ventricular arrythmias - miami county ems · ventricular arrythmias. ventricular arrthmias ......

VENTRICULAR VENTRICULAR ARRYTHMIASARRYTHMIAS

VENTRICULAR ARRTHMIASVENTRICULAR ARRTHMIAS

PVCPVCIDIOIDIO--VENTRICULARVENTRICULARACC. VENTRICULARACC. VENTRICULARVV--TACH (MONO AND POLY)TACH (MONO AND POLY)TORSADES DE POINTESTORSADES DE POINTESVV--FLUTTERFLUTTERVV--FIBFIB

ANALYZE THE RHYTHMANALYZE THE RHYTHM

PREMATURE VENTRICULAR PREMATURE VENTRICULAR COMPLEXESCOMPLEXES

Early Depolarization of the VentriclesEarly Depolarization of the VentriclesOccurs as a result of Automaticity or Occurs as a result of Automaticity or ReentryReentryRemember a PVC is only a characteristic Remember a PVC is only a characteristic of an underlying rhythmof an underlying rhythm--you still have to you still have to identify the underlying rhythm!!!identify the underlying rhythm!!!

CAUSES OF PVC(S)CAUSES OF PVC(S)

HypoxiaHypoxiaMyocardial IschemiaMyocardial IschemiaElectrolyte imbalanceElectrolyte imbalanceDigitalis ToxicityDigitalis ToxicityStimulants (caffeine, Stimulants (caffeine, cocaine)cocaine)Chronic heart disease Chronic heart disease (CHF, COPD)(CHF, COPD)Smoking, ETOHSmoking, ETOH

CardiomyopathyCardiomyopathyMyocardial ContusionMyocardial ContusionTCATCA’’ssStressStressExhaustionExhaustionHypercapnia( CO2 Hypercapnia( CO2 poisoning)poisoning)Thyroid problemsThyroid problems

PVC CHARACTERISTICSPVC CHARACTERISTICS

Complex is earlier than expectedComplex is earlier than expectedWide QRS (What are reasons for this?)Wide QRS (What are reasons for this?)Often has compensatory pauseOften has compensatory pauseNo associations with P waveNo associations with P waveT wave has opposite deflectionT wave has opposite deflectionMay or may not result in perfused beatMay or may not result in perfused beat

TERMS ASSOCIATED WITH PVCTERMS ASSOCIATED WITH PVC

UnifocalUnifocalMultifocalMultifocalCoupletCoupletR on TR on TBigemeny, Trigemeny, Etc.Bigemeny, Trigemeny, Etc.Run of PVC, aka VRun of PVC, aka V--TacTacInterpolatedInterpolated

THOUGHTS???THOUGHTS???

PREMATURE VENTRICULAR COMPLEX(S)PREMATURE VENTRICULAR COMPLEX(S)

NOTNOT--Always dangerousAlways dangerousCommon for some peopleCommon for some peopleConsider treatment ifConsider treatment if--–– >12 per minute>12 per minute–– Severe chest painSevere chest pain–– Hypotension/Decreased Hypotension/Decreased

perfusionperfusion–– Shortness of BreathShortness of Breath–– Presence of an AMIPresence of an AMI

Also consider treatment if Also consider treatment if the following is noticedthe following is noticed–– CoupletsCouplets–– MultifocalMultifocal–– Runs of VRuns of V--TacTac–– R on TR on T

MANAGEMENT OF PVC(S)MANAGEMENT OF PVC(S)

Underlying rate <60Underlying rate <60–– OxygenOxygen–– ECG including 12ECG including 12--leadlead–– IVIV–– Asses underlying rhythmAsses underlying rhythm

Treat Bradycardia withTreat Bradycardia with–– AtropineAtropine–– TCPTCP–– EPI DripEPI Drip–– Dopamine DripDopamine Drip

MANAGEMENT OF PVC(S)MANAGEMENT OF PVC(S)

Underlying rate >60Underlying rate >60–– OxygenOxygen–– ECG including 12ECG including 12--leadlead–– IVIV–– Assess underlying rhythmAssess underlying rhythm–– IF SYMPTOMATICIF SYMPTOMATIC

Treat accordingly, i.e. Brady, ACS, etc.Treat accordingly, i.e. Brady, ACS, etc.

