.
-second most arrhythmias asso. With MI.
28. Perioperative T/t-:
1. Avoidance of ppt. factors and sympathetic
stimulation.
2. Pharmacological T/t required only if the PACs
trigger sec. dysrhythmias.
3. Usually suppressed by calcium channel
blocker or Beta blocker.
30. • Atrial Fibrillation
– No discernable p-waves preceding the QRS complex
• The atria are not depolarizing effectively, but fibrillating
– Rhythm is grossly irregular
– If the heart rate is <100 it is considered controlled a-
fib, if >100 it is considered to have a “rapid ventricular
response”
– AV node acts as a “filter”, blocking out most of the
impulses sent by the atria in an attempt to control the
heart rate
Atrial Rhythms
31. • Atrial Fibrillation (con’t)
– Often a chronic condition, medical attention only
necessary if patient becomes symptomatic
– Patient will report history of atrial fibrillation.
– Symptoms range from palpitation to angina
pectoris, CHF, pul. Oedema and hypotension
– Often associated with fatigue and generalized
weakness.
– Predisposing factors are :RHD, hypertension,
thyrotoxicosis, IHD, chronic COPD, pericarditis
and pulmonary embolus.
Atrial Rhythms
32. Perioperative management-
-If new onset of AF, surgery should be postponed if possible
untill control of dysrhythmia.
-T/t of AF during Sx depends on hemodynamic stability of pt.
-if hemodynamically significat, the T/t is cardioversion
-Synchronized electrical cardioversion (100 to 200 J) is most
effective.
-Pharmacological cardioversion by IV amiodarone (pref.drug),
diltiazem or verapamil may be attempted.
-Pt with chronic AF should be maintained on their
antidysrhythmic drugs with close attention to serum
electrolyte(K &Mg).
-Manage the transition on and off IV and oral anticoagulation.
33. Atrial Flutter
Heart Rate Rhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
Atrial=250
– 400
Ventricular
Var.
Irregular Sawtooth
Not
Measur-
able
<.12
Atrial Rhythms
34. • Atrial Flutter
– More than one p-wave for every QRS complex
• Demonstrate a “sawtooth” appearance
– Atrial rhythm is regular. Ventricular rhythm will be
regular if the AV node conducts consistently. If the
pattern varies, the ventricular rate will be irregular
– Rate will depend on the ratio of impulses conducted
through the ventricles
– Most commonly atrial rate compared to ventricular
rate 2:1 (if atrial rate is 300bpm and 2:1 conduction,pt
can present with venticular rate of 150 with sign and
symptoms)
Atrial Rhythms
35. • Peioperative T/t-
-T/t depends on hemodynamic stability of
patient.
-If AF is hemodymamically sig. the T/t is
cardioversion, synchronized elec. Cardioversion
satarting at 50 J is indicated.
-Pharmacological control of ventricular response
with IV amiodarone, diltiazem or verapamil may
be tried, if vital signs are stable.
36. Atrial Rhythms
• Atrial Flutter
– Atrial flutter is classified as a ratio of p-waves
per QRS complexes (ex: 3:1 flutter 3 p-waves
for each QRS)
– Not considered life threatening, consult
physician if patient symptomatic
37. • Rhythms that originate at the AV junction
• Junctional rhythms do not have
characteristic p-waves.
Junctional Rhythms
38. Premature Junctional Contraction PJC
Heart
Rate
Rhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
Usually
normal
Irregular
Premature,
abnormal, may be
inverted or hidden
Short
<.12
Normal
<.12
Junctional Rhythms
39. • Premature Junctional Contraction (PJC)
– P-wave can come before or after the QRS complex,
or it may lost in the QRS complex
• If visible, the p-wave will be inverted
– Rhythm will be irregular due to single ectopic beat
– Heart rate will depend on underlying rhythm
– Underlying rhythm must be identified
– Classify as rare, occasional, or frequent PJC based
on frequency
– Atria are depolarized via retrograde conduction
Junctional Rhythms
41. • Accelerated Junctional Rhythm
– P-wave can come before or after the QRS
complex, or lost within the QRS complex
• If p-waves are seen they will be inverted
– Rhythm is regular
– Heart rate between 60-100 beats per minute
• Within the normal HR range
• Fast rate for the junction (normally 40-60 bpm)
Junctional Rhythms
43. • Junctional Tachycardia
– P-wave can come before or after the QRS complex or
lost within the QRS entirely
• If a p-wave is seen it will be inverted
– Rhythm is regular
– Rate is between 100-180 beats per minute
• In the tachycardia range, but not originating from SA node
– AV node has sped up to override the SA node for
control of the heart
– Junctional rhythm often result in AV dyssynchrony
and a junctional tachycardia can severly impaired
Cardiac output.
