Indiana ENA 2011 Tachyarrhythmias
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1. The document provides an overview of treating various tachyarrhythmias, including wide complex tachycardia (WCT). 2. It emphasizes that WCT should be treated as ventricular tachycardia (VT) until proven otherwise, as an electrocardiogram cannot reliably distinguish VT from supraventricular tachycardia. 3. Specific treatments are discussed for different arrhythmias, including the use of procainamide for most cases of WCT when the rhythm is uncertain, as well as contraindications for certain drugs.
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Indiana ENA 2011 Tachyarrhythmias
- 2. Andrew J. Bowman Acute Care Nurse Practitioner Fellow – American College CV Nurses Registered Nurse Paramedic
- 4. TACHYARRHYTHMIAS What works… What doesn’t… What KILLS!!!
- 5. OVERVIEW • • • • • Wide Complex Tachycardia (WCT) Ventricular Tachycardia (VT) Adenosine in WCT Wolff-Parkinson-White Syndrome The “walking-talking” VF patient
- 6. ACLS Algorithm • 2010 AHA Guidelines for WCT – Determine Stability – Obtain 12 Lead EKG (if Stable) – Regular or Irregular
- 7. ACLS Algorithm • Regular WCT – If confirm VT or SVT with Aberrancy • Treat accordingly – If not able to determine • Adenosine likely safe to treat and/or diagnose
- 8. ACLS Algorithm • Irregular WCT – Atrial Fibrillation or Flutter • Rate Control • Rhythm Control – Polymorphic VT • Defibrillation Likely Needed • Treat baseline long QTc if present
- 9. Wide Complex Tachycardia • Definition – ANY heart rhythm with… – QRS duration >= 120ms (3 little boxes) – Ventricular rate > 100bpm – VERY BROAD & INCLUSIVE!!!
- 10. WCT • Differential Dx – VT – VT!! –VT!!! – SVT with BBB – SVT with Aberrant Conduction – Paced Rhythms – AV Re-Entrant Tachycardia with Antidromic Conduction – Electrolyte Abnormalities – Drug Toxicity (Na+ Channel Blockers)
- 11. Yes or No? • EKG can reliably distinguish VT from SVT with BBB /aberrant conduction ?
- 12. Yes or No? • EKG can reliably distinguish VT from SVT with BBB /aberrant conduction? •NO!!!!!
- 13. Yes or No? • EKG can reliably distinguish VT from SVT with BBB /aberrant conduction? •NO!!!!! • EKG rules IN VT • Nothing reliably rules OUT VT
- 14. “BEST” Teaching • Assume wide complex tachycardia (WCT) is VT until proven otherwise • When in doubt, assume and treat WCT as VT
- 15. EKG Favors VT • • • • • • • AV Dissociation Fusion Beats Left Axis or Right Axis Extreme Right Axis QRS > 140ms duration RS > 100ms Precordial Concordance – (All UP or All DOWN)
- 16. Fusion
- 17. QRS > 140ms RS > 100ms
- 18. Concordance
- 19. Brugada Criteria • 4 step process – No RS complex all precordial leads? – RS interval > 100ms in 1 precordial lead? – AV dissociation? – Morphology criteria for VT present in precordial leads V1-2 and V6?
- 20. Brugada Criteria • 27 EKG’s with WCT • 3 ED Physicians • Applied Brugada Criteria • 22% Intra-operator variability with OPEN BOOK TEST!!!
