Project: Ghana Emergency Medicine Collaborative Document Title: Approach to Bradycardias and Tachycardias Author(s): Rockefeller Oteng (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/

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Bradycardia  

James Heilman, MD, Wikimedia Commons 3  3  

-  Prepare for transcutaneous pacing

-  Consider atropine

-  Consider epinephrine or dopamine

Signs or symptoms of poor perfusion caused by the bradycardia? (e.g. acute altered mental status, ongoing chest pain, hypotension, or other signs of shock?

Brady-­‐  Arrhythmias  

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BRADYCARDIA Heart Rate <60 bpm

and inadequate for clinical condition

-  Maintain patient airway; assist breathing as needed

-  Give oxygen -  Monitor EKG (id rhythm),

blood pressure, oximetry -  Establish IV access

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3

Observe/Monitor 4A

4

-  Prepare for transvenous pacing

-  Treat contributing causes

-  Consider expert consultation 5

REMINDERS -  If pulseless arrest, go to pulseless arrest algorithm -  Search for and treat possible contributing factors:

-  Hypovolemia - Toxins -  Hypoxia - Tamponade, cardiac -  H+ ion (acidosis) - Tension pneumothorax -  Hypo/hyperkalemia - Thrombosis (coronary/pulmonary) -  Hypoglycemia - Trauma (hypovolemia/ñICP) -  Hypothermia

Adequate perfusion Poor perfusion

Unstable/Poor  Perfusion  

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-  Prepare for transcutaneous pacing

-  Consider atropine -  Consider epinephrine or

dopamine 4

-  Prepare for transvenous pacing -  Treat contributing causes -  Consider expert consultation 5

Poor perfusion

Geo Swan, Wikimedia Commons 6  6  

Reminders  

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•  If  pulseless  arrest  develops,  go  to  pulseless  arrest  algorithm  •  Search  for  and  treat  possible  contribuHng  factors:    Hypovolemia    Hypoxia  Hydrogen  ion  (acidosis)  Hypo/hyperkalemia  Hypoglycemia  Hypothermia  

Toxins  (drugs)  Tamponade  (cardiac)  Tension  PTX  Thrombosis  (coronary  or  pulmonary)  Trauma  (hypovolemia,  increased  ICP)  

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Tachy-­‐  Arrhythmias  

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TACHYCARDIA With Pulses

-  Assess and support ABC’s -  Give oxygen -  Monitor EKG, blood pressure, oximetry -  Id and treat reversible causes

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Stable Is patient stable? 3

WIDE QRS -> is rhythm REGULAR?

-  Establish IV access -  Obtain 12 lead EKG -  Is QRS narrow (<0.12

sec)?

NARROW QRS-> is rhythm REGULAR?

Narrow QRS

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12

5

-  Attempt vagal maneuvers

-  Give adenosine IV push 6

Does rhythm convert? Consider: expert consult 8

Wide QRS

Perform immediate, synchronized cardioversion 4

Unstable Symptoms persist

-  Irregular Narrow Complex Tachycardia

-  Likely: A. fib, A. flutter, MAT -  Consider: expert consult, B-

blockers to control HR 11 7

Regular Irregular -  If V. tachycardia or uncertain

rhythm: * Amiodarone * Synchronized cardioversion -  If SVT with aberrancy: * Adenosine (Box 7)

-  If A. fibrillation with aberrancy:

* See Box 11 -  If pre-excited A. fibrillation: * Expert consult advised * Avoid adenosine, digoxin, diltiazem, verapamil * Consider amiodarone -  If recurrent polymorphic VT * Seek expert consult -  If torsades de pointes * Give magnesium

Regular Irregular

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14 -  Likely reentry SVT * Observe for recurrence * Treat recurrence with adenosine, diltiazem, B-blockers

-  Likely A. flutter, ectopic atrial tachycardia, or junctional tachycardia

-  Consider diltiazem and B-blockers to control HR

-  Treat underlying cause -  Consider expert consult

Converts Does Not Convert

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NOTE: If patient becomes unstable at any point, go to Box 4

During evaluation: -  Secure and verify airway and vascular access -  Consider expert consult -  Prepare for cardioversion Treat possible contributing factors: -  Hypovolemia - Toxins -  Hypoxia - Tamponade, cardiac -  H+ ion (acidosis) - Tension pneumothorax -  Hypo/hyperkalemia - Thrombosis (coronary/

pulmonary) -  Hypoglycemia - Trauma (hypovolemia/ñICP) -  Hypothermia

Stable  or  Unstable?  Narrow  or  Wide?  

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TACHYCARDIA With Pulses

-  Assess and support ABC’s -  Give oxygen -  Monitor EKG, blood pressure,

oximetry -  Id and treat reversible causes

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2

Stable Is patient stable? 3

WIDE QRS -> is rhythm REGULAR?

-  Establish IV access -  Obtain 12 lead

EKG -  Is QRS narrow

(<0.12 sec)?

Narrow QRS 12

5 Wide QRS

Perform immediate, synchronized cardioversion 4 Unstable

Symptoms persist

Stable  and  Narrow  

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WIDE QRS -> is rhythm REGULAR?

NARROW QRS-> is rhythm REGULAR?