Junctional Rhythms
44. • Perioperative T/t-
-Junctional rhythm is not frquent during GA.
-Transient Junctional rhythm require no T/t
-Loss of AV synchrony during a junctional
rhythm may result in MI, heat failure or
hypotension
-Atropine 0.5 mg can be used to treat
hemodynamically significat junctional rhythms
45. Ventricular Rhythms
Premature Ventricular Contraction (PVC)
Heart
Rate
Rhythm P Wave
PR
Interval
(sec.)
QRS
(Sec.)
Var. Irregular
No P waves
associated with
premature beat
NA
Wide
>.12
46. Ventricular Rhythms
• Premature Ventricular Contraction (PVC)
– The ectopic beat is not preceded by a p-wave
– Irregular rhythm due to ectopic beat
– Rate will be determined by the underlying rhythm
– QRS is wide and may be bizarre in appearance
– Caused by a irritable focus within the ventricle which
fires prematurely
47. Ventricular Rhythm
• Premature Ventricular Contraction
– Classify as rare, occasional, or frequent
– Classify as unifocal, or multifocal PVC’s
• Unifocal-originating from same area of the
ventricle; distinguished by same morphology
48. Ventricular Rhythm
• Premature Ventricular Contraction
– Classify as unifocal, or multifocal PVC’s
– Unifocal-originating from same area of the
ventricle; distinguished by same morphology
– Multifocal-originating from different areas of the
ventricle; distinguished by different morphology
49. Ventricular Rhythm
• Premature Ventricular Contraction
– Bigeminy
• A PVC occurring every other beat
– Also seen as Trigeminy, Quadrigeminy
51. • Causes of PVCs
- Arterial hypoxemia
- MI
- Myocarditis
- SNS activation
- Hypokalemia/Hypomagnesemia
- Digitalis toxicity
- Caffeine, cocaine,Alcohol
- Mechanical irritation-(CV or Pulm. Artery
catheter)
52. • Prioperative T/t-
-During anaesthesia, if pt exhibits 6 or more PVCs
per minute and repetetive or multifocal forms,
there is increased risk of developing life
threatining dysrhythmia.
-T/t include a D/d of possible cause and t/t of that
cause, while t/t of cause, the immediate
availability of a defibrillator should be confirmed.
-Beta blockers are the most successful drug,
amiodarone,lidocaine and other antiarhythmic
are indicated if the PVCs progress to VT or
ferquent to cause hemodynamic instability.
54. Ventricular Rhythms
• Ventricular Tachycardia
– No discernable p-waves with QRS
– Rhythm is regular
– Atrial rate cannot be determined, ventricular
rate is between 150-250 beats per minute
– Must see 4-6 beats in a row to classify as v-
tach
55. Ventricular Rhythms
• Ventricular Tachycardia
– THIS IS A DEADLY RHYTHM
• Check patient:
– If patient awake and alert, monitor patient and call physician
– Pt with symptomatic or unstable VT or SVT cardioverted
immediately.
– If vitals signs stable and VT is persistent or recurrent after
cardioversion, Amiodarone 150mg over 10min should be
given, other drugs may be used like procainamide,lignocaine
or sotalol.
