Acute  Diagnosis  and  Treatment  of    Common  Dysrhythmias  

ACNP/PA  Cri9cal  Care  Boot  Camp  Vanderbilt  University  Medical  Center  

September  9,  2014    

Ariel  Kappa  RN,  MSN,  ACNP-­‐BC  

Objec9ves  •  Review  

– Cardiac  conduc9on  cycle  – EKG  

•  Dysrhythmia  Diagnosis  and  Treatment  – Characteris9cs  – E9ology  – Pharmacological  Management  

•  Case  Studies  

Blocks?  Infarc9on?  

Rhythm  (P  waves,  QRS)  

Rate  (Fast  or  Slow)  

Stable  or  Unstable  (Shock  ?)  

Mechanism  of  Dysrhythmias  •  Automa9city                        or    

•  Ectopic  foci  /  Escape  beats      •  Reentry  /  Conduc9on  block  

Tachycardia    

Regular  

Narrow  

Sinus  Tachycardia,  

Atrial  Tachycardia,  AVNRT/AVRT,  Atrial  flu;er  

Wide  

Monomorphic  VT,    

SVT  with  aberrancy/

block/pacing-­‐mediated  

Irregular  

Narrow  

Atrial  fibrillaEon,  

MAT  

Wide  

Polymorphic  VT/VF/  Torsades,  

Irregular  SVT  with  

aberrancy/block  

Ini9al  considera9ons  •  Stable?  

– Hypotension,  AMS,  signs  of  shock,  CP  – 12-­‐lead  EKG    

•  Pharmacological  management    •  Non-­‐Pharmacological  management  

– Synchronized  cardioversion  (50-­‐200  J)  •  Oxygen,  airway,  monitor,  seda9on  

   

Pharmacology  Class   Common  Examples   Mechanism     Clinical  Use  

Ia   Quinidine  Procainamide  

Na+  Channel  blocker;  Fast  (effects  QRS)  

Pre-­‐excited  afib,  Stable  monomorphic  VT  

Ib   Lidocaine,  Mexili9ne,  Phenytoin  

Na+  Channel  blocker;  No    effect  on  conduc9on;  may  prolong  APD  

VT  

Ic   Fleicanide,  Propafenone  

Na+  Channel  blocker;  (no  effect  on  QRS)  

SVT,  PVCs,    WPW  

II   Metoprolol,  Esmolol,  Propranalol  

Block  beta-­‐adrenergic  receptors   Afib  rate  control,  Narrow  Stable  SVT  

III   Amiodarone*,  Sotalol*,  Ibitulide  

K+  channel  blocker   SVT  (Regular  and  Irregular)    

IV   Verapamil,  DilEazem   Non-­‐dihydropyridine  Calcium  channel  blocker,  vasodilate,  nega9ve  inotrope  

Rate  control  SVT  *Avoid  in  CHF/VT  Pre-­‐exited  Afib  

Misc.   Digoxin,    Adenosine  Magnesium  

Dig-­‐  parasympathe9c  ê  AV,    +  Inotrope  Adenosine-­‐  êAV    Mag-­‐  effect  Na/K  transport  

Dig-­‐  SVT,  Afib  in  HF,  Adenosine-­‐  SVT,  stable  WCT,  Mg-­‐  Polymorphic  VT/Torsades  

Regular  Narrow  Complex  

•  Sinus  Tachycardia  •  Atrial  Tachycardia  •  Atrioventricular  Nodal  Tachycardia  (AVNRT)  •  Atrioventricular  Tachycardia  (AVRT,  Orthodromic)  

•  Atrial  flueer  

Sinus Tachycardia Atrial Tachycardia

EKG characteristics: Constant PR interval Varies with stimulation/respiration Normal Rate 220 bpm –age (yrs) Etiology: Physiologic Treatment: Fix underlying physiologic insult (Fever, anxiety, thyrotoxicosis, exogenous catecholamines, anticholinergic, LV dysfunction- MI etc.

EKG characteristics: Atrial rate 150-250 Distinct P wave morphology Etiology: CHF, HTN, electrolyte abnormalities Treatment: Adenosine, Class II, Class III *Dig toxicity?

