Perioperative%20%20%20%20%20%20%20%20 arrhythmias
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PERIOPERATIVE ARRHYTHMIAS
Guided By- Dr. Vijeta khandelwal
Presented By-Dr. C.L. khedia
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• Definition: Arrhythmia is defined as "Abnormality of cardiac rate, rhythm or conduction.
• Cardiac arrhythmias are the most frequent perioperative cardiovascular abnormalities in patients undergoing both cardiac and non-cardiac surgery.
• The occurrence of arrhythmias have been reported in 70% of patients subjected to general anaesthesia for various surgical procedures.
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Mechanisms of Arrhythmia
Production• Re-entry (refractory tissue reactivated due to conduction
block, causes abnormal continuous circuit. eg accessory pathways linking atria and ventricles in Wolff-Parkinson-White syndrome)
• Injury or damage (pathology) to the cardiac conduction systems
• Abnormal pacemaker activity/ automaticity in non-conducting/conducting tissue (eg. ischaemia)
• Delayed after-depolarisation (automatic depolarisation of cardiac cell triggers ectopic beats, can be caused by drugs eg digoxin)
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Contributing factors and causes1. Patient related factors-• preexisting cardiac disease• central nervous system disease• Old age2.Anaesthesia related factors• Tracheal intubation• general anaesthetics• regional anaesthesia• Electrolyte imbalance and abnormal arterial
blood gases• Central venous cannulation
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Reversible cause of arrhythmia
• Hypoxemia
• Hypercarbia
• Hypotension
• Acidosis
• Light anesthesia
• Proarrhythemic drugs
• Cardiac ischemia
• Electrolyte imbalance
• Hypothermia
• Mechanical irritation:
PAC, Chest tube
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Classification of Cardiac
Arrhythmias
• Heart rate (increased/decreased)
• Heart rhythm (regular/irregular)
• Site of origin (supraventricular / ventricular)
• Complexes on ECG (narrow/broad)
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• Bradyarrhythmias
• Sinus bradycardia
• Sinoatrial block
• Sinus arrest
• Atroventricular block
• Bundle branch block
• Tachyarrhythmias
• Supraventricular arrhythmias
• Ventricular arrhythmias
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Supraventricular tachyarrhythmias
• Sinus tachycardia
• Prematue atrial contractions (PACs)
• Atrial tachycardia
• Atrial flutter/fibrillation (AF)
• Atrioventricular nodal reentrant tachycardia (AVNRT)
• Atrioventricular reentrant tachycardia (AVRT)
Ventricular tachyarrhythmias
• Premature ventricular contractions (PVCs)
• Ventricular tachycardia (VT)
• Monomorphic vs Polymorphic VT
• Ventricular flutter/fibrillation (VF)
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Anaesthetic considerations
• All patients undergoing anaesthesia and surgery should have ECG monitoring.
• Lead II and V 5 are superior for arrhythmia detection and diagnosis before the appearance of physical signs.