- 21. Wellens Criteria • QRS width > 0.14 secs • Left axis deviation > -30 • AV Dissociation • Certain QRS configurations – RBBB type QRS • Monophasic R, qR, QR, RS in V1 • R/S < 1, monophasic R, QR, QS in V6 – LBBB type QRS • qR or Qs in V6
- 22. Akhtar Criteria • AV Dissociation • LBBB and rightward axis >90 • Positive QRS concordance • RBBB and QRS > 0.14 secs • QRS axis between – 90 and +180 • LBBB and QRS > 0.16 secs • QRS morphology during tachycardia different from baseline preexisting BBB
- 23. Griffith Criteria • SVT diagnosed only if QRS morphology is typical of a BBB – RBBB • rSR’ in V1 and RS in V6 with R/S > 1 – LBBB • rS or QS in V1 and V2 and delay to S nadir < 70 msecs • R wave and no Q wave in V6
- 24. But What Did We Say??? • EKG can • Rule ONLY… IN VT • NOT… • Rule OUT VT
- 25. VT or SVT with BBB • Can only say SVT with BBB…IF… • Tachycardia EKG QRS configuration EXACTLY same as baseline EKG QRS configuration
- 26. 43 Male with Palpitations
- 28. th 11 Commandment • Thou shalt not give verapamil to WCT tachycardia! •IT KILLS!!!!!!!
- 29. Clinical Information? • Hemodynamic Status? • Younger Age? • No History Cardiac Disease? •NO!!!!!
- 30. Adenosine (Adenocard) • Can convert SOME VT • Adenosine will NOT convert all SVT • Adenosine responsive VT • Usually younger • No prior known history cardiac disease • SOUND FAMILIAR?????
- 31. Tx of VT • Pulseless • Unstable VT with Pulse • Stable VT
- 32. Pulseless • Treat as VF • Defibrillate
- 33. Unstable VT with Pulse • Synchronized Cardioversion
- 34. Stable VT • Lidocaine? • Amiodarone?? • Procainamide???
- 35. Lidocaine • Poor success rate for converting VT to NSR • 20-30%
- 36. Amiodarone • “GOOD FOR EVERYTHING” • Except…
- 37. Except Cardiac Arrest • “There is no evidence that ANY antiarrhythmic drug given routinely during cardiac arrest increases survival to hospital discharge.” (Hazinski, Circulation, 2005)
- 38. Except Pregnancy • Avoid amiodarone in pregnancy – The ONLY class D antiarrhythmic – Fetal hypothyroidism, IUGR, fetal bradycardia, prematurity – Only if other drugs fail • Procainamide or Lidocaine preferred in pregnant patients with ventricular arrhythmias
- 39. Except A-Fib with WPW • More on this later!
- 40. Except Torsades de Pointes • TDP from prolonged QTc – Further prolongs QTc and worsens TDP – If baseline EKG has NORMAL QTc then it is not TDP, it is polymorphic VT
- 41. Young Woman - Syncope
- 43. Except “SLOW VT” • WCT < 120-130bpm – Think… • AIVR • Na channel blocker OD • Hyperkalemia
- 44. “Slow VT”
- 45. Post - Tx
- 46. “Slow VT” • Inappropriate Tx of “Slow VT” may cause ASYSTOLE – WCT from hyperkalemia may be mis-Dx as VT – AIVR may be mis-Dx as VT – Tx with Lidocaine = ASYSTOLE!! – Tx with Amiodarone = ASYSTOLE!!
- 47. Tx Slow VT • Hyperkalemia – NaHCO3 • TCA OD (Na+ Channel Blocker) – NaHCO3 • AIVR – Benign Neglect
- 48. So What to Use???
- 50. Procainamide • Excellent success ALL types of WCT’s – VT – SVT or Afib with BBB – SVT or Afib with WPW • When in doubt…. …reach for procainamide
- 51. Procainamide Dosing • 20 – 50 mg/min “bolus” until… – Arrhythmia suppression – Hypotension – QRS widens > 50% baseline – 17mg/kg total dose • Then 1-4mg/min infusion
- 52. Wolff-Parkinson-White • Pre-excitation of ventricles because of abnormal pathway of conduction that bypasses the AV node.
