arrhythmia recognition and treatment cardiology acute care day

Arrhythmia recognition and treatment

Cardiology Acute Care Day

Objectives

Normal sinus rhythm

How to recognise an arrhythmia

Bradyarrhythmias

Tachyarrhythmias

Treatment strategy for arrhythmias

Outline

Objectives

Normal sinus rhythm

How to recognise an arrhythmia

Bradyarrhythmias

Tachyarrhythmias

Treatment strategy for arrhythmias

Outline

Normal rate

Regular, narrow QRS

P waves present

P:QRS is 1:1

ECG of sinus rhythmECG of sinus rhythm

P

QRS

Objectives

Normal sinus rhythm

How to recognise an arrhythmia

Bradyarrhythmias

Tachyarrhythmias

Treatment strategy for arrhythmias

Outline

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?

How to recognise an arrhythmiaHow to recognise an arrhythmia

Objectives

Normal sinus rhythm

How to recognise an arrhythmia

Bradyarrhythmias

Tachyarrhythmias

Treatment strategy for arrhythmias

Outline

Sinus bradycardia

Sinus arrest (“Sick Sinus Syndrome”)

Junctional bradycardia

Atrioventricular block(First degree)

Second degree

- type I (Wenckebach) / type II

Third degree

BradyarrhythmiasBradyarrhythmias

*Rate < 60bpm

Regular, narrow QRS

P waves present

P:QRS is 1:1

Sinus bradycardia

Sinus arrest

*Rate < 60bpm

Irregular, narrow QRS

P waves present

P:QRS is 1:1

Pause with absence of P wave

*

Rate < 60bpm

Regular, narrow QRS

No P waves

Junctional bradycardia

*

Rate variable

Regular, narrow QRS

P waves present

P:QRS is 1:1 with PR interval >200ms

First degree AV block

*

*

Rate < 60bpm

Irregular narrow QRS

P:QRS not 1:1

increasing PR interval

then dropped beat

Second degree AV block (type I)

*

*

Rate < 60bpm

Irregular narrow QRS

P:QRS not 1:1

normal PR interval with

intermittent dropped beats

*

Second degree AV block (type II)

Rate < 60bpm

Regular broad QRS

No relation between P and QRS

*

Third degree (complete) AV block

Objectives

Normal sinus rhythm

How to recognise an arrhythmia

Bradyarrhythmias

Tachyarrhythmias

Treatment strategy for arrhythmias

Outline

Irregular

Atrial fibrillation

Regular

Narrow QRS

Sinus tachycardia

Supraventricular tachycardia (SVT)

Atrial flutter

Broad QRS

Ventricular tachycardia

SVT with Bundle Branch Block

Tachyarrhythmias

Rate variable

Irregular, narrow QRS

No P waves

Atrial fibrillation

Rate > 100bpm

Regular, narrow QRS

P waves present

P:QRS is 1:1

*

Sinus tachycardia

Supraventricular tachycardias

Atrial tachycardia

Junctional tachycardia

AV re-entrant tachycardia

AV node re-entrant tachycardia

*

*

Rate > 100bpm

Regular, narrow QRS

P waves variable

- not apparent, or after QRS

*

*

Supraventricular tachycardia

Rate variable

Regular, narrow QRS

Sawtooth atrial activity 300bpm

- variable AV block

Atrial flutter

*

Rate > 100bpm

Regular, broad QRS

P waves variable

- may be dissociated

Ventricular tachycardia

Rate > 100bpm

Regular, broad QRS

P waves variable

- usually not visible

SVT with Bundle Branch Block

*

*

X

Normal sinus rhythm

How to diagnose an arrhythmia

Bradyarrhythmias

Tachyarrhythmias

Treatment strategy for arrhythmias

OutlineOutline

First assess the patient and CHECK THEIR PULSE

Are they compromised?

low BP, impaired consciousness, heart failure, chest pain

Then assess 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

Treatment strategy

89 year old female

Syncope

BP 75/40

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?

Assess the patientIf 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?

Third degree (complete) AV block

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

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

Temporary pacing

75 yr old male

Mild breathlessness

BP 135/85

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?

Assess the patientIf they are compromised DC cardioversion

If not, decide treatment strategyRate control vs rhythm control

Rate controlAV nodal blockers

CCB, β-blocker, digoxin

Rhythm controlAnti-arrhythmics

Amiodarone, flecainide

Anticoagulation

Atrial fibrillation

Following administration of beta-blocker

47 year old female

Palpitations

BP 120/70

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?

Assess the patientIf they are compromised DCCV

If not compromised:Vagal manoeuvresIV Adenosine (extremely short half-life, need to give rapidly)

Terminates re-entry circuits using AVNWill slow atrial tachycardia and atrial flutter

IV verapamil

Consider:AVN slowing (digoxin)Antiarrhythmic (amiodarone)DCCV/ A pacing

Supraventricular tachycardia

Termination of SVT with Adenosine

adenosine 6mg IV

62 year old male

Palpitations

BP 120/70

IV adenosine

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?

Following bisoprolol

82 year old male

Chest pain

BP 80/50

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?

Assess the patient DO THEY HAVE A PULSE? No? Use BLS/ALS ALGORITHM

If any compromise:

Immediate DCCVCall anaesthetistSecure airwayConscious sedationSynchronised DC shockManage on CCU

If no compromise: (GET 12 LEAD ECG)Consider IV amiodarone/other antiarrhythmics

Consider reversible causes

Ventricular tachycardia

First assess the patient and CHECK THEIR PULSE

Are they compromised?

low BP, impaired consciousness, heart failure, chest pain

Then assess 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

Treatment strategy

Normal sinus rhythm

How to recognise an arrhythmia

Bradyarrhythmias

Tachyarrhythmias

Treatment strategy for arrhythmias

Any questions? Any questions