dysrhythmias april 2013
TRANSCRIPT
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