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Waveform Analysis
– For each strip it is necessary to go through steps
to correctly identify the rhythm
1. Is there a P-wave for every QRS?
• P-waves are upright and uniform
• One P-wave preceding each QRS
2. Is the rhythm regular?
• Verify by assessing R-R interval
• Confirm by assessing P-P interval
3. What is the rate?
• Count the number of beats occuring in one minute
• Counting the p-waves will give the atrial rate
• Counting QRS will give ventricular rate
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• Normal
– Heart rate = 60 – 100 bpm
– PR interval = 0.12 – 0.20 sec
– QRS interval <0.12
– SA Node discharge = 60 – 100 / min
– AV Node discharge = 40 – 60 min
– Ventricular Tissue discharge = 20 – 40 min
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• Cardiac cycle
– P wave = atrial depolarization
– PR interval = pause between atrial and
ventricular depolarization
– QRS = ventricular depolarization
– T wave = ventricular depolarization
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Normal Sinus Rhythm
Heart
RateRhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
60 -
100Regular
Before each QRS,
Identical.12 - .20 <.12
Sinus Rhythms
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• Normal Sinus Rhythm
– Sinus Node is the primary pacemaker
– One upright uniform p-wave for every QRS
– Rhythm is regular
– Rate is between 60-100 beats per minute
Sinus Rhythms
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Sinus Bradycardia
Heart
RateRhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
<60 RegularBefore each QRS,
Identical.12 - .20 <.12
Sinus Rhythms
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• Sinus Bradycardia
– One upright uniform p-wave for every QRS
– Rhythm is regular
– Rate less than 60 beats per minute
• SA node firing slower than normal
• Normal for many individuals
• Identify what is normal heart rate for patient
Sinus Rhythms
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Perioperative causes of Sinus Bradycardia-:
1. Vagal stimulation- Oculocardiac reflex, Celiac plexus stimulation(traction on mesentry), laryngoscopy, Abdominal insufflation, Nausea and ECT
2. Drugs- Beat blocker, Cal channel blocker, opioids(fentanyl/sufentanyl)
3. Succinylcholine 4.Hypothermia
5. Hypothyroidism 6. Atheletic heart syndrome
7. SA node disease or ischemia
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Perioperative T/T-
- In asymptomatic pt no t/t requires
- In Mildly symptomatic pts, underlying factors should be eleminated
- In severly symptomatic pts, those with chest pain or syncope, immediate transcutaneous/transvenous pacing is required.
- Atropine 0.5 mg Iv every 3-5 min(max 3mg) may be given. It should be noted dose of atropine (<0.5mg) can cause further slowing of HR.
- An epinephrine or dopamine infusion may be titrated while awaiting cardiac pacing.
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•
Sinus Tachycardia
Heart
RateRhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
>100 RegularBefore each QRS,
Identical.12 - .20 <.12
Sinus Rhythms
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• Sinus Tachycardia
– One upright uniform p-wave for every QRS
– Rhythm is regular
– Rate is greater than 100 beats per minute due to increased SA node discharge sec. to sympathetic stimulation (physiological/pathological /pharmacological response)
• Usually between 100-160 (>160 SVT)
• Can be high due to anxiety, stress, fever, medications
(anything that increases oxygen consumption)
Sinus Rhythms
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Treatment-:
-correcting underlying cause of symp. Stimulation.
-Beta blockers may be employed to lower heart rate and decrease myocardial o2 demand(if pt is not hypovolemic).
-supplemental O2 to increase supply in response to increase demand.
-Avoidance of vagolytic drug (pancuronium) intraoperatively
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Sinus Arrhythmia
Heart
RateRhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
Var. IrregularBefore each QRS,
Identical.12 - .20 <.12
Sinus Rhythms
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• Sinus Arrhythmia
– One upright uniform p-wave for every QRS
– Rhythm is irregular
• Rate increases as the patient breathes in
• Rate decreases as the patient breathes out
– Rate is usually 60-100 (may be slower)
– Variation of normal, not life threatening
Sinus Rhythms
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Premature Atrial Contraction (PAC)
Heart
RateRhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
NA Irregular
Premature &
abnormal or
hidden
.12 - .20 <.12
Atrial Rhythms
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– Premature Atrial Contraction (PAC)
• One P-wave for every QRS
– P-wave may have different morphology on ectopic beat,
but it will be present
• Single ectopic beat will disrupt regularity of
underlying rhythm
• Rate will depend on underlying rhythm
• Underlying rhythm must be identified
• Classified as rare, occasional, or frequent PAC’s
based on frequency
Atrial Rhythms
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• Sign and symptoms
-PACs arises from ectopic foci in atria. Typical symptoms include an awareness of a fluttering or a heavy heart beat.
-Precipitated by excessive caffeine, stress, alcohol, nicotine and hyperthyroidism.
-Often occur at rest and become less frequent by exercise.
-second most arrhythmias asso. With MI.
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Perioperative T/t-:
1. Avoidance of ppt. factors and sympathetic stimulation.
2. Pharmacological T/t required only if the PACs
trigger sec. dysrhythmias.
3. Usually suppressed by calcium channel blocker or Beta blocker.
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Atrial Fibrillation
Heart
RateRhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
Var. Irregular Wavy irregular NA <.12
Atrial Rhythms
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• Atrial Fibrillation– No discernable p-waves preceding the QRS complex
• The atria are not depolarizing effectively, but fibrillating
– Rhythm is grossly irregular
– If the heart rate is <100 it is considered controlled a-fib, if >100 it is considered to have a “rapid ventricular response”
– AV node acts as a “filter”, blocking out most of the impulses sent by the atria in an attempt to control the heart rate
Atrial Rhythms
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• Atrial Fibrillation (con’t)
– Often a chronic condition, medical attention only
necessary if patient becomes symptomatic
– Patient will report history of atrial fibrillation.
