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Arrhythmia recognition and treatment

Learn about identifying arrhythmias, normal sinus rhythm, bradyarrhythmias, and tachyarrhythmias plus treatment approaches in cardiology.

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Arrhythmia recognition and treatment

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  1. Arrhythmia recognition and treatment Cardiology Acute Care Day

  2. Objectives Outline • Normal sinus rhythm • How to recognise an arrhythmia • Bradyarrhythmias • Tachyarrhythmias • Treatment strategy for arrhythmias

  3. Objectives Outline • Normal sinus rhythm • How to recognise an arrhythmia • Bradyarrhythmias • Tachyarrhythmias • Treatment strategy for arrhythmias

  4. ECG of sinus rhythm ECG of sinus rhythm QRS P Normal rate Regular, narrow QRS P waves present P:QRS is 1:1

  5. Objectives Outline • Normal sinus rhythm • How to recognise an arrhythmia • Bradyarrhythmias • Tachyarrhythmias • Treatment strategy for arrhythmias

  6. How to recognise an arrhythmia How to recognise an arrhythmia • 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?

  7. Objectives Outline • Normal sinus rhythm • How to recognise an arrhythmia • Bradyarrhythmias • Tachyarrhythmias • Treatment strategy for arrhythmias

  8. Bradyarrhythmias Bradyarrhythmias • Sinus bradycardia • Sinus arrest (“Sick Sinus Syndrome”) • Junctional bradycardia • Atrioventricular block • (First degree) • Second degree - type I (Wenckebach) / type II • Third degree

  9. Sinus bradycardia * Rate < 60bpm Regular, narrow QRS P waves present P:QRS is 1:1

  10. Sinus arrest * Rate < 60bpm Irregular, narrow QRS P waves present P:QRS is 1:1 Pause with absence of P wave

  11. Junctional bradycardia * Rate < 60bpm Regular, narrow QRS No P waves

  12. First degree AV block * Rate variable Regular, narrow QRS P waves present P:QRS is 1:1 with PR interval >200ms

  13. Second degree AV block (type I) * * Rate < 60bpm Irregular narrow QRS P:QRS not 1:1 increasing PR interval then dropped beat

  14. Second degree AV block (type II) * * * Rate < 60bpm Irregular narrow QRS P:QRS not 1:1 normal PR interval with intermittent dropped beats

  15. Third degree (complete) AV block * Rate < 60bpm Regular broad QRS No relation between P and QRS

  16. Objectives Outline • Normal sinus rhythm • How to recognise an arrhythmia • Bradyarrhythmias • Tachyarrhythmias • Treatment strategy for arrhythmias

  17. Tachyarrhythmias • Irregular • Atrial fibrillation • Regular • NarrowQRS Sinus tachycardia Supraventricular tachycardia (SVT) Atrial flutter • Broad QRS • Ventricular tachycardia • SVT with Bundle Branch Block

  18. Atrial fibrillation Rate variable Irregular, narrow QRS No P waves

  19. Sinus tachycardia * Rate > 100bpm Regular, narrow QRS P waves present P:QRS is 1:1

  20. Supraventricular tachycardias • Atrial tachycardia • Junctional tachycardia • AV re-entrant tachycardia • AV node re-entrant tachycardia * *

  21. Supraventricular tachycardia * Rate > 100bpm Regular, narrow QRS P waves variable - not apparent, or after QRS *

  22. Atrial flutter Rate variable Regular, narrow QRS Sawtooth atrial activity 300bpm - variable AV block

  23. Ventricular tachycardia * Rate > 100bpm Regular, broad QRS P waves variable - may be dissociated

  24. SVT with Bundle Branch Block * Rate > 100bpm Regular, broad QRS P waves variable - usually not visible * X

  25. Outline Outline • Normal sinus rhythm • How to diagnose an arrhythmia • Bradyarrhythmias • Tachyarrhythmias • Treatment strategy for arrhythmias

  26. Treatment strategy • Firstassess the patient and CHECK THEIR PULSE Are they compromised? low BP, impaired consciousness, heart failure, chest pain Thenassess 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

  27. 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? 89 year old female Syncope BP 75/40

  28. Third degree (complete) AV block • Assess the patient • If 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?

  29. 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

  30. 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

  31. Temporary pacing

  32. 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? 75 yr old male Mild breathlessness BP 135/85

  33. Atrial fibrillation • Assess the patient • If they are compromised DC cardioversion • If not, decide treatment strategy • Rate control vs rhythm control • Rate control • AV nodal blockers CCB, β-blocker, digoxin • Rhythm control • Anti-arrhythmics • Amiodarone, flecainide • Anticoagulation

  34. Following administration of beta-blocker

  35. 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? 47 year old female Palpitations BP 120/70

  36. Supraventricular tachycardia • Assess the patient • If they are compromised DCCV • If not compromised: • Vagal manoeuvres • IV Adenosine (extremely short half-life, need to give rapidly) Terminates re-entry circuits using AVN • Will slow atrial tachycardia and atrial flutter • IV verapamil • Consider: • AVN slowing (digoxin) • Antiarrhythmic (amiodarone) • DCCV/ A pacing

  37. Termination of SVT with Adenosine adenosine 6mg IV

  38. 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? 62 year old male IV adenosine Palpitations BP 120/70

  39. Following bisoprolol

  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? 82 year old male Chest pain BP 80/50

  41. Ventricular tachycardia • Assess the patient • DO THEY HAVE A PULSE? No? Use BLS/ALS ALGORITHM • If any compromise: • Immediate DCCV • Call anaesthetist • Secure airway • Conscious sedation • Synchronised DC shock • Manage on CCU • If no compromise: (GET 12 LEAD ECG) • Consider IV amiodarone/other antiarrhythmics • Consider reversible causes

  42. Treatment strategy • Firstassess the patient and CHECK THEIR PULSE Are they compromised? low BP, impaired consciousness, heart failure, chest pain Thenassess 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

  43. Any questions? Any questions • Normal sinus rhythm • How to recognise an arrhythmia • Bradyarrhythmias • Tachyarrhythmias • Treatment strategy for arrhythmias

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