Management of peri arrest arrhythmias

Management of Peri-arrest Arrhythmias

Presented: Dr Hesham Faisal, MD, MRCP, EDIC

Consultant Intensivist SFH-Dammam

Objectives

• ECG and rhythm information interpretation within the context of total patient assessment

• The concept of symptomatic &/or unstable• Basic ECG interpretation• Tachy-arrhythmias and Brady-arrhythmias• ECG strips

SymptomaticBradycardia and Tachycardia

• ACLS providers treatment decisions – Should not depend solely on rhythm interpretation and neglect clinical

evaluation.– must evaluate the patient’s symptoms and clinical signs (ventilation,

oxygenation, HR, BP, level of consciousness, and signs of inadequate organ perfusion)

– Must define the cause of the patient’s instability in order to properly direct treatment.

• unstable – vital organ function is acutely impaired or cardiac arrest is ongoing or

imminent• Symptomatic

– arrhythmia is causing symptoms (palpitations, lightheadedness, or dyspnea)– patient is stable and not in imminent danger

The Electrocardiogram

• Relationship of the ECG to Electrical Events in the Heart– ECG Components• P Wave• QRS Complex• T Wave• U Wave


– Refractory Periods• Absolute• Relative

Bradycardia

• HR <60 beat/minute• Symptomatic bradycardia < 50 beat/minute• hypoxemia is a common cause of bradycardia• Assessment:

– signs of increased work of breathing (tachypnea, intercostal retracions, suprasternal retracions, paradoxical abdominal breathing)

– Hypoxemia as determined by pulse oximetry• Action:

– provide supplementary oxygen. – Attach a monitor to the patient, – evaluate blood pressure– establish IV access. – If possible, obtain a 12-lead ECG to better define the rhythm.

Dysrhythmias Originating in the SA Node

NormalQRS

NormalPRI

Upright & normalP Waves

SA nodePacemaker Site

RegularRhythm

Less than 60Rate

Sinus BradycardiaRules of Interpretation

Bradycardia

• Signs & Symptoms of poor perfusion– Hypotension– acute altered mental status– ischemic chest discomfort,– acute heart failure, hypotension, or other signs of

shock,• the patient should receive immediate

treatment.

A first-degree AV block(generally benign)

Usually < 0.12 secondsQRS

> 0.20 SecondsPRI

NormalP Waves

SA node or atrialPacemaker Site

Usually regularRhythm

Depends on underlying rhythmRate

First-Degree AV BlockRules of Interpretation

Second Degree, Mobitz type I block, the block is at the AV node;

the block is often transient and asymptomatic

Usually < 0.12 secondsQRS

Increases until QRS is dropped, then repeatsPRI

Normal, some P waves not followed by QRSP Waves

SA node or arialPacemaker Site

Atrial, regular; ventricular, irregularRhythm

Atrial, normal; ventricular, normal to slowRate

Mobitz Type I Second-Degree AV Block

Rules of Interpretation

Second Degree Mobitz type II block block is usually below the AV node

often symptomatic potential to progress to complete AVblock.

Normal or > 0.12 secondsQRS

Constant for conducted beats, may be > 0.21 secondsPRI

Normal, some P waves not followed by QRSP Waves

SA node or atrialPacemaker Site

May be regular or irregularRhythm

Atrial, normal; ventricular, slowRate

Mobitz Type II Second-Degree AV Block


Third Degree AV block AV node,bundle of His, or bundle branches

0.12 seconds or greaterQRS

No relationship to QRSPRI

Normal,with no correlation to QRSP Waves

SA node and AV junction or ventriclePacemaker Site

Both atrial and ventricular are regularRhythm

Atrial, normal; ventricular, 40–60Rate

Third-Degree AV Block


Treatment of Bradycardia

Atropine:• first-line drug for acute symptomatic bradycardia

(Class IIa, LOE B)• Dose: 0.5 mg IV every 3 to 5 minutes to a maximum

total dose of 3 mg• Use cautiously in the presence of acute coronary

ischemia or MI• ineffective in cardiac transplant patient• Avoid in type II second-degree or third degree AV

block with a new wide-QRS complex


Transcutaneous pacing (TCP):• unstable patients who do not respond to

atropine (Class IIa, LOE B)• patient should be prepared for transvenous

pacing and expert consultation should be obtained.


