Management of peri arrest arrhythmias
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This document provides an overview of peri-arrest arrhythmias including objectives, ECG interpretation, bradycardia, tachycardia, treatment approaches, and specific arrhythmias like atrial fibrillation, ventricular tachycardia, supraventricular tachycardia, and electrolyte abnormalities. The objectives are ECG interpretation in context of patient assessment, concepts of symptomatic and unstable arrhythmias, basic ECG reading, and treatments for tachycardias and bradycardias. Evaluation of stability and symptoms is emphasized over rhythm alone for treatment decisions.
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Management of peri arrest arrhythmias
- 1. Management of Peri-arrest Arrhythmias Presented: Dr Hesham Faisal, MD, MRCP, EDIC Consultant Intensivist SFH-Dammam
- 2. Objectives • ECG and rhythm information interpretation within the context of total patient assessment • The concept of symptomatic &/or unstable • Basic ECG interpretation • Tachy-arrhythmias and Brady-arrhythmias • ECG strips
- 3. Symptomatic Bradycardia and Tachycardia • ACLS providers treatment decisions – Should not depend solely on rhythm interpretation and neglect clinical evaluation. – must evaluate the patient’s symptoms and clinical signs (ventilation, oxygenation, HR, BP, level of consciousness, and signs of inadequate organ perfusion) – Must define the cause of the patient’s instability in order to properly direct treatment. • unstable – vital organ function is acutely impaired or cardiac arrest is ongoing or imminent • Symptomatic – arrhythmia is causing symptoms (palpitations, lightheadedness, or dyspnea) – patient is stable and not in imminent danger
- 4. The Electrocardiogram • Relationship of the ECG to Electrical Events in the Heart – ECG Components • P Wave • QRS Complex • T Wave • U Wave
- 12. The Electrocardiogram – Refractory Periods • Absolute • Relative
- 13. Bradycardia • HR <60 beat/minute • Symptomatic bradycardia < 50 beat/minute • hypoxemia is a common cause of bradycardia • Assessment: – signs of increased work of breathing (tachypnea, intercostal retracions, suprasternal retracions, paradoxical abdominal breathing) – Hypoxemia as determined by pulse oximetry • Action: – 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.
- 14. Dysrhythmias Originating in the SA Node Rules of Interpretation Sinus Bradycardia Rate Less than 60 Rhythm Regular Pacemaker Site SA node P Waves Upright & normal PRI Normal QRS Normal
- 15. Bradycardia • Signs & Symptoms of poor perfusion – Hypotension – acute altered mental status – ischemic chest discomfort, – acute heart failure, hypotension, or other signs of shock, • the patient should receive immediate treatment.
- 16. A first-degree AV block (generally benign) Rules of Interpretation First-Degree AV Block Depends on underlying Rate rhythm Rhythm Usually regular Pacemaker Site SA node or atrial P Waves Normal PRI > 0.20 Seconds QRS Usually < 0.12 seconds
- 17. Second Degree, Mobitz type I block, the block is at the AV node; the block is often transient and asymptomatic Rules of Interpretation Mobitz Type I Second-Degree AV Block Atrial, normal; ventricular, Rate normal to slow Atrial, regular; Rhythm ventricular, irregular Pacemaker Site SA node or arial Normal, some P waves not P Waves followed by QRS Increases until QRS is PRI dropped, then repeats QRS Usually < 0.12 seconds
- 18. Second Degree Mobitz type II block block is usually below the AV node often symptomatic potential to progress to complete AVblock . Rules of Interpretation Mobitz Type II Second-Degree AV Block Atrial, normal; Rate ventricular, slow May be regular or Rhythm irregular Pacemaker Site SA node or atrial Normal, some P waves not P Waves followed by QRS Constant for conducted PRI beats, may be > 0.21 seconds QRS Normal or > 0.12 seconds
- 19. Third Degree AV block AV node,bundle of His, or bundle branches Rules of Interpretation Third-Degree AV Block Atrial, normal; Rate ventricular, 40–60 Both atrial and ventricular Rhythm are regular SA node and AV Pacemaker Site junction or ventricle Normal,with no P Waves correlation to QRS PRI No relationship to QRS QRS 0.12 seconds or greater
- 20. Treatment of Bradycardia Atropine: • first-line drug for acute symptomatic bradycardia (Class IIa, LOE B) • Dose: 0.5 mg IV every 3 to 5 minutes to a maximum total dose of 3 mg • Use cautiously in the presence of acute coronary ischemia or MI • ineffective in cardiac transplant patient • Avoid in type II second-degree or third degree AV block with a new wide-QRS complex
- 21. Treatment of Bradycardia Transcutaneous pacing (TCP): • unstable patients who do not respond to atropine (Class IIa, LOE B) • patient should be prepared for transvenous pacing and expert consultation should be obtained.