IF PVC TREATMENT IS INDICATEDIF PVC TREATMENT IS INDICATED

LidocaineLidocaine--–– 1.01.0--1.5mg/kg IV bolus1.5mg/kg IV bolus–– Repeat dose every 5min as Repeat dose every 5min as

needed at half initial dose, needed at half initial dose, 0.50.5--0.75mg/kg to 3mg/kg 0.75mg/kg to 3mg/kg maxmax

–– Follow with a 1Follow with a 1--4mg/min 4mg/min maintenance infusionmaintenance infusion

–– Increase infusion 1 mg for Increase infusion 1 mg for every 1 mg IV bolus givenevery 1 mg IV bolus given

AmiodaroneAmiodarone--–– 150mg over 10min150mg over 10min–– Can be repeatedCan be repeated–– Follow with a 1mg/min Follow with a 1mg/min

maintenance infusionmaintenance infusion

ANALYZE RHYTHMANALYZE RHYTHM

IDIOVENTRICULARIDIOVENTRICULAR

CharacteristicsCharacteristics–– Ventricular focus takes Ventricular focus takes

over as escape over as escape pacemaker sitepacemaker site

–– Rate is usually 20Rate is usually 20--4040–– Wide QRS >.12Wide QRS >.12–– No P waveNo P wave

CausesCauses–– Myocardial IschemiaMyocardial Ischemia–– HypoxiaHypoxia–– Excessive Vagal ToneExcessive Vagal Tone–– Drug EffectsDrug Effects

IDIOVENTRICULARIDIOVENTRICULAR

ManagementManagement–– Slow rate and lack of Atrial Kick will decrease Slow rate and lack of Atrial Kick will decrease

cardiac outputcardiac output–– Usually a later and often preUsually a later and often pre--terminal rhythmterminal rhythm–– If symptomatic treat as unstable BradycardiaIf symptomatic treat as unstable Bradycardia–– DO NOT GIVE LIDOCAINE OR OTHER DO NOT GIVE LIDOCAINE OR OTHER

VENTRICULAR ANTIDYSRYTHMICS!!!VENTRICULAR ANTIDYSRYTHMICS!!!

ANYLYZE THE RHYTHMANYLYZE THE RHYTHM

ACCERLATED IDIOVENTRICULARACCERLATED IDIOVENTRICULAR

CharacteristicsCharacteristics–– Same as Same as

Idioventricular, except Idioventricular, except for ratefor rate

–– Rate is 40Rate is 40--100100

ManagementManagement–– Monitor cardiac output Monitor cardiac output

and perfusionand perfusion–– Often preOften pre--terminalterminal–– Identify and treat Identify and treat

underlying causeunderlying cause–– DO NOT GIVE DO NOT GIVE

LIDOCAINE OR OTHER LIDOCAINE OR OTHER VENTRICULAR VENTRICULAR ANTIDYSRYTHMICS!!!ANTIDYSRYTHMICS!!!

VENTRICULAR TACHYCARDIAVENTRICULAR TACHYCARDIA

CharacteristicsCharacteristics–– Rate is 100Rate is 100--250250–– Looks like PVCLooks like PVC’’ss–– Pacemaker sitePacemaker site

Irritable ventricular Irritable ventricular focus take over as focus take over as pacemaker site ORpacemaker site ORMay result from many May result from many ventricular foci ventricular foci attempting to become attempting to become pacemaker sitepacemaker site

CausesCauses–– Myocardial IschemiaMyocardial Ischemia–– HypoxiaHypoxia–– Electrolyte ImbalanceElectrolyte Imbalance–– Digitalis ToxicityDigitalis Toxicity–– Myocardial TraumaMyocardial Trauma


ComplicationsComplications–– Decrease cardiac outputDecrease cardiac output–– Increase cardiac workload, MV02Increase cardiac workload, MV02–– Decreases Coronary PerfusionDecreases Coronary Perfusion–– Can quickly transition to VCan quickly transition to V--FIBFIB


TypesTypes–– MonomorphicMonomorphic-- all complexes look the sameall complexes look the same–– PolymorphicPolymorphic-- complexes differcomplexes differ–– ““Torsades de PointesTorsades de Pointes””

Twisting of the PointsTwisting of the PointsUsually > 200bpmUsually > 200bpmSusceptible in slow repolarization ( long QT)Susceptible in slow repolarization ( long QT)


Treatment of Treatment of ““StableStable”” VTVT–– OxygenOxygen–– ECG including 12 lead, assess mechanical with ECG including 12 lead, assess mechanical with

electricalelectrical–– IVIV–– Determine type (mono, poly)Determine type (mono, poly)

If unable to determine wide complex of unknown If unable to determine wide complex of unknown origin attempt to use 12 lead to determine.origin attempt to use 12 lead to determine.


