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Bradydysrhythmias

Bradydysrhythmias. Rich Kaplan MD, MS, FACEP. Causes of Bradycardia. Intrinsic Idiopathic Infarction/Ischemia Infiltrative diseases Collagen vascular diseases Surgical trauma Infectious diseases. Causes of Bradycardia. Extrinsic causes Autonomically mediated Neurocardiac

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Bradydysrhythmias

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  1. Bradydysrhythmias Rich Kaplan MD, MS, FACEP

  2. Causes of Bradycardia • Intrinsic • Idiopathic • Infarction/Ischemia • Infiltrative diseases • Collagen vascular diseases • Surgical trauma • Infectious diseases

  3. Causes of Bradycardia • Extrinsic causes • Autonomically mediated • Neurocardiac • Carotid-sinus hyperactivity • Situational

  4. Causes of Bradycardia • Extrinsic • B-blockers • Calcium blockers • Clonidine • Digoxin • Antiarrhythmics • Hypothyroid • Hypokalemia • Hyperkalemia

  5. Sinus Bradycardia Depressed automaticity in the sinus node

  6. Sinus Node • Sinus node artery • Right coronary artery (65%) • Circumflex (25%) • Both (10%)

  7. AV Node • AV nodal artery- • Proximal portion of descending artery • Right coronary artery (80%) • Circumflex (10%) • Both (10%)

  8. Sinus Arrest Pauses of 3 seconds without atrial activity

  9. Sinus pause or arrest • Failure of either inpulse formation or conduction out of the nodal region to the surrounding atrium

  10. Sinus Node Dysfunction • Sick sinus syndrome • 1/600 over 65 years of age • ~50% pacers in US

  11. Sinoatrial exit block Normal P wave axis Progressive shortening of PP interval until one P wave does not conduct (2nd degree, Type 1) or Sinus pause - exact multiple of baseline PP interval 2nd degree ,Type II)

  12. Bradycardia-Tachycardia Syndrome Alternating periods of atrial tachyarrhythmias and bradycardia

  13. 1st Degree AV Block PR > 0.2 seconds Every P wave followed by QRS complex

  14. 1st Degree Block • PR • Conduction time from sinus node through the atrium, AV node and His-Purkinje system to the onset of ventricular depolarization

  15. AV Conduction Disturbances • AV node or Bundle of His • Delays below the Bundle of His • BBB or fascicular blocks • AV conduction should be maintained unless all 3 fascicles are simultaneously affected • Intrinsic and Extrinsic causes

  16. 2nd degree AV Block Mobitz I Wenckebach Progressive lengthening of PR interval Shortening of RR interval until a P wave is blocked PR interval after blocked beat is shorter than preceding PR interval

  17. 2nd Degree AV Block Mobitz II Intermittently blocked P waves PR interval of conducted beats is constant

  18. 2nd Degree Block • Organized atrial rhythm does not conduct to ventricles in a 1:1 ratio, but some atrial-ventricular relation is maintained • Mobitz I is usually due to a delay in the AV node but may occur in the Bundle of His in patients with advanced disease • Mobitz II is most often with disease in His-Purkinje

  19. 2nd degree High-Grade AV block Conduction ratio of 3:1 or more PR interval of conducted beats is constant

  20. 3rd Degree AV Block Dissociation of atrial and ventricular activity Atrial rate is faster than ventricular rate, which Is junctional or ventricular

  21. 3rd Degree Block • Atrial and ventricular activity are independent of each other • Location of the block is implied by the escape rhythm • Narrow QRS- • HR 40-60 • AV nodal block • Wide QRS escape rhythm • usually at slower rates • His-Purkinje

  22. AV Dissociation

  23. Pacer Tips • Bipolar • Proximal pole- positive anode • Distal pole - negative cathode • Want catheter tip in apex of RV • When the catheter tip touches the RV, ST elevation is seen • 6F catheter

  24. The Subclavian

  25. Anesthetize skin overlying and inferior to junction of lateral and middle 1/3 of clavicle Advance the needle to anesthetize the clavicle at junction of medial and middle 1/3 of clavicle Insert the introducer needle just inferior to the junction of the lateral and middle 1/3 of the clavicle Orient the needle inferomedially Direct the needle medially and slightly Ccphalad- Aim for the SC junction or Suprasternal notch Using a shallow angle to the skin, Advance the needle just posterior to the bone of the clavicle at the junction of the medial and middle 1/3 With posterior pressure, direct the needle under the clavicle

  26. The Internal Jugular

  27. Identify the SCM triangle formed by the clavicle, sternal and clavicular heads IJ is in this triangle- lateral to carotid Anesthetize the skin and soft tissue overlying the apex of the triangle ( where the sternal and clavicular heads join) Insert the introducer at the apex at 30- 45 degree angle to skin and aim the needle toward the ipsilateral nipple Access the vein in the lateral aspect of the triangle at a depth of 1-3 cm

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