Arrhythmia recognition and treatment Cardiology Acute Care Day.
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Transcript of Arrhythmia recognition and treatment Cardiology Acute Care Day.
![Page 1: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/1.jpg)
Arrhythmia recognition and treatment
Cardiology Acute Care Day
![Page 2: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/2.jpg)
Objectives
Normal sinus rhythm
How to recognise an arrhythmia
Bradyarrhythmias
Tachyarrhythmias
Treatment strategy for arrhythmias
Outline
![Page 3: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/3.jpg)
Objectives
Normal sinus rhythm
How to recognise an arrhythmia
Bradyarrhythmias
Tachyarrhythmias
Treatment strategy for arrhythmias
Outline
![Page 4: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/4.jpg)
Normal rate
Regular, narrow QRS
P waves present
P:QRS is 1:1
ECG of sinus rhythmECG of sinus rhythm
P
QRS
![Page 5: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/5.jpg)
Objectives
Normal sinus rhythm
How to recognise an arrhythmia
Bradyarrhythmias
Tachyarrhythmias
Treatment strategy for arrhythmias
Outline
![Page 6: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/6.jpg)
What is the QRS rate?
Are the QRS complexes regular?
Is the QRS broad or narrow?
Are there P waves?
What is the P:QRS relation?
How to recognise an arrhythmiaHow to recognise an arrhythmia
![Page 7: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/7.jpg)
Objectives
Normal sinus rhythm
How to recognise an arrhythmia
Bradyarrhythmias
Tachyarrhythmias
Treatment strategy for arrhythmias
Outline
![Page 8: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/8.jpg)
Sinus bradycardia
Sinus arrest (“Sick Sinus Syndrome”)
Junctional bradycardia
Atrioventricular block(First degree)
Second degree
- type I (Wenckebach) / type II
Third degree
BradyarrhythmiasBradyarrhythmias
![Page 9: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/9.jpg)
*Rate < 60bpm
Regular, narrow QRS
P waves present
P:QRS is 1:1
Sinus bradycardia
![Page 10: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/10.jpg)
Sinus arrest
*Rate < 60bpm
Irregular, narrow QRS
P waves present
P:QRS is 1:1
Pause with absence of P wave
![Page 11: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/11.jpg)
*
Rate < 60bpm
Regular, narrow QRS
No P waves
Junctional bradycardia
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*
Rate variable
Regular, narrow QRS
P waves present
P:QRS is 1:1 with PR interval >200ms
First degree AV block
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*
*
Rate < 60bpm
Irregular narrow QRS
P:QRS not 1:1
increasing PR interval
then dropped beat
Second degree AV block (type I)
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*
*
Rate < 60bpm
Irregular narrow QRS
P:QRS not 1:1
normal PR interval with
intermittent dropped beats
*
Second degree AV block (type II)
![Page 15: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/15.jpg)
Rate < 60bpm
Regular broad QRS
No relation between P and QRS
*
Third degree (complete) AV block
![Page 16: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/16.jpg)
Objectives
Normal sinus rhythm
How to recognise an arrhythmia
Bradyarrhythmias
Tachyarrhythmias
Treatment strategy for arrhythmias
Outline
![Page 17: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/17.jpg)
Irregular
Atrial fibrillation
Regular
Narrow QRS
Sinus tachycardia
Supraventricular tachycardia (SVT)
Atrial flutter
Broad QRS
Ventricular tachycardia
SVT with Bundle Branch Block
Tachyarrhythmias
![Page 18: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/18.jpg)
Rate variable
Irregular, narrow QRS
No P waves
Atrial fibrillation
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Rate > 100bpm
Regular, narrow QRS
P waves present
P:QRS is 1:1
*
Sinus tachycardia
![Page 20: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/20.jpg)
Supraventricular tachycardias
Atrial tachycardia
Junctional tachycardia
AV re-entrant tachycardia
AV node re-entrant tachycardia
*
*
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Rate > 100bpm
Regular, narrow QRS
P waves variable
- not apparent, or after QRS
*
*
Supraventricular tachycardia
![Page 22: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/22.jpg)
Rate variable
Regular, narrow QRS
Sawtooth atrial activity 300bpm
- variable AV block
Atrial flutter
![Page 23: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/23.jpg)
*
Rate > 100bpm
Regular, broad QRS
P waves variable
- may be dissociated
Ventricular tachycardia
![Page 24: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/24.jpg)
Rate > 100bpm
Regular, broad QRS
P waves variable
- usually not visible
SVT with Bundle Branch Block
*
*
X
![Page 25: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/25.jpg)
Normal sinus rhythm
How to diagnose an arrhythmia
Bradyarrhythmias
Tachyarrhythmias
Treatment strategy for arrhythmias
OutlineOutline
![Page 26: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/26.jpg)
First assess the patient and CHECK THEIR PULSE
Are they compromised?
low BP, impaired consciousness, heart failure, chest pain
Then assess the ECG
Is there a high risk of cardiac arrest?