– Symptoms range from palpitation to angina
pectoris, CHF, pul. Oedema and hypotension
– Often associated with fatigue and generalized
weakness.
– Predisposing factors are :RHD, hypertension,
thyrotoxicosis, IHD, chronic COPD, pericarditis
and pulmonary embolus.
Atrial Rhythms
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Perioperative management-
-If new onset of AF, surgery should be postponed if possibleuntill control of dysrhythmia.
-T/t of AF during Sx depends on hemodynamic stability of pt.
-if hemodynamically significat, the T/t is cardioversion
-Synchronized electrical cardioversion (100 to 200 J) is mosteffective.
-Pharmacological cardioversion by IV amiodarone (pref.drug),diltiazem or verapamil may be attempted.
-Pt with chronic AF should be maintained on theirantidysrhythmic drugs with close attention to serumelectrolyte(K &Mg).
-Manage the transition on and off IV and oral anticoagulation.
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Atrial Flutter
Heart Rate Rhythm P WavePR Interval
(sec.)
QRS
(Sec.)
Atrial=250
– 400
Ventricular
Var.
Irregular Sawtooth
Not
Measur-
able
<.12
Atrial Rhythms
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• Atrial Flutter– More than one p-wave for every QRS complex
• Demonstrate a “sawtooth” appearance
– Atrial rhythm is regular. Ventricular rhythm will be regular if the AV node conducts consistently. If the pattern varies, the ventricular rate will be irregular
– Rate will depend on the ratio of impulses conducted through the ventricles
– Most commonly atrial rate compared to ventricular rate 2:1 (if atrial rate is 300bpm and 2:1 conduction,ptcan present with venticular rate of 150 with sign and symptoms)
Atrial Rhythms
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• Peioperative T/t-
-T/t depends on hemodynamic stability of patient.
-If AF is hemodymamically sig. the T/t is cardioversion, synchronized elec. Cardioversion satarting at 50 J is indicated.
-Pharmacological control of ventricular response with IV amiodarone, diltiazem or verapamil may be tried, if vital signs are stable.
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Atrial Rhythms
• Atrial Flutter
– Atrial flutter is classified as a ratio of p-waves
per QRS complexes (ex: 3:1 flutter 3 p-waves
for each QRS)
– Not considered life threatening, consult
physician if patient symptomatic
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• Rhythms that originate at the AV junction
• Junctional rhythms do not have
characteristic p-waves.
Junctional Rhythms
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Premature Junctional Contraction PJC
Heart
RateRhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
Usually
normalIrregular
Premature,
abnormal, may be
inverted or hidden
Short
<.12
Normal
<.12
Junctional Rhythms
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• Premature Junctional Contraction (PJC)– P-wave can come before or after the QRS complex,
or it may lost in the QRS complex• If visible, the p-wave will be inverted
– Rhythm will be irregular due to single ectopic beat
– Heart rate will depend on underlying rhythm
– Underlying rhythm must be identified
– Classify as rare, occasional, or frequent PJC based on frequency
– Atria are depolarized via retrograde conduction
Junctional Rhythms
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Accelerated Junctional
Heart
RateRhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
Var. RegularInverted, absent or
after QRS<.12 <.12
Junctional Rhythms
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• Accelerated Junctional Rhythm
– P-wave can come before or after the QRS complex, or lost within the QRS complex• If p-waves are seen they will be inverted
– Rhythm is regular
– Heart rate between 60-100 beats per minute • Within the normal HR range
• Fast rate for the junction (normally 40-60 bpm)
Junctional Rhythms
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Junctional Tachycardia
Heart
RateRhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
>100 RegularMay be inverted or
hidden
Short
<.12
Normal
<.12
Junctional Rhythms
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• Junctional Tachycardia
– P-wave can come before or after the QRS complex or lost within the QRS entirely
• If a p-wave is seen it will be inverted
– Rhythm is regular
– Rate is between 100-180 beats per minute
• In the tachycardia range, but not originating from SA node
– AV node has sped up to override the SA node for
control of the heart
– Junctional rhythm often result in AV dyssynchrony
and a junctional tachycardia can severly impaired
Cardiac output.
