Arrhythmia recognition and treatment
Cardiology Acute Care Day
Objectives
Normal sinus rhythm
How to recognise an arrhythmia
Bradyarrhythmias
Tachyarrhythmias
Treatment strategy for arrhythmias
Outline
Objectives
Normal sinus rhythm
How to recognise an arrhythmia
Bradyarrhythmias
Tachyarrhythmias
Treatment strategy for arrhythmias
Outline
ECGofofsinus
sinus rhythm
ECG
QRS
P
Normal rate
Regular, narrow QRS
P waves present
P:QRS is 1:1
Objectives
Normal sinus rhythm
How to recognise an arrhythmia
Bradyarrhythmias
Tachyarrhythmias
Treatment strategy for arrhythmias
Outline
How
recognisean
an arrhythmia
arrhythmia
How
toto
recognise
What is the QRS rate?
Are the QRS complexes regular?
Is the QRS broad or narrow?
Are there P waves?
What is the P:QRS relation?
Objectives
Normal sinus rhythm
How to recognise an arrhythmia
Bradyarrhythmias
Tachyarrhythmias
Treatment strategy for arrhythmias
Outline
Bradyarrhythmias
Bradyarrhythmias
Sinus bradycardia
Sinus arrest (“Sick Sinus Syndrome”)
Junctional bradycardia
Atrioventricular block
(First degree)
Second degree
- type I (Wenckebach) / type II
Third degree
Sinus bradycardia
Rate < 60bpm
Regular, narrow QRS
P waves present
P:QRS is 1:1
*
Sinus arrest
Rate < 60bpm
Irregular, narrow QRS
P waves present
P:QRS is 1:1
Pause with absence of P wave
*
Junctional bradycardia
Rate < 60bpm
Regular, narrow QRS
No P waves
*
First degree AV block
Rate variable
Regular, narrow QRS
P waves present
P:QRS is 1:1 with PR interval >200ms
*
Second degree AV block (type I)
*
Rate < 60bpm
Irregular narrow QRS
P:QRS not 1:1
increasing PR interval
then dropped beat
*
Second degree AV block (type II)
*
*
Rate < 60bpm
Irregular narrow QRS
P:QRS not 1:1
normal PR interval with
intermittent dropped beats
*
Third degree (complete) AV block
Rate < 60bpm
Regular broad QRS
No relation between P and QRS
*
Objectives
Normal sinus rhythm
How to recognise an arrhythmia
Bradyarrhythmias
Tachyarrhythmias
Treatment strategy for arrhythmias
Outline
Tachyarrhythmias
Irregular
Atrial fibrillation
Regular
Narrow QRS
Sinus tachycardia
Supraventricular tachycardia (SVT)
Atrial flutter
Broad QRS
Ventricular tachycardia
SVT with Bundle Branch Block
Atrial fibrillation
Rate variable
Irregular, narrow QRS
No P waves
Sinus tachycardia
Rate > 100bpm
Regular, narrow QRS
P waves present
P:QRS is 1:1
*
Supraventricular tachycardias
Atrial tachycardia
Junctional tachycardia
AV re-entrant tachycardia
AV node re-entrant tachycardia
*
*
Supraventricular tachycardia
Rate > 100bpm
Regular, narrow QRS
P waves variable
- not apparent, or after QRS
*
*
Atrial flutter
Rate variable
Regular, narrow QRS
Sawtooth atrial activity 300bpm
- variable AV block
Ventricular tachycardia
Rate > 100bpm
Regular, broad QRS
P waves variable
- may be dissociated
*
SVT with Bundle Branch Block
*
Rate > 100bpm
Regular, broad QRS
P waves variable
- usually not visible
*
X
Outline
Normal sinus rhythm
How to diagnose an arrhythmia
Bradyarrhythmias
Tachyarrhythmias
Treatment strategy for arrhythmias
Treatment strategy
First assess the patient and CHECK THEIR PULSE
Are they compromised?
low BP, impaired consciousness, heart failure, chest pain
Then assess the ECG
Is there a high risk of cardiac arrest?
VT, complete heart block
If compromise or high risk
Treat with electricity
DC cardioversion / temporary pacing
If not
Look for reversible causes / treat with drugs
89 year old female
Syncope
BP 75/40
What is the QRS rate?
Is the QRS regular?
Is the QRS broad or narrow? Are there p-waves?
What is the p – QRS relation?
Third degree (complete) AV block
Assess the patient
If compromised:
Immediate temporary pacing (initially transcutaneous,
refer to expert to consider placing a temporary pacing wire)
If not compromised:
What is the risk of asystole?
Third degree (complete) AV block
What factors predict a high risk of asystole?
- Recent asystole
- Mobitz type II AV block
- Third degree heart block with broad QRS
- Ventricular pause >3seconds
Third degree (complete) AV block
What is this patients risk of asystole?
High
Consider temporary pacing
Address reversible causes:
Drugs affecting the conducting system
Acute MI
Temporary
pacing
75 yr old male
Mild breathlessness
BP 135/85
What is the QRS rate?
Is the QRS regular?
Is the QRS broad or narrow? Are there p-waves?
What is the p – QRS relation?
Atrial fibrillation
Assess the patient
If they are compromised DC cardioversion
If not, decide treatment strategy
Rate control vs rhythm control
Rate control
AV nodal blockers
CCB, β-blocker, digoxin
Rhythm control
Anti-arrhythmics
Amiodarone, flecainide
Anticoagulation
Following administration of beta-blocker
What is the QRS rate?
Is the QRS regular?
Is the QRS broad or narrow? Are there p-waves?
What is the p – QRS relation?
47 year old female
Palpitations
BP 120/70
Supraventricular tachycardia
Assess the patient
If they are compromised DCCV
If not compromised:
Vagal manoeuvres
IV Adenosine
(extremely short half-life, need to give rapidly)
Terminates re-entry circuits using AVN
Will slow atrial tachycardia and atrial flutter
IV verapamil
Consider:
AVN slowing (digoxin)
Antiarrhythmic (amiodarone)
DCCV/ A pacing
Termination of SVT with Adenosine
adenosine 6mg IV
What is the QRS rate?
Is the QRS regular?
Is the QRS broad or narrow? Are there p-waves?
What is the p – QRS relation?
62 year old male
Palpitations
BP 120/70
IV adenosine
Following bisoprolol
What is the QRS rate?
Is the QRS regular?
Is the QRS broad or narrow? Are there p-waves?
What is the p – QRS relation?
82 year old male
Chest pain
BP 80/50
Ventricular tachycardia
Assess the patient
DO THEY HAVE A PULSE?
No? Use BLS/ALS ALGORITHM
If any compromise:
Immediate DCCV
Call anaesthetist
Secure airway
Conscious sedation
Synchronised DC shock
Manage on CCU
If no compromise: (GET 12 LEAD ECG)
Consider IV amiodarone/other antiarrhythmics
Consider reversible causes
Treatment strategy
First assess the patient and CHECK THEIR PULSE
Are they compromised?
low BP, impaired consciousness, heart failure, chest pain
Then assess the ECG
Is there a high risk of cardiac arrest?
VT, complete heart block
If compromise or high risk
Treat with electricity
DC cardioversion / temporary pacing
If not
Look for reversible causes / treat with drugs
Any
questions
Any
questions?
Normal sinus rhythm
How to recognise an arrhythmia
Bradyarrhythmias
Tachyarrhythmias
Treatment strategy for arrhythmias