Alternative Drugs:• unresponsive for atropine• Temporizing measure awaiting TCP• overdose of a β blocker or Ca channel blocker.Dopamine• 2-10 mcg/kg/minute and titrate to patient responseEpinephrine• 2 -10 mcg/min and titrate to patient responseIsoproterenol• 2 to 10 mcg/min by IV infusion, titrated according to heart

rate and

Tachycardia• Heart rate > 100 beats/minute• clinical significance ≥ 150 beats/minute• hypoxemia is a common cause of tachycardia,

Assessment:– signs of increased work of breathing (tachypnea, intercostal retracions,

suprasternal retracions, paradoxical abdominal breathing)– Hypoxemia as determined by pulse oximetry

Action:– provide supplementary oxygen. – Attach a monitor to the patient, – evaluate blood pressure– establish IV access. – If possible, obtain a 12-lead ECG to better define the rhythm immediate cardioversion should not be delayed if the patient is

unstable

Unstable tachycardia

Evaluate • unstable tachycardia • with severe signs and symptoms related to a suspected

arrhythmia– acute altered mental status, – ischemic chest discomfort, – acute heart failure,– hypotension, or other signs of shock

Treat:• Immediate Cardioversion• Selected cases of regular narrow complex tachycardia:

Adenosine

Synchronized Cardioversion

• establish IV access before cardioversion• sedation if the patient is conscious• shock delivery that is timed (synchronized) with the QRS

complex• avoids shock delivery during the relative refractory period of

the cardiac cycle when a shock could produce VF• recommended to treat

1. unstable atrial fibrillation →120 - 200 J2. unstable SVT → 50 - 100 J3. Unstable atrial flutter → 50 - 100 J4. unstable monomorphic (regular) VT → 100 J.


– Refractory Periods• Absolute• Relative

Stable tachycardia

Evaluate:• narrow-complex or wide-complex tachycardia• rhythm is regular or irregular• Wide complexes QRS morphology is – monomorphic– Polymorphic

Treat:• Tailored accordingly

Narrow–QRS-complex (SVT) tachycardias

QRS< 0.12 second in order of frequency• Sinus tachycardia• Atrial fibrillation• Atrial flutter• AV nodal reentry• Accessory pathway–mediated tachycardia• Atrial tachycardia (including automatic and reentry• forms)• Multifocal atrial tachycardia (MAT)• Junctional tachycardia (rare in adults)

Sinus Tachycardiaphysiologic compensation rather than the cause of instability

NormalQRS

NormalPRI

Upright & normalP Waves

SA nodePacemaker Site

RegularRhythm

>100 (220-age )Rate

Sinus TachycardiaRules of Interpretation

Supraventricular Tachycardia (Re-entry SVT)

Usually normalQRS

Usually normalPRI

Often buried in preceding T waveP Waves

Atrial (outside SA Node)Pacemaker Site

RegularRhythm

150–250Rate

Paroxysmal Supraventricular Tachycardia


Treatment of stable PSVT

Vagal Maneuvers• Valsalva maneuver or carotid sinus massage• preferred initial therapeutic choices for the termination of

stable PSVT• may transiently slow the ventricular rate & assist rhythm

diagnosisAdenosine (Class I, LOE B)• 6 mg rapid IV push followed by a 20 mL saline flush• 12 mg rapid IV push• Defibrillator should be available• Side effects: flushing, dyspnea & chest discomfort

Treatment of stable PSVTcalcium channel blockers (Class IIa, LOE B)

• verapamil– 2.5 mg to 5 mg IV bolus over 2 minutes– repeated doses of 5 -10 mg q 15-30 minutes to a total dose

of 20 mg– Contraindicated in impaired LV function or heart failure

• Diltiazem– 15 -20 mg IV over 2 minutes– maintenance infusion dose is 5-15 mg/hour

IV β-blockers (Class IIa, LOE C)

• metoprolol,atenolol, propranolol, esmolol• used with caution in patients with COPD or CCF

Wide–QRS-complex tachycardias

QRS > 0.12 second• Ventricular tachycardia (VT) • SVT with aberrancy• Pre-excited tachycardias [WPW] syndrome• Ventricular paced rhythms