Junctional Rhythms
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• Perioperative T/t-
-Junctional rhythm is not frquent during GA.
-Transient Junctional rhythm require no T/t
-Loss of AV synchrony during a junctional rhythm may result in MI, heat failure or hypotension
-Atropine 0.5 mg can be used to treat hemodynamically significat junctional rhythms
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Ventricular Rhythms
Premature Ventricular Contraction (PVC)
Heart
RateRhythm P Wave
PR
Interval
(sec.)
QRS
(Sec.)
Var. Irregular
No P waves
associated with
premature beat
NAWide
>.12
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Ventricular Rhythms
• Premature Ventricular Contraction (PVC)
– The ectopic beat is not preceded by a p-wave
– Irregular rhythm due to ectopic beat
– Rate will be determined by the underlying rhythm
– QRS is wide and may be bizarre in appearance
– Caused by a irritable focus within the ventricle which
fires prematurely
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Ventricular Rhythm
• Premature Ventricular Contraction
– Classify as rare, occasional, or frequent
– Classify as unifocal, or multifocal PVC’s
• Unifocal-originating from same area of the
ventricle; distinguished by same morphology
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Ventricular Rhythm
• Premature Ventricular Contraction – Classify as unifocal, or multifocal PVC’s
– Unifocal-originating from same area of the ventricle; distinguished by same morphology
– Multifocal-originating from different areas of the ventricle; distinguished by different morphology
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Ventricular Rhythm
• Premature Ventricular Contraction
– Bigeminy• A PVC occurring every other beat
– Also seen as Trigeminy, Quadrigeminy
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Ventricular Rhythm• Dangerous PVC’s
– R on T
– Runs of PVC’s– 3 or more considered Vtach
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• Causes of PVCs
- Arterial hypoxemia- MI- Myocarditis- SNS activation- Hypokalemia/Hypomagnesemia
- Digitalis toxicity- Caffeine, cocaine,Alcohol- Mechanical irritation-(CV or Pulm. Artery
catheter)
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• Prioperative T/t-
-During anaesthesia, if pt exhibits 6 or more PVCs
per minute and repetetive or multifocal forms, there is increased risk of developing life threatining dysrhythmia.
-T/t include a D/d of possible cause and t/t of that cause, while t/t of cause, the immediate availability of a defibrillator should be confirmed.
-Beta blockers are the most successful drug, amiodarone,lidocaine and other antiarhythmic are indicated if the PVCs progress to VT or ferquent to cause hemodynamic instability.
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Ventricular Rhythms
Ventricular Tachycardia
Heart
RateRhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
100 –
250Regular
No P waves
corresponding to QRS,
a few may be seen
NA >.12
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Ventricular Rhythms
• Ventricular Tachycardia
– No discernable p-waves with QRS
– Rhythm is regular
– Atrial rate cannot be determined, ventricular
rate is between 150-250 beats per minute
– Must see 4-6 beats in a row to classify as v-
tach
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Ventricular Rhythms
• Ventricular Tachycardia– THIS IS A DEADLY RHYTHM
• Check patient:
– If patient awake and alert, monitor patient and call physician
– Pt with symptomatic or unstable VT or SVT cardioverted
immediately.
– If vitals signs stable and VT is persistent or recurrent after
cardioversion, Amiodarone 150mg over 10min should be
given, other drugs may be used like procainamide,lignocaine
or sotalol.