- 22. Treatment of Bradycardia Alternative Drugs: • unresponsive for atropine • Temporizing measure awaiting TCP • overdose of a β blocker or Ca channel blocker. Dopamine • 2-10 mcg/kg/minute and titrate to patient response Epinephrine • 2 -10 mcg/min and titrate to patient response Isoproterenol • 2 to 10 mcg/min by IV infusion, titrated according to heart rate and
- 24. Tachycardia • Heart rate > 100 beats/minute • clinical significance ≥ 150 beats/minute • hypoxemia is a common cause of tachycardia, Assessment: – signs of increased work of breathing (tachypnea, intercostal retracions, suprasternal retracions, paradoxical abdominal breathing) – Hypoxemia as determined by pulse oximetry Action: – 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 immediate cardioversion should not be delayed if the patient is unstable
- 25. Unstable tachycardia Evaluate • unstable tachycardia • with severe signs and symptoms related to a suspected arrhythmia – acute altered mental status, – ischemic chest discomfort, – acute heart failure, – hypotension, or other signs of shock Treat: • Immediate Cardioversion • Selected cases of regular narrow complex tachycardia: Adenosine
- 26. Synchronized Cardioversion • establish IV access before cardioversion • sedation if the patient is conscious • shock delivery that is timed (synchronized) with the QRS complex • avoids shock delivery during the relative refractory period of the cardiac cycle when a shock could produce VF • recommended to treat 1. unstable atrial fibrillation →120 - 200 J 2. unstable SVT → 50 - 100 J 3. Unstable atrial flutter → 50 - 100 J 4. unstable monomorphic (regular) VT → 100 J.
- 27. The Electrocardiogram – Refractory Periods • Absolute • Relative
- 28. Stable tachycardia Evaluate: • narrow-complex or wide-complex tachycardia • rhythm is regular or irregular • Wide complexes QRS morphology is – monomorphic – Polymorphic Treat: • Tailored accordingly
- 29. Narrow–QRS-complex (SVT) tachycardias QRS< 0.12 second in order of frequency • Sinus tachycardia • Atrial fibrillation • Atrial flutter • AV nodal reentry • Accessory pathway–mediated tachycardia • Atrial tachycardia (including automatic and reentry • forms) • Multifocal atrial tachycardia (MAT) • Junctional tachycardia (rare in adults)
- 30. Sinus Tachycardia physiologic compensation rather than the cause of instability Rules of Interpretation Sinus Tachycardia Rate >100 (220-age ) Rhythm Regular Pacemaker Site SA node P Waves Upright & normal PRI Normal QRS Normal
- 31. Supraventricular Tachycardia (Re-entry SVT) Rules of Interpretation Paroxysmal Supraventricular Tachycardia Rate 150–250 Rhythm Regular Pacemaker Atrial (outside SA Node) Site Often buried in P Waves preceding T wave PRI Usually normal QRS Usually normal
- 32. Treatment of stable PSVT Vagal Maneuvers • Valsalva maneuver or carotid sinus massage • preferred initial therapeutic choices for the termination of stable PSVT • may transiently slow the ventricular rate & assist rhythm diagnosis Adenosine (Class I, LOE B) • 6 mg rapid IV push followed by a 20 mL saline flush • 12 mg rapid IV push • Defibrillator should be available • Side effects: flushing, dyspnea & chest discomfort
- 33. Treatment of stable PSVT calcium channel blockers (Class IIa, LOE B) • verapamil – 2.5 mg to 5 mg IV bolus over 2 minutes – repeated doses of 5 -10 mg q 15-30 minutes to a total dose of 20 mg – Contraindicated in impaired LV function or heart failure • Diltiazem – 15 -20 mg IV over 2 minutes – maintenance infusion dose is 5-15 mg/hour IV β-blockers (Class IIa, LOE C) • metoprolol,atenolol, propranolol, esmolol • used with caution in patients with COPD or CCF
- 34. Wide–QRS-complex tachycardias QRS > 0.12 second • Ventricular tachycardia (VT) • SVT with aberrancy • Pre-excited tachycardias [WPW] syndrome • Ventricular paced rhythms
- 35. Wide-Complex Tachycardia Evaluation 1. Stable or unstable patient – Unstable → immediate cardioversion 2. 12 lead ECG 3. Regular or irregular a. Regular VT or SVT with aberrancy b. Irregular atrial fibrillation with aberrancy or polymorphic VT/torsades de pointes
