Project: Ghana Emergency Medicine Collaborative Document Title: Approach to Bradycardias and Tachycardias Author(s): Rockefeller Oteng (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/
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Bradycardia
James Heilman, MD, Wikimedia Commons 3 3
- Prepare for transcutaneous pacing
- Consider atropine
- Consider epinephrine or dopamine
Signs or symptoms of poor perfusion caused by the bradycardia? (e.g. acute altered mental status, ongoing chest pain, hypotension, or other signs of shock?
Brady-‐ Arrhythmias
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BRADYCARDIA Heart Rate <60 bpm
and inadequate for clinical condition
- Maintain patient airway; assist breathing as needed
- Give oxygen - Monitor EKG (id rhythm),
blood pressure, oximetry - Establish IV access
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2
3
Observe/Monitor 4A
4
- Prepare for transvenous pacing
- Treat contributing causes
- Consider expert consultation 5
REMINDERS - If pulseless arrest, go to pulseless arrest algorithm - Search for and treat possible contributing factors:
- Hypovolemia - Toxins - Hypoxia - Tamponade, cardiac - H+ ion (acidosis) - Tension pneumothorax - Hypo/hyperkalemia - Thrombosis (coronary/pulmonary) - Hypoglycemia - Trauma (hypovolemia/ñICP) - Hypothermia
Adequate perfusion Poor perfusion
Unstable/Poor Perfusion
5 5
- Prepare for transcutaneous pacing
- Consider atropine - Consider epinephrine or
dopamine 4
- Prepare for transvenous pacing - Treat contributing causes - Consider expert consultation 5
Poor perfusion
Geo Swan, Wikimedia Commons 6 6
Reminders
7 7
• If pulseless arrest develops, go to pulseless arrest algorithm • Search for and treat possible contribuHng factors: Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo/hyperkalemia Hypoglycemia Hypothermia
Toxins (drugs) Tamponade (cardiac) Tension PTX Thrombosis (coronary or pulmonary) Trauma (hypovolemia, increased ICP)
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Tachy-‐ Arrhythmias
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TACHYCARDIA With Pulses
- Assess and support ABC’s - Give oxygen - Monitor EKG, blood pressure, oximetry - Id and treat reversible causes
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2
Stable Is patient stable? 3
WIDE QRS -> is rhythm REGULAR?
- Establish IV access - Obtain 12 lead EKG - Is QRS narrow (<0.12
sec)?
NARROW QRS-> is rhythm REGULAR?
Narrow QRS
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12
5
- Attempt vagal maneuvers
- Give adenosine IV push 6
Does rhythm convert? Consider: expert consult 8
Wide QRS
Perform immediate, synchronized cardioversion 4
Unstable Symptoms persist
- Irregular Narrow Complex Tachycardia
- Likely: A. fib, A. flutter, MAT - Consider: expert consult, B-
blockers to control HR 11 7
Regular Irregular - If V. tachycardia or uncertain
rhythm: * Amiodarone * Synchronized cardioversion - If SVT with aberrancy: * Adenosine (Box 7)
- If A. fibrillation with aberrancy:
* See Box 11 - If pre-excited A. fibrillation: * Expert consult advised * Avoid adenosine, digoxin, diltiazem, verapamil * Consider amiodarone - If recurrent polymorphic VT * Seek expert consult - If torsades de pointes * Give magnesium
Regular Irregular
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14 - Likely reentry SVT * Observe for recurrence * Treat recurrence with adenosine, diltiazem, B-blockers
- Likely A. flutter, ectopic atrial tachycardia, or junctional tachycardia
- Consider diltiazem and B-blockers to control HR
- Treat underlying cause - Consider expert consult
Converts Does Not Convert
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NOTE: If patient becomes unstable at any point, go to Box 4
During evaluation: - Secure and verify airway and vascular access - Consider expert consult - Prepare for cardioversion Treat possible contributing factors: - Hypovolemia - Toxins - Hypoxia - Tamponade, cardiac - H+ ion (acidosis) - Tension pneumothorax - Hypo/hyperkalemia - Thrombosis (coronary/
pulmonary) - Hypoglycemia - Trauma (hypovolemia/ñICP) - Hypothermia
Stable or Unstable? Narrow or Wide?
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TACHYCARDIA With Pulses
- Assess and support ABC’s - Give oxygen - Monitor EKG, blood pressure,
oximetry - Id and treat reversible causes
1
2
Stable Is patient stable? 3
WIDE QRS -> is rhythm REGULAR?
- Establish IV access - Obtain 12 lead
EKG - Is QRS narrow
(<0.12 sec)?
Narrow QRS 12
5 Wide QRS
Perform immediate, synchronized cardioversion 4 Unstable
Symptoms persist
Stable and Narrow
10 10
WIDE QRS -> is rhythm REGULAR?
NARROW QRS-> is rhythm REGULAR?
