2 unstable : altered mental status ischemic chest discomfort acute heart failure hypotension ...

BRADYCARDIA & TACHYCARDIA

Bradycardia & Tachycardia

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ARRHYTHMIA

Unstable : Altered mental status Ischemic chest discomfort Acute heart failure Hypotension Other signs of shock

Symptomatic: Palpitations Lightheadedness Dyspnea

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BRADYCARDIA IS DEFINED AS

A heart rate of <60 beats per minute.

When bradycardia is the cause of symptoms, the rate is generally <50 beats per minute, which is the working definition of bradycardia used here.

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BRADYCARDIA ALGORITHM FOCUSES ON

Management of

clinically significant bradycardia.

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INITIAL EVALUATION OF ANY PATIENT WITH BRADYCARDIA:

Should focus on : signs of increased work of breathing

Tachypnea Intercostal retractions Suprasternal retractions Paradoxical abdominal breathing

oxyhemoglobin saturation as determined by pulse oximetry.

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IF OXYGENATION IS INADEQUATE OR THE PATIENT SHOWS SIGNS OF INCREASED WORK OF BREATHING

Provide supplementary oxygen

Attach a monitor to the patient

Evaluate blood pressure

Establish IV access.

If possible, obtain a 12-lead ECG to better define the rhythm.

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ASYMPTOMATIC OR MINIMALLY SYMPTOMATIC PATIENTS

Do not necessarily require treatment

Unless: There is suspicion that the rhythm is likely

to progress to symptoms Or become life-threatening (eg, Mobitz type

II second-degree AV block in the setting of acute myocardial infarction [AMI])

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IF THE BRADYCARDIA

Is suspected to be the cause of: Acute altered mental status Ischemic chest discomfort Acute heart failure Hypotension Or other signs of shock

The patient should receive immediate treatment

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Immediate treatment


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SINUS BRADYCARDIA:

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ATRIOVENTRICULAR (AV) BLOCKS:

Are classified as: First Second Third-degree

Blocks may be caused by :Medications Electrolyte disturbancesStructural problems resulting from AMI or othermyocardial diseases

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FIRST-DEGREE AV BLOCK:

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SECOND-DEGREE AV BLOCK:

Is divided into Mobitz types I and II Mobitz types I:

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MOBITZ TYPES II:

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THIRD DEGREE AV BLOCK:

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THERAPY:

Atropine remains the first-line drug for acute symptomatic bradycardia

Atropine : Should be considered a temporizing measure

while awaiting a transcutaneous or transvenous pacemaker

For patients with Symptomatic sinus bradycardia Conduction block at the level of the AV node Sinus arrest.

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CONT. ATROPINE:

The recommended dose is: 0.5 mg IV every 3 to 5 minutes to a

maximum total dose of 3 mg.

Doses of ‹0.5 mg may paradoxically result in further slowing of the heart rate

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CONT. ATROPINE:

Use atropine cautiously in the presence of acute coronary ischemia or MI

Increased heart rate may worsen ischemia or increase infarction size.

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CONT. ATROPINE:

Atropine will likely be :

Ineffective in patients who have undergone cardiac transplantation

Because the transplanted heart lacks vagal innervation

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CONT. ATROPINE:

Avoid relying on atropine in : Type II second-degree or third degree AV block

These bradyarrhythmias are not likely to be responsive to reversal of cholinergic effects by atropine

These are preferably treated with TCP or adrenergic support as temporizing measures while the patient is prepared for transvenous pacing

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PACING:

TCP may be useful for the treatment of symptomatic bradycardias

TCP is, at best, a temporizing measure

TCP is painful in conscious patients whether effective or not :

The patient should be prepared for transvenous pacing

And expert consultation should be obtained.

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CONT. PACING:

It is reasonable to initiate TCP in unstable patients who do not respond to atropine

Immediate pacing might be considered in unstable patients with high-degree AV block when IV access is not available

If the patient does not respond to drugs or TCP, transvenous pacing is probably indicated

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ALTERNATIVE DRUGS TO CONSIDER: Although not first-line agents for

treatment of symptomatic bradycardia: Dopamine Epinephrine Isoproterenol

Use alternatives when a bradyarrhythmia is : Unresponsive to or inappropriate for treatment with

atropine, Or as a temporizing measure while awaiting the

availability of a pacemaker.

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DOPAMINE:

Dopamine infusion may be used for : Patients with symptomatic bradycardia Particularly if associated with:

Hypotension, In whom atropine may be inappropriate Or after atropine fails

Begin dopamine infusion at 2 to 10 mcg/kg per minute and titrate to patient response.

