Arrhytmias 2013


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Arrhytmias 2013

  1. 1. Arrhytmias Tamás Ötvös m.d. 2013
  2. 2. Initial assessment and treatment • Follow the ABCDE approach! • Asses for adverse signs! • Administration of high flow oxygen! • Obtain intravenous access! • Establish monitoring (ECG,BP,SpO2)! • Record a 12-lead-ECG! • Correct electrolyte abnormalities(K+,Mg+,Ca+)! • Look for the cause of arrhytmia!
  3. 3. Initial assessment and treatment • The treatment depends on the condition of the patient! (stable vs. unstable) • Anti-arrhytmic drugs: – slower in onset – for stable patients without adverse signs • Electrical treatment (CV or PM) for unstable patients
  4. 4. Adverse signs Shock • pallor, sweating, cold extremities (increased sympathetic activity) • impaired consciousness (reduced cerebral blood flow) • hypotension (systolic BP<90mmHg)
  5. 5. Adverse signs Syncope • loss of consciousness • reduced cerebral blood flow
  6. 6. Adverse signs Heart failure • arrhytmias decrease coronary blood flow • acute left ventricle failure • acute right ventricle failure
  7. 7. Adverse signs Myocardial ischaemia • chest pain • silent ischaemia
  8. 8. Unstable patient with tachycardia • synchronized electrical cardioversion • the shock is synchronized with the „R”-wave • for broad-complex tachycardia start with 200J monophasic or 120-150J biphasic • for narrow-complex tachycardia start with 100J monophasic or 70-120J biphasic • If CV fails, amiodarone 300mg iv over 10-20min and re-attempt CV
  9. 9. Stable patient with tachycardia Regular broad-complex tachycardia • Ventricular tachycardia • Supraventricular tachycardia with bundle branch block (for diff. diagnosis can give adenosine) • Amiodarone 300mg iv. over 20-60 min. followed by infusion of 900mg over 24 h. • Other drugs: procainamide, nifekalan, sotalol
  10. 10. Stable patient with tachycardia Irregular broad complex tachycardia • AF with bundle branch block (treat as AF) • Pre-excitation sy. (WPW,LGL) (avoid adenosine, digoxin, verapamil, diltiazem) • Polymorphic VT (torsade de pointes)(give magnesium sulphate 2g over 10 min)
  11. 11. Stable patient with tachycardia Regular narrow-complex tachycardia • Sinus tachycardia – can be physiological response – e.g. pain, fever, anaemia, blood loss, heart failure – NEVER try to treat!!!
  12. 12. Stable patient with tachycardia Regular narrow-complex tachycardia • AVNRT & AVRT (paroxysmal SVT) – AVNRT is the commonest type (without any form of heart desease) and benign – AVRT is seen with WPW-sy (usually benign, often no visible atrial activity on ECG)
  13. 13. AVNRT
  14. 14. Stable patient with tachycardia Regular narrow-complex tachycardia • Atrial flutter with regular AV conduction (often 2:1 block) – Atrial rate 300/min
  15. 15. Atrial flutter 2:1 conduction
  16. 16. Stable patient with tachycardia Treatment of regular narrow complex tachycardia • If the patient is unstable attempt CV (until CV can try adenosine) • Start with vagal manoeuvres: carotid sinus massage or the Valsalva manoeuvre • Give adenosine 6mg,12mg,12mg • Give a calcium channel blocker (e.g., verapamil or diltiazem)
  17. 17. Stable patient with tachycardia Irregular narrow-complex tachycardia • AF or atrial flutter with variable AV-block • If there are no adverse features, treatment options include: – rate control by drug therapy – rhythm control using drugs to encourage chemical cardioversion; – rhythm control by electrical cardioversion; – treatment to prevent complications (e.g., anticoagulation)
  18. 18. Atrial fibrillation
  19. 19. Stable patient with tachycardia Atrial fibrillation • The longer a patient remains in AF, the greater is the likelihood of atrial clot developing. • Patients who have been in AF for more than 48 h should not be treated by cardioversion (electrical or chemical) until they have received full anticoagulation or absence of atrial clot has been shown by transoesophageal echocardiography.
  20. 20. Stable patient with tachycardia Atrial fibrillation treatment • If the aim is control the HR: beta-blockers or diltiazem, digoxin or amiodarone in heart failure. (Magnesium) • If the duration of AF<48hr, chemical cardioversion: ibutilide, flecainide or dofetilide, amiodarone, propafenone. • Or electrical CardioVersion!
  21. 21. Bradycardia • HR<60/min • Cardiac causes: e.g., myocardial infarction;myocardial ischaemia; sick sinus syndrome • Non-cardiac causes:e.g., vasovagal response, hypothermia; hypoglycaemia; hypothyroidism,raised intracranial pressure) • Drug toxicity:e.g., digoxin; beta-blockers; calcium channel blockers
  22. 22. SSS
  23. 23. 1st degree AV-block
  24. 24. Second degree AV-block(Mobitz-I)
  25. 25. Second degree AV-block(Mobitz-II)
  26. 26. Third degree AV-block
  27. 27. Treatment of bradycardia • ABCDE approach • Consider the potential cause of the bradycardia and look for the adverse signs! • Initial treatments are pharmacological, with pacing being reserved for patients unresponsive to pharmacological treatments or with risks factors for asystole.
  28. 28. Treatment of bradycardia • Atropin: 0.5mg in bolus, repeat it in 3-5min up to 3mg! • Second line drugs: – isoprenaline (5microgramm/min starting dose) – adrenaline (2–10microgramm/min) – dopamine (2–10microgramm/kg/min) – theophylline (100–200mg slow intravenous injection) – glucagon if beta-blockers or calcium channel blockers are a potential cause of the bradycardia
  29. 29. Treatment of bradycardia PACING • Initiate transcutaneous pacing immediately if there is no response to atropine!