AV  Nodal  Reentrant  Tachycardia  (AVNRT)  

•  EKG  characteris9cs:  Rate  140-­‐280,    P  wave  undetected  (ac9va9on  atria/ventricle  simultaneously),    

•  E9ology:  Triggered  by  PACs,  Reentry  at  AV  node  (atrial  stretch,  inflamma9on,  irritability-­‐  catecholamines)  

•  Treatment:  Vagal  maneuvers,  Adenosine  6-­‐12  mg  IV  push,  Ca++  channel  blockers,  Digoxin,  Beta  blockers  

AV  Nodal  Tachycardia  (AVRT)  or  Orthodromic  

•  E9ology:  Macroreentry  through  normal  conduc9on  system  with  accessory  AV  pathway;  Delayed  ac9va9on  of  atria  =  visible  P  wave    

•  Treatment:    Similar  to  treatment  of  AVNRT,  AV  nodal  blockers,  eventual  abla9on  

Atrial  Flueer  

EKG  Characteris9cs:  ‘Sawtooth’  paeern:  atrial  rate  ~300,  ventricular  rate  75-­‐150  bpm  (unless  irregular).  Usually  with  2:1/4:1block  at  AV  node.  Rhythm  constant  amplitude,  morphology,  dura9on.    **May  be  variable  and  irregular    

E9ology:  Reentrant  circuit  in  the  wall  of  the  atrium    

Treatment:  Class  III  (Ibu9lide,  sotalol,  amiodarone):  prolong  refractory  period  (not  slowing  conduc9on)  *Small  risk  for  torsades.  Ventricular  rate  control  can  be  difficult,  AV  nodal  blockers  prevent  1:1  conduc9on.  Unmasking  of  flueer  waves  with  adenosine.    

*Nonpharmacological  :  Rapid  pacing  or  low  voltage  DC  cardioversion  is  effec9ve.    

Regular  Wide  Complex  

•  Ventricular  Tachycardia  (VT)    •  Wide  complex  SVT    

– Bundle  branch  block  – An9dromic-­‐  Wolf-­‐Parkinson-­‐White  (WPW)  – Pacemaker-­‐mediated      

Monomorphic  VT  

EKG  characteris9cs:    3  consecu9ve  beats  >100  bpm,  QRS  >120ms    Brugada  criteria:  Precordial  leads-­‐  No  RS  complex  or  RS  >100ms,  AV  dissocia9on,  QRS  morphology  E9ology:    CAD,  CM,  Ischemia  Treatment:  Correct  aggrava9ng  condi9ons  (hypokalemia,  ischemia)  *Wide  QRS  presumed  VT  if  unclear  (LOE:  C).  *DCCV  unstable  (LOE:  C).  Class  Ia:  Procainamide-­‐  careful  in  LV  dysfunc9on,  CHF,  hypotension-­‐  prolong  QT.  Class  III-­‐  Sotalol,  Amiodarone  (benefit  IV  to  PO).  Class  IIb-­‐  IV  lidocaine  ini9al  treatment  associated  with  MI  (LOE:  C).        

Wide  Complex  SVT  

 •  EKG  characteristcs:  Regular,  Wide  complex,  Fails  Brugada  criteria  •  E9ology:  BBB/IVCD,  Preexcita9on,  Presence  of  PPM/ICD  •  Treatment:    WPW-­‐  Procainamide  (*Avoid  AV  nodal  blockers)  •  Vagal  maneuvers,  Adenosine,  Class  II,  Class  III,  Cardioversion  

Delta  wave    WPW   Pacemaker-­‐

Mediated  

Irregular  Narrow  Complex  

•  Atrial  fibrilla9on    •  MAT  

•  Sinus  Tachycardia  w/  Premature  atrial  contrac9ons  (PACs)  

•  SVT  with  block    

Atrial  Fibrilla9on  

EKG  Characteris9cs:  Irregularly  Irregular.      

E9ology:  Numerous  waves  of  depolariza9on  spreading  throughout  the  atria,  leading  to  an  absence  of  coordinated  atrial  contrac9on.  

Treatment:    Stable:  rate  control  not  rhythm  control  –  AFFIRM  trial  (NEJM  2002).  Class  II,  Class  IV,  Class  III,    Digoxin:  HF  (inotropic  support).  Unstable:  Low  voltage  DC  cardioversion  

Mul9focal  Atrial  Tachycardia  (MAT)  

•  EKG  characteris9cs:  at  least  3  P  wave  morphologies,  variable  intervals  P-­‐P,  R-­‐R,  P-­‐R,  look  for  isoelectric  baseline  

•  E9ology:  No  single  dominant  pacemaker,  mul9ple  atrial  foci  fire  independently.  COPD/CHF  

•  Treatment:  Treat  underlying  cause  (electrolyte  derangement,  hypoxemia).  Rate  control-­‐  Class  IV-­‐  CCBs,  Class  II-­‐  Beta-­‐blockers  

ST   • PACs  

Irregular,  Wide  Complex    •  Polymorphic  VT  

–  E9ology:  Ischemia,  Catecholamines  –  Treatment:  Defibrilla9on  

•  Ventricular  fibrilla9on,  Torsades  de  pointes  –  E9ology-­‐  QT  prolonga9on,  Class  I,  III-­‐  prolong  refractory  period  

   

 

Bradycardia  

Regular  

Sinus  Bradycardia,  Junc9onal  Bradycardia,  Idioventricular  

escape  rhythm,  1st  Degree  AV  block,  3rd  Degree  AV  

block  

Irregular  

2nd  Degree  Type  I  AV  block,  2nd  

Degree  Type  II  AV  block,    

Ini9al  considera9ons    •  Stable?  

