Telemetry / Arrythmias

Dan Crouch

Kristi Kuhn

Kate Lindley

Ben Voss

Unresponsive patient in ED

Junctional tachycardia

Regular Narrow complex No P waves

Surgical consult for arrhythmia

Paroxysmal SVT (PAT)

Benign rhythm If sustained:

• Vagal maneuvers

• Adenosine

• DCCV

70 yo AAF with palpitations

Premature ventricular complexes

Abnormal but usually benign• Concerns: very frequent, history of ischemia

Ask about symptoms (palpitations, “skipping a beat”)• Beta-blockers for symptomatic patients

Called to see sleeping patient

NSVT

ICM or NICM• Usually not an indication for ICD

Ask about symptoms Use more beta-blockers

Patient with L-sided weakness

Atrial fibrillation

Irregular No coordinated atrial activity (no P waves) Rate control Anticoagulation

Lung transplant pt with SOB

Atrial flutter (2:1)

Regular rhythm Flutter circuit rate: 300 bpm Re-entrant circuit Diagnostic maneuvers: vagal stimulation, adenosine

Typical atrial flutter

“Sawtooth” pattern

Atrial flutter (variable block)

Regular flutter waves @ 300 bpm Irregular ventricular response

• Usually seen with AV nodal blockade

May be difficult to distinguish from coarse Afib

Nursing student asks for help

Mobitz I (Wenkebach)

Regular P waves Lengthening P-R interval Shortening R-R interval Predictably dropped beats (grouped beats)

Patient with syncope

Mobitz II

Randomly dropped beats Frequently progresses to 3rd degree AVB or complete

heart block Can be indication for pacemaker

27 yo WM with syncope at work

Complete Heart Block

Normal sinus node activity (P waves) No ventricular response Pt presented with syncope while driving forklift

Patient with chest pain

Ventricular tachycardia

Wide complex tachycardias• VT until proven otherwise for patients with ischemia

• Brugada criteria: only AV dissociation useful on tele– GET AN EKG!!

• Non-malignant rhythm with aberrancy also possible

Pt missed dialysis

Hyperkalemia

QRS widening Peaked T waves Treatment:

• Calcium first• Insulin/glucose, albuterol, glucagon, NaHCO3, IVF/Lasix• Kayexalate last

18 yo WF postpartum

Torsades de pointes

Polymorphic ventricular tachycardia Life-threatening with degeneration to VF Usually precipitated by PVC in setting of long QT Often associated with QT-prolonging drugs Check for electrolyte disturbances (especially Mg)

Regardless of the telemetry…