VT, complete heart block
If compromise or high risk
Treat with electricity
DC cardioversion / temporary pacing
If not
Look for reversible causes / treat with drugs
Treatment strategy
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89 year old female
Syncope
BP 75/40
What is the QRS rate? Is the QRS regular?Is the QRS broad or narrow? Are there p-waves?What is the p – QRS relation?
![Page 28: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/28.jpg)
Assess the patientIf compromised:
Immediate temporary pacing (initially transcutaneous, refer to expert to consider placing a temporary pacing wire)
If not compromised:What is the risk of asystole?
Third degree (complete) AV block
![Page 29: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/29.jpg)
Third degree (complete) AV block
What factors predict a high risk of asystole?
- Recent asystole
- Mobitz type II AV block
- Third degree heart block with broad QRS
- Ventricular pause >3seconds
![Page 30: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/30.jpg)
Third degree (complete) AV block
What is this patients risk of asystole?
High
Consider temporary pacing
Address reversible causes:
Drugs affecting the conducting system
Acute MI
![Page 31: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/31.jpg)
Temporary pacing
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75 yr old male
Mild breathlessness
BP 135/85
What is the QRS rate? Is the QRS regular?Is the QRS broad or narrow? Are there p-waves?What is the p – QRS relation?
![Page 33: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/33.jpg)
Assess the patientIf they are compromised DC cardioversion
If not, decide treatment strategyRate control vs rhythm control
Rate controlAV nodal blockers
CCB, β-blocker, digoxin
Rhythm controlAnti-arrhythmics
Amiodarone, flecainide
Anticoagulation
Atrial fibrillation
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Following administration of beta-blocker
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47 year old female
Palpitations
BP 120/70
What is the QRS rate? Is the QRS regular?Is the QRS broad or narrow? Are there p-waves?What is the p – QRS relation?
![Page 36: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/36.jpg)
Assess the patientIf they are compromised DCCV
If not compromised:Vagal manoeuvresIV Adenosine (extremely short half-life, need to give rapidly)
Terminates re-entry circuits using AVNWill slow atrial tachycardia and atrial flutter
IV verapamil
Consider:AVN slowing (digoxin)Antiarrhythmic (amiodarone)DCCV/ A pacing
Supraventricular tachycardia
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Termination of SVT with Adenosine
adenosine 6mg IV
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62 year old male
Palpitations
BP 120/70
IV adenosine
What is the QRS rate? Is the QRS regular?Is the QRS broad or narrow? Are there p-waves?What is the p – QRS relation?
![Page 39: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/39.jpg)
Following bisoprolol
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82 year old male
Chest pain
BP 80/50
What is the QRS rate? Is the QRS regular?Is the QRS broad or narrow? Are there p-waves?What is the p – QRS relation?
![Page 41: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/41.jpg)
Assess the patient DO THEY HAVE A PULSE? No? Use BLS/ALS ALGORITHM
If any compromise:
Immediate DCCVCall anaesthetistSecure airwayConscious sedationSynchronised DC shockManage on CCU
If no compromise: (GET 12 LEAD ECG)Consider IV amiodarone/other antiarrhythmics
Consider reversible causes
Ventricular tachycardia
![Page 42: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/42.jpg)
First assess the patient and CHECK THEIR PULSE
Are they compromised?
low BP, impaired consciousness, heart failure, chest pain
Then assess the ECG
Is there a high risk of cardiac arrest?
VT, complete heart block
If compromise or high risk
Treat with electricity
DC cardioversion / temporary pacing
If not
Look for reversible causes / treat with drugs
Treatment strategy
![Page 43: Arrhythmia recognition and treatment Cardiology Acute Care Day.](https://reader036.fdocuments.in/reader036/viewer/2022062308/56649d9f5503460f94a89ebd/html5/thumbnails/43.jpg)
Normal sinus rhythm
How to recognise an arrhythmia
Bradyarrhythmias
Tachyarrhythmias
Treatment strategy for arrhythmias
Any questions? Any questions