– Hypotension,  AMS,  Light-­‐headedness,/syncope,  angina  

 

•  Pharmacologic  – Atropine  (selec9ve  muscarinic  antagonist)      

– Epinephrine,  Dopamine  

•  Non-­‐pharmacologic  –  Transcutaneous  pacing  >  Transvenous  –   Expert  consulta9on,  PPM      

 

Sinus  Bradycardia  

•  EKG  Characteris9cs:  <60  bpm,  normal  P  wave  with                  PR  <.20  prior  to  every  narrow  QRS  

•  E9ology:  Normal  variant,  hypoxemia,  Increased  ICP,  SSS,  OSA,  hypothermia,  MI,  Drugs  

•  Treatment:  Symptoma9c?  •  CCB  and  Beta-­‐blocker  overdose-­‐  IV  calcium,  glucagon      

with  or  without  insulin    

Junctional Escape Idioventricular Escape

EKG Characteristics: 40-60 bpm (regular w/ narrow QRS), No P waves, >60bpm= ‘accelerated’

Etiology: Escape rhythm with focus from AV node

Treatment: Usually stable.

EKG Characteristics: Regular rate 30-45 bpm, QRS wide (below AV node), >60bpm= ‘accelerated’

Etiology: Focus in His-bundle branch system

Treatment: Pacing

3rd Degree AV block

EKG Characteristics: No relationship between P waves and QRS, atrial rate faster than ventricular rate, PP intervals and RR intervals remain regular and constant

Etiology: Inferior MI

Symptoms: Syncopal symptoms, angina, CHF

Treatment: Transcutaneous Pacemaker

1st Degree AV block

EKG Characteristics: Prolongation of the PR interval, which is constant. All P waves are conducted

Etiology: Usually benign

Treatment: None

2nd  Degree  AV  Block    (Mobitz  I,  Wenckebach)  

EKG Characteristics: Progressive prolongation of the PR interval until a P wave is not conducted. PR interval prolongs, the RR interval actually shortens, Narrow QRS.

Etiology: High AV nodal block. Usually benign unless associated with underlying pathology, i.e. Inferior MI, Toxicity (beta-blockers, CCBs).

2nd  Degree  AV  Block    (Mobitz  II)  

EKG Characteristics: Constant PR interval with intermittent failure to conduct. Rhythm is dangerous as the block is lower in the conduction system

Etiology: Infranodal His-Purkinje system conduction delay. Inferior/Anterior MI-fibrotic disease of the conduction system

Leu  Bundle  Branch  Block  

R-wave (R’) in V1, and a slurred S-wave in V5 - V6.

QS or rS complex in lead V1 and a monophasic or notched R wave in lead V6.

Etiology: CAD, HTN, CM, Aortic valve disease

Etiology: Congenital, MI, PE

Right  Bundle  Branch  Block  

Case  Study  #  1  •  78  yo  female  POD  3  s/p  AVRt.    

•  Pa9ent  c/o  palpita9ons.    

•  Vitals  HR:  160s,  SBP:  119/65,  SPO2:  95%  4  LNC  

Case  Study  #  2  

•  54  yo  male  POD  1  s/p  TURP  recovering  on  stepdown.  RRT  for  Chest  Pain.  

•  Pt  c/o  SOB.  Diaphore9c    •  HR:  41,  SBP:  108/69,    SPO2:  96%  2L  NC  

Case  Study  #  3  

44  yo  male  admieed  to  observa9on  unit  for  SOB,  dyspnea...    HR  174,  SBP  92/60,  SPO2  94%  NRB    

References  •  The  Atrial  Fibrilla9on  Follow-­‐up  Inves9ga9on  of  Rhythm  Management  (AFFIRM)  Inves9gators  .  A  comparison  of  

rate  control  and  rhythm  control  in  pa9ents  with  atrial  fibrilla9on.  New  England  Journal  of  Medicine.  2002,  347,  1825-­‐1833.    