Narrow QRS

-  Attempt vagal maneuvers

-  Give adenosine IV push

Does rhythm convert? Consider: expert consult 8

Wide QRS

-  Irregular Narrow Complex Tachycardia

-  Likely: A. fib, A. flutter, MAT

-  Consider: expert consult, B-blockers to control HR 11

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Irregular

Converts Does Not Convert

Regular

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SVT  –  Mechanism  Reentry via accessory pathway

A) Normal conduction B) PAC C) Orthodromic reentrant pathway

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•  AV nodal reentrant circuit - 60% •  Atrio-ventricular reentrant circuit w/ accessory pathway - 30% •  Atrial tachycardia – 10% •  Other rare forms: Sinus-node reentrant tachycardia, inappropriate sinus

tachycardia, ectopic junctional tachycardia, and non-paroxysmal junctional tachycardia.

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SVT  –  Mechanism  

SVT  -­‐  Treatment  •  Adenosine:

–  6 mg - termination in 60-80% –  12 mg - termination in 90-95% –  Contraindicated in heart transplant, COPD/asthma, and wide complex

tachycardia (unless 100% certain is SVT w/ aberrancy) –  Avoid with evidence of pre-excitation

•  Beta blockers or Ca++ channel blockers - contraindicated in antidromic WPW •  Last resort: procainamide, ibutilide, propafenone, or flecainide •  If unstable - electricity!

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SVT  -­‐    Treatment  w/  Adenosine  

Displaced, Wikimedia Commons 14  14  

A\er  Adenosine  

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-  Likely reentry SVT * Observe for recurrence * Treat recurrence with adenosine, diltiazem, B-blockers

-  Likely A. flutter, ectopic atrial tachycardia, or junctional tachycardia

-  Consider diltiazem and B-blockers to control HR

-  Treat underlying cause -  Consider expert consult

Converts Does Not Convert

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10

Stable  and  Wide  Regular  or    Irregular?  

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WIDE QRS -> is rhythm REGULAR? 12

Wide QRS

-  If V. tachycardia or uncertain rhythm:

* Amiodarone * Synchronized cardioversion -  If SVT with aberrancy: * Adenosine (Box 7)

-  If A. fibrillation with aberrancy: * See Box 11 -  If pre-excited A. fibrillation: * Expert consult advised * Avoid adenosine, digoxin, diltiazem, verapamil * Consider amiodarone -  If recurrent polymorphic VT: * Seek expert consult -  If torsades de pointes: * Give magnesium

Regular Irregular

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Wide  Complex  Tachycardia  

Afib  with  LBBB  Steven Fruitsmaak, Wikimedia Commons 17  17  

Wide  Complex  Tachycardia  •  Stable

–  Amiodarone 150 mg over 10 min or other anti-arrhythmics –  Prepare for synchronized cardioversion

•  Unstable –  ABC’s/Call for help/Start CPR –  Defibrillate: Biphasic 120-200 J (When in doubt pick 200 J),

monophasic 360 J –  Epinephrine 1 mg IV q3-5 min –  Vasopressin 40 Units IV –  May try amiodarone or lidocaine after 3 attempts at defibrillation

•  Amiodarone 300 mg, may repeat w/ 150 mg x1 •  Lidocaine 1-1.5 mg/kg, then 0.5-0.75 mg/kg, max is 3 mg/kg

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H’s  and  T’s  

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Treat  contribuHng  factors:  Hypovolemia  Hypoxia  

Hydrogen  ion  (acidosis)  Hypo/hyperkalemia  Hypoglycemia  

Hypothermia  

During  EvaluaHon  

•  Secure,  verify  airway  and  vascular  access  when  possible  

•  Consider  expert  consultaHon  

•  Prepare  for  cardioversion  

 

Toxins  (drugs)  Tamponade  (cardiac)  Tension  PTX  Thrombosis  (coronary/pulmonary)  Trauma    

Review  

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Bradycardias  Tx  of  Bradycardias  

•  Stable  – MI  – Adequate  perfusion?  – Monitor  BP!!  

 •  Unstable  

– Poor  perfusion  –  Immediate  transcutaneous  pacing  – Consider  atropine  while  awaiHng  pacer,  0.5-­‐1.0  mg  – Consider  epi  or  dopamine  if  pacing  ineffecHve  

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Tachycardia’s  Stable  vs.  Unstable  

•  Stable  – MI  – 12  lead  – Narrow  complex  – Wide  complex  – Treat  causes  

• H’s  and  T’s  

•  Unstable  – Altered  MS  – CP  – Hypotension  – Signs  of  shock  

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Tx  of  Stable  Tachycardias  

•  A-­‐fib/fluger  – DilHazem  (Ca++  channel  blocker)  –  Consider  cardioversion  

•  SVT  – Vagal  maneuvers  – Adenosine  

•  6  mg  then  12  mg  then  12  mg  

•  V-­‐Tach  (WITH  PULSE)  – AnHarrhythmic:  Lidocaine,  Amiodarone,  (Mg+  for  torsades)  

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Tx  of  Unstable  Tachycardias  

•  Stable  – Amiodarone  150  mg  over  10  min  or  other  anH-­‐arrhythmics  

– Prepare  for  synchronized  cardioversion  •  Perform  immediate  synchronized  cardioversion  

– MI  – Sedate  if  conscious  – DO  NOT  DELAY  CARDIOVERSION  

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ContribuHng  Factors    H’s  and  T’s  

•  Hypovolemia  •  Hypoxia  •  Hydrogen  ion  (acidosis)  •  Hypo/hyperkalemia  •  Hypoglycemia  •  Hypothermia  •  Toxins  (drugs)  •  Tamponade  (cardiac)  •  Tension  PTX  •  Thrombosis  (coronary  or  pulmonary)  •  Trauma   25  25