Narrow QRS
- Attempt vagal maneuvers
- Give adenosine IV push
Does rhythm convert? Consider: expert consult 8
Wide QRS
- Irregular Narrow Complex Tachycardia
- Likely: A. fib, A. flutter, MAT
- Consider: expert consult, B-blockers to control HR 11
7
Irregular
Converts Does Not Convert
Regular
12
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SVT – Mechanism Reentry via accessory pathway
A) Normal conduction B) PAC C) Orthodromic reentrant pathway
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• AV nodal reentrant circuit - 60% • Atrio-ventricular reentrant circuit w/ accessory pathway - 30% • Atrial tachycardia – 10% • Other rare forms: Sinus-node reentrant tachycardia, inappropriate sinus
tachycardia, ectopic junctional tachycardia, and non-paroxysmal junctional tachycardia.
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SVT – Mechanism
SVT -‐ Treatment • Adenosine:
– 6 mg - termination in 60-80% – 12 mg - termination in 90-95% – Contraindicated in heart transplant, COPD/asthma, and wide complex
tachycardia (unless 100% certain is SVT w/ aberrancy) – Avoid with evidence of pre-excitation
• Beta blockers or Ca++ channel blockers - contraindicated in antidromic WPW • Last resort: procainamide, ibutilide, propafenone, or flecainide • If unstable - electricity!
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SVT -‐ Treatment w/ Adenosine
Displaced, Wikimedia Commons 14 14
A\er Adenosine
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- Likely reentry SVT * Observe for recurrence * Treat recurrence with adenosine, diltiazem, B-blockers
- Likely A. flutter, ectopic atrial tachycardia, or junctional tachycardia
- Consider diltiazem and B-blockers to control HR
- Treat underlying cause - Consider expert consult
Converts Does Not Convert
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10
Stable and Wide Regular or Irregular?
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WIDE QRS -> is rhythm REGULAR? 12
Wide QRS
- If V. tachycardia or uncertain rhythm:
* Amiodarone * Synchronized cardioversion - If SVT with aberrancy: * Adenosine (Box 7)
- If A. fibrillation with aberrancy: * See Box 11 - If pre-excited A. fibrillation: * Expert consult advised * Avoid adenosine, digoxin, diltiazem, verapamil * Consider amiodarone - If recurrent polymorphic VT: * Seek expert consult - If torsades de pointes: * Give magnesium
Regular Irregular
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Wide Complex Tachycardia
Afib with LBBB Steven Fruitsmaak, Wikimedia Commons 17 17
Wide Complex Tachycardia • Stable
– Amiodarone 150 mg over 10 min or other anti-arrhythmics – Prepare for synchronized cardioversion
• Unstable – ABC’s/Call for help/Start CPR – Defibrillate: Biphasic 120-200 J (When in doubt pick 200 J),
monophasic 360 J – Epinephrine 1 mg IV q3-5 min – Vasopressin 40 Units IV – May try amiodarone or lidocaine after 3 attempts at defibrillation
• Amiodarone 300 mg, may repeat w/ 150 mg x1 • Lidocaine 1-1.5 mg/kg, then 0.5-0.75 mg/kg, max is 3 mg/kg
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H’s and T’s
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Treat contribuHng factors: Hypovolemia Hypoxia
Hydrogen ion (acidosis) Hypo/hyperkalemia Hypoglycemia
Hypothermia
During EvaluaHon
• Secure, verify airway and vascular access when possible
• Consider expert consultaHon
• Prepare for cardioversion
Toxins (drugs) Tamponade (cardiac) Tension PTX Thrombosis (coronary/pulmonary) Trauma
Review
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Bradycardias Tx of Bradycardias
• Stable – MI – Adequate perfusion? – Monitor BP!!
• Unstable
– Poor perfusion – Immediate transcutaneous pacing – Consider atropine while awaiHng pacer, 0.5-‐1.0 mg – Consider epi or dopamine if pacing ineffecHve
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Tachycardia’s Stable vs. Unstable
• Stable – MI – 12 lead – Narrow complex – Wide complex – Treat causes
• H’s and T’s
• Unstable – Altered MS – CP – Hypotension – Signs of shock
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Tx of Stable Tachycardias
• A-‐fib/fluger – DilHazem (Ca++ channel blocker) – Consider cardioversion
• SVT – Vagal maneuvers – Adenosine
• 6 mg then 12 mg then 12 mg
• V-‐Tach (WITH PULSE) – AnHarrhythmic: Lidocaine, Amiodarone, (Mg+ for torsades)
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Tx of Unstable Tachycardias
• Stable – Amiodarone 150 mg over 10 min or other anH-‐arrhythmics
– Prepare for synchronized cardioversion • Perform immediate synchronized cardioversion
– MI – Sedate if conscious – DO NOT DELAY CARDIOVERSION
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ContribuHng Factors H’s and T’s
• Hypovolemia • Hypoxia • Hydrogen ion (acidosis) • Hypo/hyperkalemia • Hypoglycemia • Hypothermia • Toxins (drugs) • Tamponade (cardiac) • Tension PTX • Thrombosis (coronary or pulmonary) • Trauma 25 25
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