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Pitfalls in ArrhythmiasJeffrey Tabas, M.D.

Professor of Emergency MedicineOffice of CME

UCSF School of Medicine

Goals

Using a case based approach, we will review pitfalls in management of:

• Tachydysrhythmias– Narrow

– Wide

• Bradydysrhythmias

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Background2010 ACLS Guidelines

BackgroundNarrow Complex Tachycardia

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Regular – SVT

• Adenosine preferred

• Beta blocker, CaCB if needed

Irregular – Atrial Fib

• Beta blocker

• CaCB

• Amiodarone

• Procainamide

BackgroundNarrow Complex Tachycardia

BackgroundRegular NCT

Adenosine

•6 – 12 mg IV

•Maximize delivery

•Beware with dipyridamole (Aggrenox), carbamezipine

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BackgroundAfib and Aflutter

Metoprolol

•5 mg IV Q5 mins x 3 then oral dose

•Causes hypotension, bronchospasm

Diltiazem

•20 mg IV over 2 min, repeat Q10-15 min

•10 mg IV if at all tenous!!!!

•60 mg po or IV drip

•Causes hypotension

Amiodarone (o.k. if wide)

•150 mg over 10 mins

•1 mg/min infusion

•Causes hypotension (less than others)

Procainamide for conversion (best for wide)

•1 gm over 1 hour

•Causes hypotension and prolongs QT

BackgroundAfib and Aflutter

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BackgroundWide Complex Tachycardia

BackgroundRegular WCT

• Adenosine

• Amiodarone

• Procainamide

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Bradycardia with Pulse

Case #1A 70 y.o. male is brought in by ambulance from nursing facility with supraventricular tachycardia. Drinks a lot of coffee. Field vitals are HR =150,BP = 88/30. Paramedics tried 6 mg and 12 mg of adenosine unsuccessfully.

26b. 50 y.o BIBA w/ near syncope.

Case #2Case #2A 50 A 50 y.oy.o. male is BIBA with palpitations. He was noted to have intermitt. male is BIBA with palpitations. He was noted to have intermittent ent VTachVTach. . Because he was Because he was ““semisemi--stablestable”” in the field, no intervention was given.in the field, no intervention was given.ED vital signs were: HR = 200, SBP = 90, RR = 18, ED vital signs were: HR = 200, SBP = 90, RR = 18, AfebrileAfebrileHis exam was significant for difficult access due to extensive His exam was significant for difficult access due to extensive hxhx of IDUof IDU

Case # 3Case # 3A 25 A 25 y.oy.o. male presents with palpitations / pain radiating to left neck.. male presents with palpitations / pain radiating to left neck. One similar One similar episode in Mexico. Told that if recurrent, he should cough or miepisode in Mexico. Told that if recurrent, he should cough or mimic having a BM.mic having a BM.

Case #4 Case #4 A 50 A 50 y.oy.o. male presents to the ED feeling weak. . male presents to the ED feeling weak. Initial vitals show: HR = 50, BP = 80/50Initial vitals show: HR = 50, BP = 80/50

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Bibliography

• Anderson JL, et al. Management of patients with atrial fibrillation: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines. J Am CollCardiol. 2013 May 7;61(18):1935-44.

Bibliography

• Neumar RW, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2;122(18 Suppl 3):S729-67

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Bibliography

• Electrocardiography in Emergency Medicine. Editors: Mattu A, Tabas J, and Barish R. ACEP Publishing 2007.