Wide-Complex Tachycardia

Evaluation1. Stable or unstable patient – Unstable → immediate cardioversion

2. 12 lead ECG3. Regular or irregular

a. Regular VT or SVT with aberrancyb. Irregular atrial fibrillation with aberrancy or

polymorphic VT/torsades de pointes

Therapy for Regular stable Wide-Complex Tachycardias

IV adenosine• safe for both treatment and diagnosis (Class IIb, LOE B).• should not be given for unstable or irregular or

polymorphic widecomplex tachycardias• 6 mg rapid IV push → 12 mg → 12 mg• defibrillator should be availableStable likely VT• IV antiarrhythmic (procainamide, amiodarone or

sotalol)• Or elective cardioversion

Dysrhythmias Originating in the Ventricles

>0.12 seconds, bizarreQRS

NonePRI

If present, not associated with QRSP Waves

VentriclePacemaker Site


100–250Rate

Ventricular Tachycardia


Irregular Tachycardias

Irregular narrow-complex or wide-complex tachycardia:

1. atrial fibrillation (with or without aberrant conduction)

2. MAT3. sinus rhythm/tachycardia with frequent atrial

premature beats

AF

NormalQRS

NonePRI

None discernibleP Waves

Atrial (outside SA Node)Pacemaker Site

Irregularly irregularRhythm

Atrial rate 350–50Ventricular rate variesRate

Atrial Fibrillation


Treatment of AF

Rate control• >48 hours are at increased risk for cardioembolic events• Avoid Electric or pharmacologic cardioversion unless the

patient is unstable• IV β –blockers or calcium channel blockers such as

diltiazem • Digoxin and amiodarone

– Congestive heart failure• wide-complex irregular rhythm (AF with pre-excitation)

– Avoid AV nodal blocking agents such as adenosine, calcium channel, β blockers, digoxin

MAT

VariableQRS

Varies depending on source of impulsePRI

Organized, nonsinus P waves; at least 3 formsP Waves

Ectopic sites in atriaPacemaker Site

IrregularRhythm

More than 100Rate

Multifocal Atrial Tachycardia


PACs

Usually normalQRS

Varies dependent on foci of impulsePRI

Occurs earlier than expectedP Waves

Ectopic sites in atriaPacemaker Site

Usually regular except for the PACRhythm

Depends on underlying rhythmRate

Premature Atrial Contractions


Dysrhythmias Originating in the Atria

Usually normalQRS

Usually normalPRI

F waves are presentP Waves

Atrial (outside SA node)Pacemaker Site


Atrial rate 250–350Ventricular rate variesRate

Atrial FlutterRules of Interpretation

• Torsade de Pointes– Polymorphic VT.– Caused by the use of certain

antidysrhythmic drugs.– Exacerbated by

coadministration of antihistamines, azole antifungal agents and macrolide antibiotics, erythromycin, azithromycin, and clarithramycin.


Polymorphic (Irregular) VTtorsades de pointes

• requires immediate defibrillation with the same strategy used for VF– stop medications known to prolong the QT interval– Correct electrolyte imbalance

• magnesium is commonly used – Polymorphic VT associated with familial long QT syndrome

• isoproterenol or ventricular pacing – Polymorphic VT with bradycardia and drug-induced QT

prolongation• IV amiodarone and β–blockers

– myocardial ischemia induced Polymorphic VT


>0.12 seconds, bizarreQRS

If present, variesPRI

None produced by ventricular pacemakers;

pacemaker spikeP Waves

Depends upon electrode placementPacemaker Site

May be regular or irregularRhythm

Varies with pacemaker

Rate

Artificial Pacemaker Rhythm


• Pre-excitation Syndromes– Excitation by an impulse

that bypasses the AV node• Wolff-Parkinson-

White Syndrome (WPW)– Short PRI and long

QRS duration– Delta waves

– Treat underlying rhythm.

Dysrhythmias Resulting from Disorders of Conduction

• Hyperkalemia– Tall Ts

• Suspect in patients with a history of renal failure.

• Hypokalemia– Prominent U waves

• Hypothermia– Osborn wave (“J” wave)– T wave inversion, sinus

bradycardia, atrial fibrillation or flutter, AV blocks, PVCs, VF, asystole

ECG Changes Due to Electrolyte Abnormalities and Hypothermia

Summary

• The goal of therapy for bradycardia or tachycardia is to– rapidly identify and treat patients who are hemodynamically

unstable or symptomatic due to the arrhythmia• Drugs or when appropriate, pacing may be used to control

unstable or symptomatic bradycardia• Cardioversion or drugs or both may be used to control unstable

or symptomatic tachycardia• ACLS providers

– should closely monitor stable patients pending expert consultation and

– should be prepared to aggressively treat those with evidence of decompensation

Management of peri arrest arrhythmias

Health & Medicine

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