– Pulseless VT requires immediate cardioversion/defibrillation
and CPR. (If patient has no vital signs, call code and start
CPR
» Defibrillate)
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Ventricular Rhythms
Ventricular Fibrillation
Heart
RateRhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
0 Chaotic None NA None
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Ventricular Rhythms
• Ventricular Fibrillation
– No discernable p-waves
– No regularity
– Unable to determine rate
– Multiple irritable foci within the ventricles all firing simultaneously
– May be coarse or fine
– This is a deadly rhythm
• Patient will have no pulse
• Call a code and begin CPR
• Survival is best if defbrillation occcurs within 3-5 min
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Asystole
Heart
RateRhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
None None None None None
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Asystole
• No p-waves
• No regularity
• No Rate
• This rhythm is associated with death
– Check patient and leads
– No pulse
• Begin CPR
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Heart Block
First Degree Heart Block
Heart
RateRhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
Norm. RegularBefore each QRS,
Identical> .20 <.12
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Heart Block– First Degree Heart Block
• P-wave for every QRS
• Rhythm is regular
• Rate may vary
• Av Node hold each impulse longer than normal before conducting normally through the ventricles
• Prolonged PR interval– Looks just like normal sinus rhythm
Cuases- increased vagal tone, digitalis toxicity, inferior wall MI and myocarditis.
-Usually asymptomatic and rarely require T/t.
-Elimination of drugs that slows AV conduction or clinical factors that enhance vagal tone can reverse 1st degree block.
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Heart BlockSecond Degree Heart Block
Mobitz Type I (Wenckebach)
Heart
RateRhythm P Wave
PR Interval
(sec.)
QRS
(Sec.
)
Norm.
can be
slow
Irregular
Present but some
not followed by
QRS
Progressively
longer<.12
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Heart Block
• Second Degree Heart Block
• Mobitz Type I (Wenckebach)– Some p-waves are not followed by QRS complexes
– Rhythm is irregular• R-R interval is in a pattern of grouped beating
– Rate 60-100 bpm
– Intermittent Block at the AV Node• Progressively prolonged p-r interval until a QRS is blocked
completely
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Heart Block
Second Degree Heart BlockMobitz Type II (Classical)
Heart
RateRhythm P Wave
PR
Interval
(sec.)
QRS
(Sec.)
Usually
slow
Regular
or
irregular
2 3 or 4 before each
QRS, Identical.12 - .20
<.12
depends
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Heart Block
• Second Degree Heart Block
• Mobitz Type II (Classical)
– More p-waves than QRS complexes
– Rhythm is irregular
– Atrial rate 60-100 bpm; Ventricular rate 30-100 bpm (depending on the ratio on conduction)
– Intermittent block at the AV node
• AV node normally conducts some beats while blocking others
• Mobitz type II block has high rate of progression to 3rd
degree heart block. A cardiac pacemaker is mandatory in this situation.
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Heart Block
Third Degree Heart Block(Complete)
Heart
RateRhythm P Wave
PR
Interval
(sec.)
QRS
(Sec.)
30 –
60Regular
Present but no
correlation to QRS
may be hidden
Varies<.12
depends
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Heart Block
• Third Degree Heart Block (Complete)– There are more p-waves than QRS
complexes– Both P-P and R-R intervals are regular
– Atrial rate within normal range; Ventricular rate between 20-60 bpm
– The block at the AV node is complete• There is no relationship between the p-waves and
QRS complexes.• Cardiac pacing is require in cases of 3rd degree
block
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• Anaesthetic management
-Previous placement of a transvenous pacemacker oravailability of of transcutaneous cardiac pacing is requiredbefore an anesthetic is administered for insertion ofpermanent cardiac pacemaker ,
-Isoproterenol may be required to maintain acceptable HRand acts as “chemical pacemaker” untill the artificialpacemaker is functional
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MODALITIES FOR TREATMENT OF ARRHYTHMIA
• Antiarrhythmic drugs
. All such drugs may aggravate or produce arrhythmias and they may also depress ventricular contractility and must, therefore, be used with caution.
