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A QUICK GLANCEATARRHYTHMIAS Ioanna Chatzichristodoulou IMT3 NNUHAGENDA Normal Sinus Rhythm Rhythm Recognition Tachyarrhythmia • SinusTachycardia ,AF,Atrial Flutter ,SVT ,VT,Torsades points ,VF ALS algorithm CasesSINUS RHYTHMNORMAL SINUS RHYTHM •Regular rhythm at a rate of 60-100 bpm (or age-appropriate rate in children) Rhythm Strip characteristics: standard speed of 25 mm/s and a voltage of 10 mm/mV •Each QRS complex is preceded by a P wave •Normal P wave axis: P waves upright in leads I and II, inverted in aVR •The PR interval remains constant . 120-200 milliseconds (3-5 small squares) •QRS complexes < 120 ms wide (3 small squares )(unless co-existent interventricular conduction delay present)6-STAGE SYSTEMTOANAL YZE RHYTHM ONAN ECG (ACCORDINGTOALS ) 1. Is there any electrical activity 2. What is the ventricular (QRS) rate? 3. Is the QRS rhythm regular or irregular ? 4. Is the QRS complex Narrow (<120ms or 3 small squares ) or broad ? 5. Is atrial activity present ? 6. Is atrial activity related to ventricular activity and if so,how ?( or is the P wave being followed by a QRS complex always)?Can you describe this rhythm ?WHATWASTHAT RHYTHM ?SINUSTACHYCARDIACAUSES OF SINUSTACHYCARDIA ¡ Fever /infection /sepsis ¡ Dehydration ¡ Hypovolemia /Shock ¡ Hemorrhage ¡ Pain ¡ Electrolytes abnormalities (Mg,K,Ca) ¡ PE ¡ Stress /anxiety ¡ Caffeine or other illicit drugs ¡ Medications ¡ ACS /HFCANYOU DESCRIBETHIS RHYTHM ?WHATWASTHAT RHYTHM?ATRIAL FIBRILATIONCANYOU DESCRIBETHIS RHYTHM?WHATWASTHAT RHYTHMATRIAL FLUTTERCANYOU DESCRIBETHIS RHYTMWHATWASTHAT RHYTHM?SUPRAVENTRICULARTACHYCARDIA (SVT)-ATRIOVENTRICULAR RE- ENTRANTTACHYCARDIASVT-AV NODAL REENTRANTTACHYCARDIACANYOU DESCRIBETHIS RHYTHM?WHATWASTHAT RHYTH?MONOMORPHICVENTRICULARTACHYCARDIACANYOU DESCRIBETHIS RHYTM?WHATWASTHAT RHYTHM?POL YMORPHICVENTRICULARTACHYCARDIA (TORSADES DE POINTS) Due to prolonged QTc (>440 ms in male >460ms in females) Causes: Inherited Long QTc syndrome Hypomagnesaemia Hypokalemia Hypocalcemia Hypothermia Myocarditis MI Medications that prolong QTc (including class I +II antiarrhythmics !) Treatment: IV Mg 2 gr over 10 minutesCANYOU DESCRIBETHIS RHYTHM?WHATWASTHAT RHYTHM?VENTRICULAR FIBRILLATION (VF)ESCALATETOYOUR SENIORS EARL Y!!!ALSALGORHITHMVAGAL MANOEUVRESRIGHTAND LEFT BUNDLE BRUNCH BLOCKRBBBVS LBBB ON ECG RBBB •QRS duration >0.12 seconds •Slurred S wave in lead I, aVL, V5, and V6 •RSR’ in V1 and V2 with R’ > RLBBB QRS duration >0.12 seconds Broad monomorphic R waves in I, aVL, V5, and V6 Broad, dominant, monomorphic S wave in V1 and V2AFAND LBBBSVTAND LBBBMONOMORPHICVT QUICKTIPS FOR DIFFERENTIATING: VT VS SVTWITHABERRANCY ¡ AV Dissociation àVT • P and QRS complexes at different rates • P waves are often superimposed on QRS complexes and may be difficult to discern ¡ Capture and fusion beats àVT Capture beats: Occur when the sinoatrial node transiently “captures” the ventricles in the midst of AV dissociation, producing a QRS complex of normal duration Fusion beats: Occur when a sinus and ventricular beat coincide to produce a hybrid complex ¡ Known previous LBBB or RBBB or obvious BBB morphology on ECG àhigher chance of SVT with aberrancy ¡ Previous history of Ischemic