 •  Carina  Blomström-­‐Lundqvist,  Melvin  M.  Scheinman,  E9enne  M.  Aliot,  Joseph  S.  Alpert,  Hugh  Calkins,  A.  John  

Camm…Hans-­‐Joachim  Trappe.  CC/AHA/ESC  Guidelines  for  the  Management  of  Pa9ents  With  Supraventricular  Arrhythmias−−Execu9ve  Summary:  A  Report  of  the  American  College  of  Cardiology/American  Heart  Associa9on  Task  Force  on  Prac9ce  Guidelines  and  the  European  Society  of  Cardiology  Commieee  for  Prac9ce  Guidelines  (Wri9ng  Commieee  to  Develop  Guidelines  for  the  Management  of  Pa9ents  With  Supraventricular  Arrhythmias).  Circula5on,  2003,  108:1871-­‐1909.  doi:  10.1161/01.CIR.0000091380.04100.84.  

•  Douglas  P.  Zipes,  A.  John  Camm,  Mar9n  Borggrefe,  Alfred  E.  Buxton,  Bernard  Chaitman,  Mar9n  Fromer…Cynthia  Tracy.  CC/AHA/ESC  2006  Guidelines  for  Management  of  Pa9ents  With  Ventricular  Arrhythmias  and  the  Preven9on  of  Sudden  Cardiac  Death:  A  Report  of  the  American  College  of  Cardiology/American  Heart  Associa9on  Task  Force  and  the  European  Society  of  Cardiology  Commieee  for  Prac9ce  Guidelines  (Wri9ng  Commieee  to  Develop  Guidelines  for  Management  of  Pa9ents  With  Ventricular  Arrhythmias  and  the  Preven9on  of  Sudden  Cardiac  Death):  Developed  in  Collabora9on  With  the  European  Heart  Rhythm  Associa9on  and  the  Heart  Rhythm  Society.    Circula5on,  2006,  114,  e385-­‐e484.  doi:  10.1161/CIRCULATIONAHA.106.178233.  

•  Dubin,  Dale.    (2000).  Rapid  Interpreta9on  of  EKGs:  Dr.  Dubin’s  classic  simplified  methodology  for  understanding  EKGs,  6th  Ed.  Loca9on.  C.o.v.e.r.  

•  ECC  Guidelines.  Part  6:  Advanced  Cardiovascular  Life  Support:  Sec9on  5:  Pharmacology  I:  Agents  for  Arrhythmias.  Circula5on.  2000,  102,  I-­‐112-­‐I-­‐128.  doi:  10.1161/01.CIR.102.suppl_1.I-­‐112.  

References  Cont.    •  Fuster  V,  Ryden  LE,  Cannom  DS,  et  al.  2011  ACCF/AHA/HRS  focused  updates  incorporated  into  the  ACC/AHA/ESC  

2006  guidelines  for  the  management  of  pa9ents  with  atrial  fibrilla9on:  a  report  of  the  American  College  of  Cardiology  Founda9on/  American  Heart  Associa9on  Task  Force  on  Prac9ce  Guidelines.  Circula5on.  2011,  123,  e269-­‐e367.    

•  Goodman  S,  Shiov  T,  Weissman  C.  Supraventricular  arrhythmias  in  intensive  care  unit  pa9ents:  short  and  long-­‐term  consequences.  Anesth  Analg.    2007,  104:880-­‐886.  

•  January  CT,  Wann  LS,  Alpert  JS,  Calkins  H,  Cleveland  JC,  Cigarroa  JE,  Con9  JB,  Ellinor  PT,  Ezekowitz  MD,  Field  ME,  Murray  KT,  Sacco  RL,  Stevenson  WG,  Tchou  PJ,  Tracy  CM,  Yancy  CW.  2014  AHA/ACC/HRS  guideline  for  the  management  of  pa9ents  with  atrial  fibrilla9on:  a  report  of  the  American  College  of  Cardiology/American  Heart  Associa9on  Task  Force  on  Prac9ce  Guidelines  and  the  Heart  Rhythm  Society.  Circula5on.  2014,  129,  1-­‐56.  DOI:  10.1161/CIR.0000000000000040.  

•  Delle  Karth  G,  Geppert  A,  Neunteufl  T  ,  et  al.  Amiodarone  versus  dil9azem  for  rate  control  in  cri9cally  ill  pa9ents  with  atrial  tachyarrhythmias.  Cri5cal  Care  Medicine.  2001,  29,  1149-­‐1153.    

•  Robert  W.  Neumar,  Chair;  Charles  W.  Oeo;  Mark  S.  Link;  Steven  L.  Kronick;  Michael  Shuster;  Cliuon  W.  Callaway…Laurie  J.  Morrison.  Part  8:  Adult  Advanced  Cardiovascular  Life  Support    2010  American  Heart  Associa9on  Guidelines  for  Cardiopulmonary  Resuscita9on  and  Emergency  Cardiovascular  Care.    Circula5on  2010,  122,  S729-­‐S767.  DOI:  10.1161/CIR.0b013e31820ff511.