dysrhythmias april 2013

Fast, irregular, broad complex tachy

WPW AF until proved otherwise

Rare but important

We can kill young people with wrong Rx

Rx?

WPW AFElectricity or Procainamide

200J

Sync or unsynch?

Synch if they have a pulse

Sedation for cardioversion

Get senior help if you have time

Otherwise Fentanyl eg 100mcg, or 50mcg in frail elderly + Midazolam 1-2mg IV

VF Shock 200J un-synch

CPR 2 min

Check rhythm

Repeat PRN

Adrenaline 1mg after 2nd shock and every 3 minutes

Amiodarone 300mg in after 3nd shock

No pulse

Wide complex tachy

No pulse

Treatment as for VT

Pulse normal BP, no CP

Wide complex tachyRx electricity

200J synched

Key questions?

Fast AF with CP and hypotension

Is there anything driving the AF? Sepsis, CCF, dehydration

How long has she been in AF? Chronic AF unlikely to cardiovert and may throw

of a clot if does cardiovert

Fast AF with CP and hypotension

New onset ( < 48 hours): fluid load, phenylephrine, analgese (fentanyl) sedate and cardiovert

Chronic AF: fluid load, phenylephrine, analgese (fentanyl)

+/- treat for ACS

Pure alpha = vasoconstriction

10mg vial in 100ml Normal Saline= 1mg in 10ml

= 100mcg in 1ml

2ml bolus = 200mcg

13 year old male with palpitation while playing play station

Hx of asthma and recent knee surgery

Questions?

Comments?

Suggestions?

Sinus tachy or SVT?

Sinus tachy or SVT?Sinus tachy

P waves Rate varies – watch the monitor Will slow with reassurance, analgesia Usually caused by something eg pain, illness Not usually the presenting complaint Gradual onset and offset

SVT Fast onset Constant rate – watch the monitor Usually presenting complaint

SVTManagement?

SVTVagal manoeuvres

Valsalva Carotid sinus massage (age < 60) Face in ice water

Adenosine Big IV line Can mix with big flush 12, 18mg

Verapamil 5mg IV

Dialysis patient

Hyper KTreatment?

Hyper KSalbutamol 10mg neb

Calcium gluconate 1 amp = 10mmol

Arrange urgent dialysis

Then think about glucose + insulin, HCO3

Resonium probably does more harm than good

40M, drowsy, BP 90/60. Hx of depression.

TCA overdose

HCO3 1-2mmol/kg, repeat ? Q5min till QRS < 120ms

Intubate

Hyperventilate

Sinus tachy with LBBB

70M, CP, hypotensive

70M, CP, hypotensive Inferior MI

Do a R sided ECG – may well have a R ventricular infarct

Try atropine – unlikely to work

Avoid GTN, avoid morphine (use fentanyl for pain)

FLUID LOAD (may need litres of fluid) before trying pacing / inotropes

Reperfuse ASAP – PCI preferred

Other options for bradycardia

Consider toxins Digoxin Beta blocker Calcium channel blocker

-> specific treatments

Otherwise Atropine Transcutaneous pacing Transvenous pacing Chronotrope eg isoprenaline/dopamine Bypass / ECMO

Narrow Complex TachyNarrow complex regular

Sinus tachy: treat cause SVT: Vagal; adenosine; verapamil or diltiazem

Narrow complex irregular Treat driver eg CCF, sepsis, ischaemia, hypoxia If still too fast or rate contributing to ischaemia or

↓BP < 48 hours: cardiovert + anticoagulation > 48 hours: rate control + anticoagulation

↓BP: fluid, phenylephrine, diltiazem, magnesium or amiodarone

Normal BP: diltiazem or beta blocker

Wide Complex Tachy Treat cause

Na channel blockers esp tricycylics -> bicarb and hyperventilation

HyperK: Salbutamol, calcium gluconate etcProlonged QT ie Torsades: Mag

Otherwise: electrical cardioversion

BradycardiaConsider RV infarct -> fluid loading

Consider toxins -> specific treatments

Atropine

Transcutaneous then transvenous pacing

Isoprenaline / dopamine

ReferencesSee

http://emtutorials.com/2013/05/funky-rhythms/ for references