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The Proper Interpretation of Tachycardias

The Proper Interpretation of Tachycardias. Breaking through the barriers. Raymond L. Fowler, M.D., FACEP. Associate Professor of Emergency Medicine The University of Texas Southwestern -------------------- Deputy EMS Medical Director The Dallas Metropolitan BioTel System

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The Proper Interpretation of Tachycardias

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  1. The Proper Interpretation of Tachycardias Breaking through the barriers

  2. Raymond L. Fowler, M.D., FACEP Associate Professor of Emergency Medicine The University of Texas Southwestern -------------------- Deputy EMS Medical Director The Dallas Metropolitan BioTel System -------------------- Co Chief in the Section on EMS, Disaster Medicine, and Homeland Security -------------------- Past President National Association of EMS Physicians --------------------

  3. www.utsw.ws www.rayfowler.com

  4. Thoughts for the Day: • I was thinking that women should put pictures of • missing husbands on beer cans! • If it’s true that we are here to help others, then • what exactly are OTHERS here for? • How much deeper would oceans be if • sponges DIDN’T live there? • If a cow laughed, would milk come out her nose? • Why don’t they just make MOUSE flavored cat food? • How come ABBREVIATED is such a long word? • I just got skylights put in my place…and the • people in the apartment above me are FURIOUS! • So, what’s the speed of “DARK”?

  5. The emerging of a subspecialty: Paramedicine

  6. Approaching the Patient

  7. “See what you see!” “People look, but they don’t see” …A. Fowler, Jr.

  8. Alertness? Level of distress? Noises? Respirations? The pulse rate? Skin? Obvious things (bleeding)

  9. The most common sign of illness . . . Elevated pulse rate

  10. What normally accelerates the pulse rate? Epinephrine

  11. Specifically: In response to stress, epinephrine is released from the adrenal glands making the heart beat stronger and faster

  12. Signs of Shock Weak, thirsty, lightheaded Pale, then sweaty Tachycardia Tachypnea Diminished urinary output Early Hypotension Altered LOC Cardiac arrest Death Late

  13. What does a low blood pressure mean? Either... • Loss of volume • Low cardiac output • Increased vascular • space Or a combination of any of these …from BTLS, editions 2, 3, 4, and 5 Fowler et al

  14. Cardiogenic Rapid pulse Distended neck veins Cyanosis Volume Loss Rapid pulse Flat neck veins Pale Shock Vasodilatory Variable pulse Flat neck veins Pale or pink

  15. Our pulse can only go so fast under sympathetic stimulation: 220 minus age

  16. Baby = (220 – 0) = 220 Snerd = (220 – 53) = 167 Aunt Minnie = (220 – 70) = 150

  17. Put another way: Our pulse rates can only go as fast as epinephrine can make them go... …unless there is a conduction abnormality

  18. So, REALLY . . . . . . ya got SINUS TACH . . . . . . and everything else

  19. Sinus Tach or PSVT, Afib, Aflutter, MAT, or VTach THE ONLY PROBLEM IS TELLING THE DIFFERENCE!!

  20. Many medics are not adept at EKG interpretation WHY???

  21. Because many EKG courses are too long, too boring, and teach difficult concepts to medics who will never use that information

  22. Rhythm Strip Interpretation Anatomically speaking...

  23. 1856 - First action potential described by von Koelliker and Muller 1887 - First EKG by Waller recorded on a lab technician named Thomas Goswell, in London 1893 - Einthoven introduces the term ‘electrocardiogram” 1895 - Einthoven names P QRS and T 1905 - Einthoven starts transmitting EKG’s from the hospital to his laboratory 1.5 k away via telephone cable, the first one on 3/22, the first ‘telecardiogram’ 1910 - First American review of EKG’s, by James at Columbia and Willaims at Cornell 1912 - Einthoven described the Leads 1, 2, 3, later called Einthoven’s triangle” 1920- Pardee publishes the first EKG of an acute MI, describing the T wave as being tall and “starts from a point well up on the descent of the R wave” 1924 - Einthoven wins the Nobel for inventing the EKG 1932 - Wolferth and Wood describe the clinical use of chest leads 1938 - The AHA and the Cardiac Society of Great Britain define the standard positions, and wiring, of the chest leads V1 – V6 1942 - Emanuel Goldberger adds the augmented limb leads avR, avL, and avF to Einthoven’s three limb leads, making the first 12 lead EKG

  24. Einthoven 1912 Goldberger 1942 AHA and Cardiac Society of Great Britain 1938

  25. Bundle of His SA AV Bundle Branches

  26. Heart Electrical Conduction

  27. Rate Rhythm P PR QRS ST T U Assessment Rhythm Strip Interpretation

  28. Basic Interpretation • ST Segment • T Wave • U Wave • Summarization • Rate • Rhythm • P Waves • PR Interval • QRS Complex

  29. Rate Rhythm P PR QRS ST T U Assessment Axis Hypertrophy Infarction

  30. The first thing you do is to perform a “primary survey” of the EKG strip

  31. Rate Rate R A T E ! ! ! Rate Rate

  32. Speaking of rate, I have found that being able to boogie makes a big difference in being able to tell one rhythm from another I mean. . .if you ain’t got rhythm, what you gonna do?

  33. IMPORTANT: • Sinus tachycardia with a rate of 150 or above • and PAT/PSVT look very similar • PAT/PSVT are not usually life threatening • except in the rare setting of a • patient having myocardial ischemia • (chest pain, diaphoresis, or dyspnea)

  34. Even More Important: • When you can’t tell if a rhythm is • sinus tachycardia or PAT/PSVT, • be wary of the more serious cause • It may be difficult, or even impossible, • to see any irregularity in very fast • atrial fibrillation

  35. The most common cause of tachycardia in Parkland ER is probably albuterol… …followed by amphetamine, cocaine, sepsis, DKA…

  36. The most common cause of bradycardia in Parkland ER is probably beta blockers… …probably ISN’T great physical conditioning…

  37. The incidence of bradycardia post-hemorrhage, especially intraperitoneally, is published to be as high as 7 to over 20%

  38. Always explain a tachycardia... Corollary: Don't depend on the presence of a tachycardia to determine that an emergency is present

  39. Sinus Tachycardia: A “physiological response”

  40. Remember: The Maximum Sinus Tachycardia for a patient is about 220 - age

  41. What is this rhythm? 220 – 55 = 165 Correct answer: “It COULD be sinus tach”

  42. If you forget everything else that I say: Remember that patients having near maximum sinus tachycardia at rest are dying!

  43. Something mobilizing a massive physiological response Hemorrhagic shock Sepsis Tension Tamponade Ruptured aorta Ruptured ectopic Massive P.E.

  44. Your job is to determine if a rapid rhythm MAY be sinus tach If it is, you must take action

  45. What is this rhythm? 220 – 60 = 160 Correct answer: “This HAS to be an arrhythmia

  46. Regularity

  47. Is there Regular Irregularity or Irregular Irregularity?

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