Peri-Arrest Rhythms Flashcards
What do you generally look for in any Arrhythmias?
- Chest pain
- Hypotension
- Pulmonary Oedema
- Palpitation
What are general tests for Arrhythmias?
- Bloods: FBC, U &E’s, calcium levels, magnesium levels, TSH.
- ECG: look for signs of IHD, Atrial Fibrillation, Short PR interval (WPW syndrome), Long QT interval (metabolic imbalance, drugs, congenital), U waves (hypokalaemia), -
- 24h ECG monitoring
- Echocardiography: structural heart disease
- Provocation tests: Exercise ECG, Cardiac Catheterization +- electrophysiological studies
What are categories of patients in Bradycardia?
- Patients with rate is less than 40 bpm and symptomatic
- Patients who are asymptomatic and rate is more than 40 bpm
What are factors to consider in patient who have a rate of less than 40 bpm and symptomatic?
- Shock
- Syncope
- Myocardial ischaemia
- Heart failure
Signify haemodynamic compromise and need for treatment
What are symptoms of shock?
- Hypotension (systolic blood pressure < 90 mmHg)
- Pallor
- Sweating
- Cold
- Clammy extremities
- Confusion
- Impaired consciousness
What are factors to consider in patient who have a rate of more than 40 bpm and asymptomatic?
Look for a cause such as:
- Drugs and stop
- beta blocker
- digoxin
- Sick sinus syndrome
- Hypothyroidism
Dont treat in this case
What is the management of Periarrest: Bradycardia?
1st Line: Atropine (500mcg IV)
What is the management of Periarrest: Bradycardia if no response to Atropine?
If there is an unsatisfactory response,
- Atropine, up to maximum of 3mg
- Transcutaneous pacing
- Isoprenaline/adrenaline infusion titrated to response
Specialist help should be sought for consideration of transvenous pacing if there is no response to the above measures.
What are risk factors for Asystole?
- Complete heart block with broad complex QRS
- Recent asystole
- Mobitz type II AV block
- Ventricular pause > 3 seconds
What is done if risk factors for Asystole identified but Atropine works?
Specialist help is indicated to consider the need for transvenous pacing:
How is Sick Sinus Syndrome managed?
Dual chamber pacing is recommended for the management of symptomatic bradycardia due to sick sinus syndrome, atrioventricular block or a combination of Sick sinus syndrome and atrioventricular block (except in frail patients who won’t benefit or patient with continuous atrial fibrillation)
What is Sick Sinus Syndrome?
Symptomatic Bradycardia (sick sinus syndrome)
How are patients classified in Periarrest: Tachycardia?
ABCDE assessment to classify patients as stable or unstable according to the presence of any adverse signs:
- Shock
- Syncope
- Myocardial ischaemia
- Heart failure
What is done with unstable patient in Periarrest: Tachycardia?
Synchronised DC shocks should be given
What is the narrow complex tachycardia?
Narrow complex tachycardia
- Rate is >100bpm
- QRS width <120).
What are differentials for narrow complex tachycardia?
- Sinus Tachycardia: normal P wave followed by normal QRS
- Supraventricular Tachycardia: P wave absent or inverted after QRS
- Atrial Flutter: atrial rate is usually 300 bpm giving flutter waves or sawtooth base line, ventricular rate often 150 bpm
- Atrial Tachycardia: abnormally shaped P waves, may outnumber QRS (consider digoxin, Maintain potassium at 4-5mmol/L)
- Multifocal Atrial Tachycardia: 3 or more P wave morphologies, irregular QRS complexes (commonly COPD. Correct hypoxia and hypercapnia. Consider verapamil or beta-blocker if rate remains >110bpm)
- Junctional Tachycardia: rate is 150-250 bpm, P wave either buried in QRS complex or occurring after QRS complex
How are Regular Rhythm Periarrest tachycardias managed?
- Vagal Manoeuvres (carotid sinus massage, Valsalva manoeuvre) transiently increase AV block and may unmask underlying atrial rhythm
- Give IV adenosine if unsuccessful with vagal manoeuvres which causes transient AV block.
- If above unsuccessful consider diagnosis of atrial flutter and control rate (e.g. Beta-blockers)
How are Irregular rhythm Periarrest tachycardias managed?
- Probable Atrial fibrillation
- If onset < 48 hr consider electrical or chemical cardioversion
- Rate control (e.g. Beta-blocker or digoxin) and anticoagulation
What is maintenance therapy in Periarrest tachycardias?
Maintenance therapy is
- Beta-blockers
- Verapamil
What is a Broad complex tachycardia?
Broad complex tachycardia
- >100bpm
- QRS >120ms
What are the differential diagnosis in Broad Complex Tachycardia?
- Ventricular Tachycardia including torsade de pointes
- Supraventricular tachycadia with aberrant conduction eg AF, Atrial Flutter
What are investigations for Periarrest Broad Complex Tachycardia?
- ECG: positive QRS in concordance in chest leads, marked left axis deviate, AV dissociation or 2:1 or 3:1 AV block
- Fusion beats or capture beats
What is done in patient with ventricular fibrillation?
DC shock
What is used to treat Regular Broad Complex Ventricular Tachycardia?
Loading dose of Amiodarone followed by 24 hour infusion
What is used to treat Irregular Broad Complex Ventricular Tachycardia?
AF with bundle branch block
- Treat as for narrow complex tachycardia
Polymorphic VT (e.g. Torsade de pointes) - IV magnesium
What are general management procedures with Periarrest Tachycardia?
- Give high flow oxygen if indicated
- Obtain IV access: send U&E’s, Cardiac enzymes, Ca2+, Mg2+.
- Correct low K+ or Mg2+
- Obtain a 12 lead ECG
- Arterial Blood Gases if evidence of pulmonary oedema, reduced conscious level, sepsis
When is an implantable cadioverter defribillation indicated for Ventricular Arrhythmia?
Treating people with previous serious ventricular arrhythmia without treatable cause:
- Survived a cardiac arrest caused by either ventricular tachycardia or ventricular fibrillation or
- Spontaneous sustained ventricular tachycardia causing syncope or significant haemodynamic compromise or
- Sustained ventricular tachycardia without syncope or cardiac arrest and also have associated reduction in left ventricular ejection fraction of less than 35% and their symptoms are no worse than class 3.
Treating people who:
- Have a familial cardiac condition with a high risk of sudden death such as long QT syndrome, hypertrophic cardiomyopathy, brugada syndrome or arrhythmogenic right ventricular dysplasia