Treatment continuedTreatment continued–– LidocaineLidocaine–– AmiodaroneAmiodarone–– If unstable synchronized cardiovert at 100JIf unstable synchronized cardiovert at 100J

If Polymorphic VT may consider Magnesium If Polymorphic VT may consider Magnesium Sulfate at 1Sulfate at 1--2 grams over 5min or greater2 grams over 5min or greaterIf using electrical therapy for Polymorphic VT treat If using electrical therapy for Polymorphic VT treat as Vas V--FibFib

???QUESTION??????QUESTION???

WHY ONLY USE ONE ANTIDYSRHYTHMIC WHY ONLY USE ONE ANTIDYSRHYTHMIC PER PATIENT? PER PATIENT? IF ONE DOES NOT WORK WHY NOT TRY IF ONE DOES NOT WORK WHY NOT TRY THE OTHER?THE OTHER?WHAT IF THE PATIENT TAKES WHAT IF THE PATIENT TAKES AMIODARONE DAILY?AMIODARONE DAILY?WHAT OTHER OPTIONS DO WE HAVE TO WHAT OTHER OPTIONS DO WE HAVE TO TREAT WIDE COMPLEX TACHYCARDIA?TREAT WIDE COMPLEX TACHYCARDIA?

SCENARIOSCENARIO

You are dispatched to a local Dr. Office for a heart You are dispatched to a local Dr. Office for a heart problem.problem.Upon arrival Dr. tells you that patient came in Upon arrival Dr. tells you that patient came in complaining of palpitations since 2am(it is now 1030 complaining of palpitations since 2am(it is now 1030 am). While in Dr. Office they found that patient was in am). While in Dr. Office they found that patient was in VV--Tac.Tac.Patient does have an AICD, however it has not Patient does have an AICD, however it has not attempted to defibrillate.attempted to defibrillate.Dr. tells you that he has called to the ED and that they Dr. tells you that he has called to the ED and that they are awaiting your arrival and have a Medtronic tech are awaiting your arrival and have a Medtronic tech awaiting your arrival as well.awaiting your arrival as well.

THOUGHTS?THOUGHTS?

Is it really VIs it really V--Tac?Tac?AMIAMIIs the VIs the V--Tac not responding to electrical Tac not responding to electrical therapy?therapy?Is something wrong with the AICD?Is something wrong with the AICD?

PATIENT PRESENTATIONPATIENT PRESENTATION

Patient is alert and Patient is alert and oriented, currently oriented, currently not complaining of not complaining of pain. pain. Seated in a wheel Seated in a wheel chair.chair.Skin is pale, cool, and Skin is pale, cool, and dry.dry.

V/SV/S–– 80/7080/70–– 130 regular130 regular–– 22 non labored22 non labored–– 99% room air99% room air–– CBBSCBBS–– GCS 15GCS 15–– Temp. 98.1 FTemp. 98.1 F

MORE INFORMATIONMORE INFORMATION

SAMPLESAMPLE–– Palpitations, diaphoresis, weakness, dyspneaPalpitations, diaphoresis, weakness, dyspnea–– NKDANKDA–– Lisinopril, Coumadin, Lovastatin, Coreg, Zetia, Lisinopril, Coumadin, Lovastatin, Coreg, Zetia,

Digoxin, Lasix, AmiodaroneDigoxin, Lasix, Amiodarone–– AMI, CHF, CAD, CABG, CA, AAMI, CHF, CAD, CABG, CA, A--FIB, HTN, Renal FIB, HTN, Renal

Insufficiency, Insufficiency, –– BreakfastBreakfast–– SleepingSleeping

????????????????????????????

SO WHAT DO WE WANT TO SO WHAT DO WE WANT TO DO/KNOW ON THIS PATIENT???DO/KNOW ON THIS PATIENT???

LABSLABS

FINALLY!!!FINALLY!!!