- 53. WPW
- 54. WPW • EKG Findings – Short PR interval – Widened QRS – Delta wave – Repolarization changes
- 56. WPW
- 57. WPW Tachyarrhythmias • Orthodromic Conduction • Antidromic Conduction • Atrial Fibrillation
- 58. Orthodromic • Conduction down AVN then back through accessory pathway • Narrow complex QRS (unless BBB)
- 59. Orthodromic Tx • Adenosine • Other AVN blockers – Calcium blockers – Beta blockers
- 60. Antidromic • Conduction down accessory pathway then back through AVN • Wide complex QRS
- 61. Antidromic Tx • Adenosine • Procainamide
- 62. A-Fib with WPW • Atria 400-600 bpm • AVN blocks many • Accessory pathway still available
- 63. A-Fib with WPW
- 64. A-Fib with WPW • Classic EKG Findings – Irregularly-irregular (may be difficult to “eyeball”) – Narrow and wide QRS morphology – Portions “very fast” (>200250bpm, may approach 300bpm)
- 65. A-Fib with WPW
- 66. WPW w A-Fib
- 67. WPW with A-Fib
- 68. WPW with A-Fib
- 69. WPW with A-Fib
- 70. A-Fib with WPW • Atria at 400-600bpm • If unopposed to ventricles • Ventricles at 400-600bpm –VF!!!
- 71. Tx A-Fib with WPW • AVOID AV NODE BLOCKERS!!!!! –A –B –C –D
- 72. Tx A-Fib with WPW • AVOID AV NODE BLOCKERS!!!!! – A – Adenosine AND Amiodarone – B – Beta Blockers – C – Calcium Channel Blockers – D - Digitalis
- 73. A-Fib, WPW & AV Nodal Blockers (The Problem) • Is there evidence of irregularity? • Is there evidence of changing QRS morphology? • Are there sections of “very fast” ventricular rates?
- 74. A-Fib, WPW & AV Nodal Blockers (The Problem)
- 75. Pitfalls • Patient with A-Fib with WPW – Mis-Dx as SVT/VT & give adenosine •VF – Mis-Dx as A-Fib with BBB & give AVN blockers •VF
- 76. AHA • Still recommends Amiodarone for A-Fib in the setting of WPW
- 77. NO!!!!! • Amiodarone – Class – Class – Class – Class I (Na+) II (Beta) III (K+) IV (Calcium)
- 78. How to Tx? • P• P-
- 79. How to Tx? • Procainamide • Propofol (or sedation of choice) and DCC.
- 81. “Walking-Talking” VF • Medics sent for “weak & dizzy all over” • BP cannot be obtained • Pulse “hard to palpate” – “keep losing it” • SpO2 80% and poor waveform
- 82. Arrival to ED • • • • Awake and talking Hoses entering chest wall Battery pack on waist Rhythm below
- 84. VAD • Ventricular Assist Device • Provides mechanical support for failing heart • Support can be… hours…days…months…years
- 85. VAD • Bridge to re-evaluation • Bridge to recovery • Bridge to transplant • Bridge to destination therapy
- 86. VAD Patient • Anti-coagulation – Triple therapy • Anti-arrhythmics • Anti-hypertensives
- 87. VAD Types • Pulsatile Flow – Heartmate XVE – Thoratec IVAD • Non-Pulsatile Flow – Heartmate II
- 88. Calling 911 • Lack of energy or weakness • Symptoms may be vague
- 89. Outpatient Emergencies • • • • • • Arrhythmia Hemolysis Renal Failure Infection Decreased Preload from Dehydration GI Bleeding
- 90. Arrhythmia • VAD’s do not affect EKG tracing • Effects of Prolonged Arrhythmia – Poor Perfusion – Hypoxia – Brain Damage – Death
- 91. Who Has A VAD???
- 92. Arrhythmia • VT / VF – DEFIBRILLATE!!!!! – May require sedation – Disconnect VAD from wall outlet
- 93. No CPR for VAD’s • Disruption of pump anastamosis site • Fatal hemorrhage • Call VAD Center
- 94. Summary • WCT = Tx as VT until proven otherwise • Adenosine probably safe for everything EXCEPT A-Fib with WPW • NO AVN Blockers A-Fib with WPW • VAD’s are more common
- 95. Thank You!!!!!