– Pulseless VT requires immediate cardioversion/defibrillation
and CPR. (If patient has no vital signs, call code and start
CPR
» Defibrillate)
57. Ventricular Rhythms
• Ventricular Fibrillation
– No discernable p-waves
– No regularity
– Unable to determine rate
– Multiple irritable foci within the ventricles all firing
simultaneously
– May be coarse or fine
– This is a deadly rhythm
• Patient will have no pulse
• Call a code and begin CPR
• Survival is best if defbrillation occcurs within 3-5 min
59. Asystole
• No p-waves
• No regularity
• No Rate
• This rhythm is associated with death
– Check patient and leads
– No pulse
• Begin CPR
60. Heart Block
First Degree Heart Block
Heart
Rate
Rhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
Norm. Regular
Before each QRS,
Identical
> .20 <.12
61. Heart Block
– First Degree Heart Block
• P-wave for every QRS
• Rhythm is regular
• Rate may vary
• Av Node hold each impulse longer than normal
before conducting normally through the ventricles
• Prolonged PR interval
– Looks just like normal sinus rhythm
Cuases- increased vagal tone, digitalis toxicity, inferior wall
MI and myocarditis.
-Usually asymptomatic and rarely require T/t.
-Elimination of drugs that slows AV conduction or clinical
factors that enhance vagal tone can reverse 1st degree
block.
62. Heart Block
Second Degree Heart Block
Mobitz Type I (Wenckebach)
Heart
Rate
Rhythm P Wave
PR Interval
(sec.)
QRS
(Sec.
)
Norm.
can be
slow
Irregular
Present but some
not followed by
QRS
Progressively
longer
<.12
63. Heart Block
• Second Degree Heart Block
• Mobitz Type I (Wenckebach)
– Some p-waves are not followed by QRS complexes
– Rhythm is irregular
• R-R interval is in a pattern of grouped beating
– Rate 60-100 bpm
– Intermittent Block at the AV Node
• Progressively prolonged p-r interval until a QRS is blocked
completely
64. Heart Block
Second Degree Heart Block
Mobitz Type II (Classical)
Heart
Rate
Rhythm P Wave
PR
Interval
(sec.)
QRS
(Sec.)
Usually
slow
Regular
or
irregular
2 3 or 4 before each
QRS, Identical
.12 - .20
<.12
depends
65. Heart Block
• Second Degree Heart Block
• Mobitz Type II (Classical)
– More p-waves than QRS complexes
– Rhythm is irregular
– Atrial rate 60-100 bpm; Ventricular rate 30-100 bpm
(depending on the ratio on conduction)
– Intermittent block at the AV node
• AV node normally conducts some beats while blocking others
• Mobitz type II block has high rate of progression to 3rd
degree heart block. A cardiac pacemaker is mandatory in this
situation.
66. Heart Block
Third Degree Heart Block
(Complete)
Heart
Rate
Rhythm P Wave
PR
Interval
(sec.)
QRS
(Sec.)
30 –
60
Regular
Present but no
correlation to QRS
may be hidden
Varies
<.12
depends
67. Heart Block
• Third Degree Heart Block (Complete)
– There are more p-waves than QRS
complexes
– Both P-P and R-R intervals are regular
– Atrial rate within normal range; Ventricular
rate between 20-60 bpm
– The block at the AV node is complete
• There is no relationship between the p-waves and
QRS complexes.
• Cardiac pacing is require in cases of 3rd degree
block
68. • Anaesthetic management
-Previous placement of a transvenous pacemacker or
availability of of transcutaneous cardiac pacing is required
before an anesthetic is administered for insertion of
permanent cardiac pacemaker ,
-Isoproterenol may be required to maintain acceptable HR
and acts as “chemical pacemaker” untill the artificial
pacemaker is functional
69. MODALITIES FOR TREATMENT OF
ARRHYTHMIA
• Antiarrhythmic drugs
. All such drugs may aggravate or produce
arrhythmias and they may also depress
ventricular contractility and must, therefore, be
used with caution.
• They are classified according to their effect on
the action potential (Vaughan Williams'
classification)
72. Management of Arrythmia’s
• ECG and rhythm information
• should be interpreted within the context of
total patient assessment
• Providers must evaluate
• Patient’s symptoms
• Clinical signs
• Ventilation, oxygenation, heart rate, blood
pressure, signs of inadequate organ perfusion
73. • In both unstable and symptomatic cases
• Provider must make an assessment whether
it is the arrhythmia that is causing the patient
to be unstable
• Patient in septic shock with sinus
tachycardia 140 / min is unstable
• Electric cardioversion will not improve this
patient’s condition
74. • If patient with severe hypoxemia becomes
hypotensive and develops bradycardia
• Bradycardia is not the primary cause of
instability
• Treating the bradycardia without treating
the hypoxemia is unlikely to improve the
patient’s condition
75.