- 36. Therapy for Regular stable Wide- Complex Tachycardias IV adenosine • safe for both treatment and diagnosis (Class IIb, LOE B). • should not be given for unstable or irregular or polymorphic widecomplex tachycardias • 6 mg rapid IV push → 12 mg → 12 mg • defibrillator should be available Stable likely VT • IV antiarrhythmic (procainamide, amiodarone or sotalol) • Or elective cardioversion
- 37. Dysrhythmias Originating in the Ventricles Rules of Interpretation Ventricular Tachycardia Rate 100–250 Rhythm Usually regular Pacemaker Site Ventricle If present, not P Waves associated with QRS PRI None QRS >0.12 seconds, bizarre
- 38. Irregular Tachycardias Irregular narrow-complex or wide-complex tachycardia: 1. atrial fibrillation (with or without aberrant conduction) 2. MAT 3. sinus rhythm/tachycardia with frequent atrial premature beats
- 39. AF Rules of Interpretation Atrial Fibrillation Atrial rate 350–50 Rate Ventricular rate varies Rhythm Irregularly irregular Pacemaker Site Atrial (outside SA Node) P Waves None discernible PRI None QRS Normal
- 40. Treatment of AF Rate control • >48 hours are at increased risk for cardioembolic events • Avoid Electric or pharmacologic cardioversion unless the patient is unstable • IV β –blockers or calcium channel blockers such as diltiazem • Digoxin and amiodarone – Congestive heart failure • wide-complex irregular rhythm (AF with pre-excitation) – Avoid AV nodal blocking agents such as adenosine, calcium channel, β blockers, digoxin
- 41. MAT Rules of Interpretation Multifocal Atrial Tachycardia Rate More than 100 Rhythm Irregular Pacemaker Site Ectopic sites in atria Organized, nonsinus P P Waves waves; at least 3 forms Varies depending on PRI source of impulse QRS Variable
- 42. PACs Rules of Interpretation Premature Atrial Contractions Depends on underlying Rate rhythm Usually regular except Rhythm for the PAC Pacemaker Site Ectopic sites in atria Occurs earlier than P Waves expected Varies dependent on PRI foci of impulse QRS Usually normal
- 43. Dysrhythmias Originating in the Atria Rules of Interpretation Atrial Flutter Atrial rate 250–350 Rate Ventricular rate varies Rhythm Usually regular Pacemaker Site Atrial (outside SA node) P Waves F waves are present PRI Usually normal QRS Usually normal
- 44. Dysrhythmias Originating in the Ventricles • Torsade de Pointes – Polymorphic VT. – Caused by the use of certain antidysrhythmic drugs. – Exacerbated by coadministration of antihistamines, azole antifungal agents and macrolide antibiotics, erythromycin, azithromycin, and clarithramycin.
- 45. Polymorphic (Irregular) VT torsades de pointes • requires immediate defibrillation with the same strategy used for VF – stop medications known to prolong the QT interval – Correct electrolyte imbalance • magnesium is commonly used – Polymorphic VT associated with familial long QT syndrome • isoproterenol or ventricular pacing – Polymorphic VT with bradycardia and drug-induced QT prolongation • IV amiodarone and β–blockers – myocardial ischemia induced Polymorphic VT
- 47. Dysrhythmias Originating in the Ventricles Rules of Interpretation Artificial Pacemaker Rhythm Varies with Rate pacemaker May be regular or Rhythm irregular Depends upon Pacemaker Site electrode placement None produced by P Waves ventricular pacemakers; pacemaker spike PRI If present, varies QRS >0.12 seconds, bizarre
- 48. Dysrhythmias Resulting from Disorders of Conduction • Pre-excitation Syndromes – Excitation by an impulse that bypasses the AV node • Wolff-Parkinson- White Syndrome (WPW) – Short PRI and long QRS duration – Delta waves – Treat underlying rhythm.
- 49. ECG Changes Due to Electrolyte Abnormalities and Hypothermia • Hyperkalemia – Tall Ts • Suspect in patients with a history of renal failure. • Hypokalemia – Prominent U waves • Hypothermia – Osborn wave (“J” wave) – T wave inversion, sinus bradycardia, atrial fibrillation or flutter, AV blocks, PVCs, VF, asystole
- 74. Summary • The goal of therapy for bradycardia or tachycardia is to – rapidly identify and treat patients who are hemodynamically unstable or symptomatic due to the arrhythmia • Drugs or when appropriate, pacing may be used to control unstable or symptomatic bradycardia • Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia • ACLS providers – should closely monitor stable patients pending expert consultation and – should be prepared to aggressively treat those with evidence of decompensation