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EPINEPHRINE:

Epinephrine infusion may be used for: Patients with symptomatic bradycardia Particularly if associated with:

Hypotension Whom atropine may be inappropriate After atropine fails

Begin the infusion at 2 to 10 mcg/min and titrate to patient response

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ISOPROTERENOL:

The recommended adult dose is 2 to 10 mcg/ min by IV infusion, titrated according to heart rate and rhythm response

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TACHYARRHYTHMIA

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TACHYCARDIA IS DEFINED AS :

An arrhythmia with a rate of 100 beats per minute

As with defining bradycardia: Rate of 150 beats per minute is more

likely attributable to an arrhythmia

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PRIMARY OR SECONDARY CAUSE: Fever Dehydration Other underlying conditions

When a heart rate is <150 beats per minute: It is unlikely that symptoms of instability

are caused primarily by the tachycardia

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INITIAL EVALUATION OF ANY PATIENT WITH TACHYCARDIA:

Should focus on : signs of increased work of breathing

Tachypnea Intercostal retractions Suprasternal retractions Paradoxical abdominal breathing

oxyhemoglobin saturation as determined by pulse oximetry.

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IF OXYGENATION IS INADEQUATE OR THE PATIENT SHOWS SIGNS OF INCREASED WORK OF BREATHING

Provide supplementary oxygen

Attach a monitor to the patient

Evaluate blood pressure

Establish IV access.

If possible, obtain a 12-lead ECG to better define the rhythm.

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IF SIGNS AND SYMPTOMS PERSIST:

The provider should assess the patient’s degree of instability and determine if the instability is related to the tachycardia

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IF THE TACHYCARDIA:

Is suspected to be the cause of: Acute altered mental status Ischemic chest discomfort Acute heart failure Hypotension Or other signs of shock

The patient should receive immediate synchronized cardioversion

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IF NOT HYPOTENSIVE:

The patient with a regular narrow-complex : May be treated with adenosine while

preparations are made for synchronized cardioversion

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CARDIOVERSION:

If possible: Establish IV access before cardioversion Administer sedation if the patient is

conscious

Do not delay cardioversion if the patient is extremely unstable

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CONT. CARDIOVERSION:

Synchronized Cardioversion

Vs

Unsynchronized Shocks(defibrillation)

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CONT. CARDIOVERSION:

Synchronized cardioversion is recommended to treat : Unstable SVT Unstable atrial fibrillation Unstable atrial flutter Unstable monomorphic (regular) VT

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WAVEFORM AND ENERGY:

Biphasic energy dose for cardioversion of : Atrial fibrillation is 120 to 200 J

Atrial flutter and other SVTs 50 J to 100 J

Monomorphic VT (regular form and rate) with a pulse 100 J If there is

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WAVEFORM AND ENERGY:

Polymorphic VT : Treat as VF deliver high-energy

unsynchronized shocks (defibrillation doses)

Any doubt whether monomorphic or polymorphic VT in the unstable patient : Defibrillation doses

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IF THE PATIENT WITH TACHYCARDIA IS STABLE:

The provider has time to : Obtain a 12-lead ECG Evaluate the rhythm Determine the width of the QRS complex Determine treatment options.

Stable patients may await expert consultation

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CLASSIFICATION OF TACHYARRHYTHMIAS

Appearance of the QRS complex Heart rate Regularity

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THERAPY:

Vagal maneuvers: Valsalva maneuver or carotid sinus massage

Adenosine: If PSVT does not respond to vagal maneuvers Give 6 mg of IV adenosine as a rapid IV push

through a large vein followed by a 20 mL saline flush

Calcium Channel Blockers and B-Blockers: Verapamil, Diltiazem, Metoprolol,Atenolol,

Propranolol,

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SINUS TACHYCARDIA

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PAROXYSMAL SUPRAVENTRICULAR TACHYCARDY(PSVT):

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ATRIAL FLUTTER

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ATRIAL FIBRILLATION

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MULTIFOCAL ATRIAL TACHYCARDIA

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WIDE–QRS-COMPLEX TACHYCARDIAS: Ventricular tachycardia (VT) Ventricular fibrillation(VF) SVT with aberrancy Pre-excited tachycardias (Wolff-

Parkinson-White syndrome) Ventricular paced rhythms

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THERAPY:

Determine if the rhythm is regular or irregular

A regular wide-complex tachycardia: Adenosine Procainamide Amiodarone Sotalol Cardioversion

An irregular wide-complex tachycardia: Procainamide Amiodarone Magnesium Isoproterenol Cardioversion

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VENTRICULAR TACHYCARDIA (VT)

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VENTRICULAR FIBRILLATION(VF)

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WPW

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POLYMORPHIC VT(TORSADES DE POINTES)

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THE END

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2 unstable : altered mental status ischemic chest discomfort acute heart failure hypotension ...

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