Approach to the patient with Suspected Dysrhythmia Flashcards
What are the 4 mechanisms of dysrhythmias
Disorders of impulse formation or automaticity
Abnormalities of impulse conduction
Reentry
Triggered activity
Premature / Ectopic / Escape beats or rhythms
Bradyarrhythmias
Tachyarrhythmias
what can lead to arrhythmias?
Genetic abnormalities
Acquired structural heart disease
Electrolyte abnormalities
Hormonal imbalances (thyrotoxicosis, hypercatecholaminergic states)
Hypoxia
Drug effects (such as QT interval prolongation or changes in automaticity, conduction, and refractoriness)
Myocardial ischemia
What are ways that palpations can present
Palpitations are defined as an unpleasant awareness of the beating of the heart
Forceful
Rapid
Irregular
can ask patients if they can beat
What are most of palpitations?
benign :)
What are the 4 goals of evaluation of palpitation
- an arrhythmia that is minor and transient
- significant cardiovascular disease
- a cardiac manifestation of a systemic disease, such as thyrotoxicosis
- a benign somatic symptom that is amplified by underlying psychosocial characteristics of the patient
should get TSH because most other systemic diseases do not present with palpitations and it is pretty easy to r/o
What are historical risk factors that are red flags for palpitations?
Family history of young onset of cardiac
Passing out (history of syncope)
sudden death
History of MI
What are some red flags of PE findings of palpitations?
Structural heart disease such as dilated or hypertrophic cardiomyopathies
Valvular disease (stenotic or regurgitant)
What are red flags of ECG findings for palpitations?
Prolonged QTC
Bradycardia
Second- or third-degree heart block
Sustained ventricular arrhythmias
What are some common descriptions of palpatations
“Flip-flopping” (or “stop and start” or “skipped beats”)
Often a result of premature contractions
Rapid “fluttering in the chest”
Is the fluttering regular (SVT, sinus tach, VT)
Or irregular (afib)
“Pounding in the neck”
Commonly occur with afib and aflutter, as well as PACs
What symptoms do you check for, for atrial flutter?
Age at first episode
The rate, duration, and degree of regularity of the heart beat
The circumstances associated with onset and termination
Abrupt onset and termination vs gradual
Setting in which they occur
SVT presentation
Abrupt change from normal to like 180
What are some associated symptoms of palpitations
Chest pain, shortness of breath
Dizziness, near syncope or syncope
What is a concerning onset of arrhythmias?
associated with exercise or syncope
What are some red fag social history for palpitations
alcohol
illicit drug use
What medications can cause palpitations?
Stimulants, OTC cold medicine
AADs
What diagnostic studies do you order for palpitations?
ALL patients get EKGs (even if you are not symptomatic)
Ambulatory Monitoring Devices
Holter monitor
Event monitors
Real-time monitors
Patch recorders
Implantable loop recorders
When should each be used? Benefits of each? Concerns / costs?
Holter monitor
24 hour - it will be normal
monitor every single heart beat over 24-48 hour period, patient gets diary so you can correlate symptoms with palpitations
longer monitoring is better
Patch, real-time, and event monitor
Monitor for longer
patches come with a phone and record if they are having symptoms (and record time) and then say what their symptoms were when there was an episode
Event monitors
Only record events or if a patient records it
real-time monitors
Record the whole time
more useful
If they have daily episodes, what is a good monitor
holter monitor (would see within that 24 hour period)
If they only have epidoses every now and again, what do you use?
Event monitors
Real-time monitors
Patch recorders
Loop recorder
clean skin
put over drape
make an incision under the skin to the left of the sternum
has an angled scapule that flattens out (so it does not go too deep)
Have a syringe
A couple syncope episodes that was not caught with other monitors
Are electrophyisiology pros and cons
Pros: measures pathways, can induce rhythms
Cons: very invasive
When is a good time to get an EKG exercise testing?
If their arrythmia is exerciseinduced
controlled environment
Use of echo for palpitations?
Pretty much every patient
See if their are structural/valvular issues
What labs should you always order for palpitations
Thyroid
Electrolytes
Goal of dysrhythmia management
Goal #1: prevent sudden death
Goal #2: reduce symptoms improve QOL
Goal #3: reduce hospitalization
Weigh benefits/harms based on patient
What are the management for dysrhythmias (read don’t memorize)
Antiarrhythmic drugs
Cardioversion
Electrical or chemical
Synchronized or unsynchronized (defibrillation)
Catheter ablation
Pacemaker
Temporary – transcutaneous or transvenous
Permanent/implanted
Cardioverter-defibrillator
Portable AED
Wearable – Life Vest
Permanent/implanted
Cardioversion use
Patches placed rather than paddles
only for tachyarrythmias (SVT, AF, VT, VF)
Atrial fibrillation / flutter
SVT
Ventricular tachycardia
What is the range of Jouels for cardioversion?