76.
77. Supraventricular Tachycardia
• (Supraventricular - a rhythm process in which
the ventricles are activated from the atria or
AV node/His bundle region)
• Refers to supraventricular tachycardia other
than afib, aflutter and MAT
• Occurs in 35 per 100,000 person-years
• Usually due to reentry—AVNRT or AVRT
78. • QRS typically narrow (in absence of bundle
branch block); thus, also termed narrow QRS
tachycardia
• Usually paroxysmal, i.e, starting and stopping
abruptly; called PSVT
• Aetiology should be considered before
therapy is instituted
79. Vagal maneuver
• Valsalva maneuver or carotid sinus massage
• Terminate up to 25% of PSVTs
• For other SVTs
• May transiently slow the ventricular rate
• Potentially assist rhythm diagnosis but will
not usually terminate such arrhythmias
80. Adenosine ( if regular)
• If PSVT does not respond to vagal maneuvers
• Give 6 mg of IV adenosine as a rapid IV push
through antecubital vein followed by a 20 mL
saline flush
• If the rhythm does not convert within 1 to 2
minutes
• Give a 12 mg rapid IV push using the method
above
82. Rate Control
• Unstable patients
• Prompt electric cardioversion
• Stable patients
• Ventricular rate control as directed by
patient symptoms
• IV nondihydropyridine calcium channel
blockers
Diltiazem are drugs of choice for acute rate
control in most individuals with atrial
fibrillation and rapid ventricular rate
83. Ventricular arrhythmias
• Non-sustained ventricular
arrhythmias
- routinely seen in the absence of cardiac
disease- may not require drug therapy in the
perioperative period.
- Conversely, in patients with structural heart
disease, these non-sustained rhythms do
predict subsequent life-threatening ventricular
arrhythmias.
84. NSVT after - cardiopulmonary bypass, unstable
patients with marginal perfusion may
deteriorate with recurrent episodes of NSVT
may benefit from suppression with lidocaine or
beta blockade.
repletion of post-bypass hypomagnesaemia
(MgCl2 2 g i.v.) reduces the incidence of NSVT
after cardiac surgery.
85. Sustained VT
• two categories: monomorphic and
polymorphic.
• monomorphic VT - the amplitude of the QRS
complex remains constant
• polymorphic ventricular tachycardia - the QRS
morphology continually changes.
86. Therapy for monomorphic wide
complex tachycardia
• If the etiology of the rhythm cannot be
determined
• QRS monomorphic, regular
• IV adenosine is relatively safe for both
treatment and diagnosis
• However, adenosine should not be given for
unstable or irregular or polymorphic wide
complex tachycardias
• • It may cause degeneration of the
arrhythmia to VF
87. • If the wide-complex tachycardia proves to be
SVT with aberrancy
• transiently slowed or converted by
adenosine to sinus rhythm
• If due to VT there will be no effect on rhythm
(except in rare cases of idiopathic VT)
• When adenosine is given for undifferentiated
wide complex tachycardia
• Defibrillator should be available
88. For patients who are stable with
likely VT
• IV antiarrhythmic drugs or elective
cardioversion is the preferred treatment
strategy
• Amiodarone
• Procainamide
• Sotalol
• Procainamide and sotalol should be avoided
in patients with prolonged QT, CHF
89. Wide-complex irregular
rhythm
• Should be considered preexcited atrial
fibrillation
• Expert consultation is advised
• Avoid AV nodal blocking agents
• adenosine, calcium channel blockers,
digoxin, and possibly β-blockers
90. Polymorphic (Irregular) VT
• First step
• Stop medications known to prolong the QT
interval
• Correct electrolyte imbalance
• Acute precipitants: drug overdose or
poisoning
91. Prolong QT interval (Torsades de
pointes)
• The management of torsades de pointes
differs markedly from other forms of VT, and
includes
• i.v. magnesium sulfate (2±4 g),
• repleting potassium,
• and manoeuvres aimed at increasing the heart
rate (atropine, isoprenolol or temporary atrial
or ventricular pacing).
• Haemodynamic collapse with torsades
requires asynchronous DC counter shocks