• They are classified according to their effect on the action potential (Vaughan Williams' classification)
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Drugs affecting different parts of the heart
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Management of Arrythmia’s
• ECG and rhythm information
• should be interpreted within the context of total patient assessment
• Providers must evaluate
• Patient’s symptoms
• Clinical signs
• Ventilation, oxygenation, heart rate, blood pressure, signs of inadequate organ perfusion
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• In both unstable and symptomatic cases
• Provider must make an assessment whether it is the arrhythmia that is causing the patient to be unstable
• Patient in septic shock with sinus tachycardia 140 / min is unstable
• Electric cardioversion will not improve this patient’s condition
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• If patient with severe hypoxemia becomes hypotensive and develops bradycardia
• Bradycardia is not the primary cause of instability
• Treating the bradycardia without treating the hypoxemia is unlikely to improve the patient’s condition
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Supraventricular Tachycardia
• (Supraventricular - a rhythm process in which the ventricles are activated from the atria or AV node/His bundle region)
• Refers to supraventricular tachycardia other than afib, aflutter and MAT
• Occurs in 35 per 100,000 person-years
• Usually due to reentry—AVNRT or AVRT
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• QRS typically narrow (in absence of bundle branch block); thus, also termed narrow QRS tachycardia
• Usually paroxysmal, i.e, starting and stopping abruptly; called PSVT
• Aetiology should be considered before therapy is instituted
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Vagal maneuver
• Valsalva maneuver or carotid sinus massage
• Terminate up to 25% of PSVTs
• For other SVTs
• May transiently slow the ventricular rate
• Potentially assist rhythm diagnosis but will not usually terminate such arrhythmias
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Adenosine ( if regular)
• If PSVT does not respond to vagal maneuvers
• Give 6 mg of IV adenosine as a rapid IV push through antecubital vein followed by a 20 mL saline flush
• If the rhythm does not convert within 1 to 2 minutes
• Give a 12 mg rapid IV push using the method above
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Narrow-complex irregulartachycardia
• Atrial fibrillation with uncontrolled ventricular response
• MAT
• sinus rhythm/tachycardia with frequent atrial premature beats
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Rate Control
• Unstable patients
• Prompt electric cardioversion
• Stable patients
• Ventricular rate control as directed by patient symptoms
• IV nondihydropyridine calcium channel blockers
Diltiazem are drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular rate
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Ventricular arrhythmias
• Non-sustained ventricular arrhythmias
- routinely seen in the absence of cardiac disease- may not require drug therapy in the perioperative period.
- Conversely, in patients with structural heart disease, these non-sustained rhythms do predict subsequent life-threatening ventricular arrhythmias.
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NSVT after - cardiopulmonary bypass, unstable patients with marginal perfusion may deteriorate with recurrent episodes of NSVT
may benefit from suppression with lidocaine or beta blockade.
repletion of post-bypass hypomagnesaemia (MgCl2 2 g i.v.) reduces the incidence of NSVT after cardiac surgery.
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Sustained VT
• two categories: monomorphic and polymorphic.
• monomorphic VT - the amplitude of the QRS complex remains constant
• polymorphic ventricular tachycardia - the QRS morphology continually changes.
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Therapy for monomorphic wide complex tachycardia
• If the etiology of the rhythm cannot be determined
• QRS monomorphic, regular
• IV adenosine is relatively safe for both treatment and diagnosis
• However, adenosine should not be given for unstable or irregular or polymorphic wide complex tachycardias
• • It may cause degeneration of the arrhythmia to VF
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• If the wide-complex tachycardia proves to be SVT with aberrancy
• transiently slowed or converted by adenosine to sinus rhythm
• If due to VT there will be no effect on rhythm (except in rare cases of idiopathic VT)
• When adenosine is given for undifferentiated wide complex tachycardia
• Defibrillator should be available
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For patients who are stable with likely VT
• IV antiarrhythmic drugs or elective
cardioversion is the preferred treatment strategy
• Amiodarone
• Procainamide
• Sotalol
• Procainamide and sotalol should be avoided in patients with prolonged QT, CHF
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Wide-complex irregularrhythm
• Should be considered preexcited atrial fibrillation
• Expert consultation is advised
• Avoid AV nodal blocking agents
• adenosine, calcium channel blockers, digoxin, and possibly β-blockers
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Polymorphic (Irregular) VT
• First step
• Stop medications known to prolong the QT interval
• Correct electrolyte imbalance
• Acute precipitants: drug overdose or poisoning
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Prolong QT interval (Torsades de pointes)
• The management of torsades de pointes differs markedly from other forms of VT, and includes
• i.v. magnesium sulfate (2±4 g),
• repleting potassium,
• and manoeuvres aimed at increasing the heart rate (atropine, isoprenolol or temporary atrial or ventricular pacing).
• Haemodynamic collapse with torsades requires asynchronous DC counter shocks
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