You arrive at the ED and Medtronic Rep. You arrive at the ED and Medtronic Rep. meets you in the room.meets you in the room.They wireless hook up to the patients They wireless hook up to the patients AICD and find the problem.AICD and find the problem.The patients AICD is set to treat sense at The patients AICD is set to treat sense at a rate of 130 and treat at a rate of 158.a rate of 130 and treat at a rate of 158.

MEDTRONICMEDTRONIC

TREATMENT IS???TREATMENT IS???

The ED doctor and the Medtronic Rep. The ED doctor and the Medtronic Rep. decide to override pace the patient.decide to override pace the patient.What does that mean???What does that mean???

OVERRIDE PACINGOVERRIDE PACING

Is an attempt to gain control of the Is an attempt to gain control of the patients Vpatients V--Tac via pacing at a faster rate Tac via pacing at a faster rate than the patients heart rate. If this works than the patients heart rate. If this works then the rate is slowed to a normal rate then the rate is slowed to a normal rate via the pacemaker.via the pacemaker.If this does not take affect then If this does not take affect then cardioversion is performed.cardioversion is performed.TCP override pacing is not a normal TCP override pacing is not a normal treatment modality.treatment modality.

OVERRIDE PACINGOVERRIDE PACING

A LOOK FROM INSIDEA LOOK FROM INSIDE

CONVERSION!!!CONVERSION!!!

PATIENTPATIENT

Complained of no pain during treatment.Complained of no pain during treatment.All vitals stabilizedAll vitals stabilized–– 126/72126/72–– 88 showing a V88 showing a V--Paced on the monitorPaced on the monitor–– 20 and non labored20 and non labored–– 99% on NC99% on NC–– GCS 15GCS 15

PATIENT OUTCOMEPATIENT OUTCOME

Patient was admitted overnight for Patient was admitted overnight for observation.observation.AICD parameters were changed to detect AICD parameters were changed to detect VV--Tac at 125bpm and treat is the rhythm Tac at 125bpm and treat is the rhythm is sustained for over 28 beats.is sustained for over 28 beats.Patient was discharged the next day with Patient was discharged the next day with a change in his Amiodarone daily dose a change in his Amiodarone daily dose from 200mg daily to 400mg daily.from 200mg daily to 400mg daily.

Facts About the PatientFacts About the Patient’’s AICDs AICD

It is a Medtronic It is a Medtronic ““ConcertoConcerto”” Cardiac Cardiac Resynchronization Therapy DefibrillatorResynchronization Therapy DefibrillatorIt also is a BiV pacemaker, meaning it has It also is a BiV pacemaker, meaning it has a lead in each ventricle to assist the a lead in each ventricle to assist the heartheart’’s pumping function. s pumping function. BiV pacemakers are specifically designed BiV pacemakers are specifically designed for patients with CHF.for patients with CHF.

Facts ContinuedFacts Continued

Other Key Features of the Other Key Features of the ““ConcertoConcerto””–– Delivers pain free therapyDelivers pain free therapy–– OPTiVolOPTiVol--a fluid status monitoring systema fluid status monitoring system–– Cardiac CompusCardiac Compus--14 months of record keeping14 months of record keeping–– ConexUsConexUs--wireless connectivitywireless connectivity–– Medtronic Care AlertMedtronic Care Alert--notifies the office of the notifies the office of the

pt.pt.’’s cardiologist of any changes or s cardiologist of any changes or mechanical problemsmechanical problems--i.e.i.e.--low batterylow battery

ANALYZE THE RHYTHMANALYZE THE RHYTHM

VENTRICULAR FLUTTERVENTRICULAR FLUTTER

More chaotic than VMore chaotic than V--Tac and is preTac and is pre--fibrillatory. fibrillatory. Sometimes referred to as extreme VSometimes referred to as extreme V--TacTacTreat as polymorphic VTreat as polymorphic V--TacTac

VENTRICULAR FIBRILATIONVENTRICULAR FIBRILATION

Multiple sites within the ventricles firing Multiple sites within the ventricles firing rapidly and independently. rapidly and independently. Results in no coordinated mechanical Results in no coordinated mechanical activity and thus, no cardiac output.activity and thus, no cardiac output.–– Fine= multiple weak sitesFine= multiple weak sites–– Course= few strong sitesCourse= few strong sites

Treat as ACLS protocols.Treat as ACLS protocols.

QUESTIONS?QUESTIONS?

ventricular arrythmias - miami county ems · ventricular arrythmias. ventricular arrthmias ......

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