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Telemetry / Arrythmias. Dan Crouch Kristi Kuhn Kate Lindley Ben Voss. Unresponsive patient in ED. Junctional tachycardia. Regular Narrow complex No P waves. Surgical consult for arrhythmia. Paroxysmal SVT (PAT). Benign rhythm If sustained: Vagal maneuvers Adenosine DCCV.
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Telemetry / Arrythmias Dan Crouch Kristi Kuhn Kate Lindley Ben Voss
Junctional tachycardia • Regular • Narrow complex • No P waves
Paroxysmal SVT (PAT) • Benign rhythm • If sustained: • Vagal maneuvers • Adenosine • DCCV
Premature ventricular complexes • Abnormal but usually benign • Concerns: very frequent, history of ischemia • Ask about symptoms (palpitations, “skipping a beat”) • Beta-blockers for symptomatic patients
NSVT • ICM or NICM • Usually not an indication for ICD • Ask about symptoms • Use more beta-blockers
Atrial fibrillation • Irregular • No coordinated atrial activity (no P waves) • Rate control • Anticoagulation
Atrial flutter (2:1) • Regular rhythm • Flutter circuit rate: 300 bpm • Re-entrant circuit • Diagnostic maneuvers: vagal stimulation, adenosine
Typical atrial flutter • “Sawtooth” pattern
Atrial flutter (variable block) • Regular flutter waves @ 300 bpm • Irregular ventricular response • Usually seen with AV nodal blockade • May be difficult to distinguish from coarse Afib
Mobitz I (Wenkebach) • Regular P waves • Lengthening P-R interval • Shortening R-R interval • Predictably dropped beats (grouped beats)
Mobitz II • Randomly dropped beats • Frequently progresses to 3rd degree AVB or complete heart block • Can be indication for pacemaker
Complete Heart Block • Normal sinus node activity (P waves) • No ventricular response • Pt presented with syncope while driving forklift
Ventricular tachycardia • Wide complex tachycardias • VT until proven otherwise for patients with ischemia • Brugada criteria: only AV dissociation useful on tele • GET AN EKG!! • Non-malignant rhythm with aberrancy also possible
Hyperkalemia • QRS widening • Peaked T waves • Treatment: • Calcium first • Insulin/glucose, albuterol, glucagon, NaHCO3, IVF/Lasix • Kayexalate last
Torsades de pointes • Polymorphic ventricular tachycardia • Life-threatening with degeneration to VF • Usually precipitated by PVC in setting of long QT • Often associated with QT-prolonging drugs • Check for electrolyte disturbances (especially Mg)