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Arrhythmia recognition and treatment

Arrhythmia recognition and treatment. Cardiology Acute Care Day. Objectives. Outline. Normal sinus rhythm How to recognise an arrhythmia Bradyarrhythmias Tachyarrhythmias Treatment strategy for arrhythmias. Objectives. Outline. Normal sinus rhythm How to recognise an arrhythmia

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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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