Common ITU Arrhythmias - UHB · Common ITU Arrhythmias . CATEGORY: SOP CLASSIFICATION: Clinical...
Transcript of Common ITU Arrhythmias - UHB · Common ITU Arrhythmias . CATEGORY: SOP CLASSIFICATION: Clinical...
Common ITU Arrhythmias
CATEGORY: SOP
CLASSIFICATION: Clinical
PURPOSE Common ITU Arrhythmias
Controlled Document Number: C017
Version Number: 1.0
Document Author: QEHB Critical Care Tactical Working Group
Approved By: Medical Scientific Advisory Group (COVID-19)
Date / Time: 06/04/2020
Review Date: 30/09/2020
Distribution:
• Recommended Reading for:
Clinicians, all non medical Prescribers, Pharmacists and nurses
• Information for: Wards Managers, Senior Nurses, ADNs, Divisional Directors
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Page 1 of 1 CDN: C017 V 1.0 Title: Common ITU Arrhythmias Issued 06.04.2020
B Pouchet
Common ITU Arrhythmias
Arrhythmias
� Most common is atrial fibrillation often with rapid ventricular response (fast AF)
� Other potential life threatening arrhythmias include: � Ventricular tachycardia (VT) � Supraventricular tachycardia (SVT) � Heart block
� These arrhythmias can decrease cardiac output (cause
shock) or can potentially or actually cause cardiac standstill (cardiac arrest)
Atrial Fibrillation
Atrial Fibrillation
� Most common arrhythmia – occurs in 15 – 28% of non- cardiac ITU patients
� Associated with increased mortality and length of stay in non-cardiac surgery patients
� Risk factors: � Increased Right Atrial Pressure regardless of fluid status � Presence of SIRS (inflammation) � Increased catecholamines � Hypovolaemia � Fluid overload in post cardiac surgery
Fast AF
� Evidence lacking for prophylaxis outside cardiothoracic surgery units
� Magnesium may be effective treatment (40% conversion)
� DC cardioversion poor conversion rate and frequent recurrence
� Digoxin rate control <50% success
� Beta blocker rate control more effective (75-80%)
� Amiodarone most effective in CTS and in general ITU for rate control and cardioversion, less favourable haemodynamics than beta blockers
AF
� May not resolve until inflammatory process such as sepsis resolves
� Rate control is needed to prevent rapid ventricular rate and reduced cardiac output from inadequate filling times
� AF reduces atrial contribution to stroke volume (about 33%)
� Cardiac beta blocker such as bisoprolol or metoprolol can be used for rate control
� Amiodarone is suitable alternative with loading dose (300mg) followed by continuous infusion for 24hours (600- 900mg/24hrs) which can be repeated without re-loading
AF - Management
� Get 12 lead ECG to confirm diagnosis � Correct electrolytes
� Rate control with beta blockers or amiodarone
� Do not try to chemically or electrically cardiovert patients unless you have ECHO evidence of no atrial thrombi or onset less than 48 hours – risk of stroke or PE
� Cardioversion only for patients who are haemodynamically unstable because of AF and have evidence of no atrial thrombi
� Consider anticoagulation for patients if AF persists more than 48hours
SVT
SVT
� Less common in ITU
� Not usually associated with electrolyte disturbance
� Treatment: adenosine and DC cardioversion
� If recurrent consider: beta blocker or verapamil +/- flecainide or amiodarone
VT/VF
� Treat as per ALS guidelines
� Medical emergency
Heart Block
� Decreased conduction through AV node resulting in bradycardia
� Three degrees: 1st, 2nd, and 3rd degree
� Type II second degree and third degree require urgent intervention
� Treatment is with atropine, isoprenaline to increase heart rate, then pacing
� Need 12 lead ECG and cardiology input
Heart block
� Ist degree: � Prolonged PR interval (>5 small squares) � Every p wave (atrial depolarization) has a QRS (ventricular
depolarization/repolarization)
� 2nd degree: � Dropped beats (p waves with no corresponding QRS) � Two types
� Mobitz type I – gradual increase in p-R interval until dropped beat occurs – relatively benign
� Mobitz type II – dropped beats ( p wave with no QRS) occurring with no preceding increase in PR interval; usually fixed ratio of p waves to QRS (eg 3:1, 3:2) – associated with structural defect in conducting system
� 3rd degree: AV dissociation – no relationship between p waves
and QRS; ventricular rate is because of ventricular pacemakers and very slow
Heart Block
Heart Block
� Get 12 lead ECG
� Contact cardiology if IIb or III degree for urgent consideration of pacing
� Cardiac output can be increased using catecholamine infusions such as isoprenaline, dobutamine or adrenaline