50-360 J
Preparation of cardioversion?
Pads placed or conduction gel applied to paddles
ALL staff/personnel must be clear of touching patient
Requires informed consent, except in unstable emergency / cardiac arrest
Requires sedation, except in unconscious unstable patient
Risk/complications of cardioversion
VT/VF due to general anesthesia or lack of synchronization between the DC shock and the QRS complex
Thromboembolus due to insufficient anticoagulant therapy
Arrhythmias: non-sustained VT, atrial arrhythmia, heart block, bradycardia, transient left bundle branch block
Myocardial necrosis, myocardial dysfunction (every shock causes death of tissue)
Transient hypotension
Pulmonary edema (pressure no long moves into the heart)
Skin burn
catheter ablation
laser or cryo (freezing) can map a PVC cell and burn it
invasive
pricy
First-line for some arrhythmias
need sedation because it hurts and is long
What conditions are catheter ablation first-line
AV nodal reentrant tachycardia
Paroxysmal atrial tachycardia
Atrial flutter
How do we get to the left atrium?
Through the right, which is why a catheter ablation is CI in people with a congental defect
Complications of catheter ablation
Generally fairly safe
Major vascular damage during catheter insertion occurs in < 2% of patients.
There is a low incidence of perforation of the myocardial wall resulting in pericardial tamponade.
Sufficient damage to the AV node to require permanent cardiac pacing occurs in < 1% of patients.
A rare but potentially fatal complication after catheter ablation of atrial fibrillation is the development of an atrio-esophageal fistula resulting from ablation on the posterior wall of the LA just overlying the esophagus.
Pacemakers are indicated for
Bradyarrythmias
can ONLY speed up the heart - kicks in with a small impulse if <60 BPM
Implantable cardioverter-defibrillator (ICD)
are indicated to prevent SCD, and ALL include pacemakers
lower power and internal
Indications for pacemakers
Symptomatic bradycardia
High-grade AV Block
Sinus pauses or afib pauses with symptoms
No reversible causes identified – this is important (treat the reversible cause first - whether it is meds or something else)
ICD Indications
Primary prevention of Sudden Cardiac Arrest (VT/VF)
EF < 35% or other at-risk population (Long QT, Brugada, Hypertrophic Cardiomyopathy - no waiting period)
Secondary prevention of Sudden Cardiac Arrest (VT/VF)
40 days after MI
90 days if others
where do you put an ICD
non-dominant side that is less active (so that there is less tearing)
normally on left side because most people are right handed
What are the different types of ICD
All devices include the can and leads (wires)
What lead is always included
Right ventricular lead
depending on the indication, it can be:
Single chamber pacemaker
RV lead only
Dual Chamber ICD
RA and RV leads
Bi-Ventricular ICD (CRT-D)
RV and LV leads +/- RA lead
How to know that leads are placed correctly?
Fish hook in right atrium
heal arch toes of apex of RV
How to know if there is a pacemaker?
Tiny thickness on end
Shock coil is larger and is seen in defibrillator
Patient education for shocks?
Pacing should not be detectable by the patient
ICD shocks are substantial!!!
The devices are METAL and are affected by MAGNETS
Therefore, patients will set off metal detectors
MRIs may be contraindicated (for the most part – newer devices are MRI-safe)
Pacing is detectable on EKG and Telemetry, marked by “pacer spikes”
Patients with a pacemaker or ICD should be following with a cardiologist, electrophysiologist, or the surgeon who implanted the device
Home wireless monitoring has improved safety
if you get out of rythym, you have a 95% chance of dying with out it, if you have it, you have a 95% chance of surviving
What do you see on pacemaker EKG
Pacemaker spikes followed by wide QRS complex
If it does not cause any EKG changes and it’s rhythm is independent to the patient’s EKG (random pacemaker spikes), then it is not working or is placed incorrectly
What should a pacemaker spike cause
depolarization of atria or ventricles
otherwise it is not working
def don’t wanna see a spike at the T wave as it can cause torsades
