Treatment and management of arrythmias Flashcards
Things to ask in medical history
-family Hx cardiac disease
-family Hx sudden cardiac death
Patient has one of the following:
-hyperlipidaemia
-hypertension
-ischaemic heart disease
-known abnormal rhythm
-ICD or pacemaker
-history of collapsing or seizures
HPC red flags
-history or physical signs of HF
-transient loss of consciousness on exertion
-family Hx of sudden cardiac death (below 40yrs)
-new or unexplained breathlessness
-cardiac murmur
-older than 65
Arrythmia presentations
-chest pain
-difficulty breathing
-palpitations
-LOC
-pre syncope
-nausea and vomiting
-asymptomatic?
Unstable/ adverse signs and symptoms
-pallor
-sweaty
-cold clammy extremities
-impaired consciousness
-hypotension
-breathlessness
-HR higher than 150 or lower than 40
Risk factors of asystole
-previous episode of asystole
-mobitz 2 AV block (2nd degree type 2)
-3rd degree heart block especially if QRS broad
-ventricular standstill of greater than 3 seconds
Bradyarrhythmia guideline flow chart
-CABCD, obs
-if signs of adverse features of absolute bradycardia -> give 500mcg atropine IV/IO -> give 2nd dose if no response then convey PA
-if no signs of absolute bradycardia but risk of asystole, give atropine
Signs absolute bradycardia
-shock
-syncope
-signs of HF
-chest pain
-signs myocardial ischaemia on ECG
Atropine and how it works
-blocks parasympathetic (vagal) influences in the heart improving AV conduction and increasing HR
-give 500mcg as a rapid bolus every 3-5mins
-max of 3mg
Atropine indications
Symptomatic bradycardia in the presence of ANY of these adverse signs:
-Absolute bradycardia (pulse <40 beats per minute).
-Systolic blood pressure below expected for age (refer to Page-for-Age for age related blood pressure readings in children).
-Paroxysmal ventricular arrhythmias requiring
suppression.
-Inadequate perfusion causing confusion, etc.
-Bradycardia following return of spontaneous
circulation (ROSC).
Atropine contraindications
-Should NOT be given to treat bradycardia in
suspected hypothermia.
-Do NOT give atropine sulfate to patients with
cardiac transplants; their hearts will not respond to vagal blocking by atropine and paradoxical high degree AV block or sinus arrest may result.
Tachyarrhythmia flow chart guideline
-CABCD, obs
-signs of adverse features convey with PA or call HEMS, consider cardioversion
-if no signs see if QRS narrow or wide
-wide QRS- if irregular possible AF with bundle branch block so convey, if irregular possible VT so convey
-narrow QRS- irregular rhythm, possible fast AF so convey, if regular rhythm valsalva manoeuvre if sinus achieved possible SVT so convey if no sinus rhythm achieved, convey
Tachyarrhythmia adverse features
same as bradyarrhythmia
-shock
-syncope
-signs of HF
-chest pain
-signs myocardial ischaemia on ECG
Cardioversion
-similar to defib but pt has a pulse
-given to pt with reduced GCS, with a pulse and a tachyarrhythmias
-requires less energy than defibrillation
-shock usually delivered during QRS wave
-not a skill paramedics have currently, carried out by SP or critical care
How valsalva manoeuvre works
-force expiration against closed glottis
-its caused by increased intrathoracic pressure which stimulates the vagus nerve increasing parasympathetic drive, slowing the HR
How to do modified valsalva manoeuvre
-blow into a 10/20 ml syringe for 15 secs preferably supine or semi recumbent
-then tilt pt backwards and raise legs for 15secs
-re assess rhythm and repeat up to 3 times
Antiarrhythmic medication
-Beta blockers for tachyarrhythmias
eg. propranolol, metoprolol, bisoprolol
-Adenosine- usually for SVT
-Amiodarone- supraventricular arrhythmias or ventricular arrhythmias eg. VT
-Flecanide- SVT, paroxysmal AF (fast AF), atrial flutter
-Verapamil (calcium channel blocker)- SVT
Fluid therapy stepwise approach
-does pt have adverse signs
-if so treat underlying cause eg. atropine for bradycardia
-if still presenting with adverse signs, consider distance to nearest ED
-fluid usually not useful if pt in cardiogenic shock as its not a problem with the volume but a problem with the pump