heart disease àhigher chance ofVT ¡ Childrenà95% of broad complex tachycardias in children are SVT with aberrancy If in doubt treat as VT !!AV Dissociation Fusion and Capture beatsCASE 1 ¡ 35 M admitted with palpitations started 2 hours ago and dizziness.With no chest pain and breathlessness .No syncope.PMH:Recurrent previous episodes of palpitations ,but not investigated.DH:Nil ,Allergies:nil ,SH:non smoker ,alcohol 14 units per week,drinks 4 coffees per day.WHATWOULDYOU FIRST? ¡ ABCDE approach ¡ O2 , ¡ Airway:patent ¡ Breathing:Speaking full sentences ,RR:15,sats 98% on RA,chest clear ¡ Circulation :cardiac monitor attached,HR:180 bpm,BP 120/80,warm peripheries ,S1S20 ,JVP(-),No peripheral oedema ,palpable BL radial pulses ,IV access gained ,VBG:Lac 1,K3.5,ph:7.4- bloods sent off ¡ Disability :GCS:15/15,Glu:6 ¡ Exposure:abdomen soft non tender,calves soft non tender ,T:36.6ECG SVT –MANAGEMENT ¡ Trial ofVagal manoeuvres:ineffective at our case ¡ Adenosine :while the patient is on continuous cardiac monitoring and defibrillator pads on. ¡ Adenosine:warn the patient before giving it they may experience :Nausea .Dizziness,Breathlessness,Flushing ,Chest tightness ¡ Adenosine IV bolus via large vein 6mg and consecutive 12mg and 18 mg.Followed by a rapid flush. ¡ Adenosine Contraindications:Heart block ,sick sinus syndrome,in COPD andAsthma with active bronchospasm. ¡ Alternatives:IV Verapamil 5-10mg over 2 minutes ,Beta blockers eg IV Metoprolol 1-5mg (1-2mg/min) then repeat if required after 5 minutes ,up to 10-15mg total doseECGAFTERADENOSINETHE PATIENT COMPLAINSAGAIN OF PALPITATIONS ECG:MANAGEMENT:ABCDE..REASSESSMENT ¡ A-patent ¡ B-RR25,Sats 100% OA,chest clear ¡ C-BP:80/50,HR:200bpm,cold peripheries ,non palpable radial pulse,no chest pain ¡ D- GCS 14/15 ,started becoming confused TREATMENT : SYNCHRONIZED DCCV CASE 2 ¡ 85 Female.PMH:T2DM ,HF,HTN ,OA,Dementia.Presented with 3 days history of breathlessness on exertion and at rest.No orthopnea or paroxysmal nocturnal dyspnoea .No Chest pain or palpitations/dizziness/LOC. ¡ Assessment: ¡ A-patent ¡ B- RR:15 ,sats 100% OA ,chest clear ¡ C-HR 140bpm ,BP 120/80 mmHG,warm peripheries,good BL radial pulse ,JVP(-),No peripheral oedema ¡ D-GCS 15/15 ,GLU:6 ¡ E-Abdomen SNT ,Calves SNT ,no signs of bleedingECG MANAGEMENT OFATRIAL FIBRILLATION (AF) TREATTHE CAUSE : ¡ Correct hypovolemia,dehydration,electrolyte disturbances ,treat infection (if any signs of infection ,eg fever ,high inflammatory markers ) RHYTHM CONTROL DCCV OR NOT ? ¡ Our patient is haemodynamically stable and does not have any adverse features ,so no need for DCCV ¡ In sudden onsetAF within the last 48 hours (when we definitely ,know the time of onset ) we can do DCCV cardioversion.This does not apply to our case. ¡ If the patient has a history of paroxysmalAF and has been anticoagulated uninterruptedly for at least 4 weeks . DCCV could again be attempted.This is usually decided by cardiologists for very symptomatic patients. ¡ Amiodarone could be used for pharmacological cardioversion .Usually after cardiology advice.MANAGEMENT OFATRIAL FIBRILLATION RATE CONTROL Use either b-blockers as first line (eg bisoprolol) or rate limiting calcium channel blockers e.g.diltiazem or verapamil Digoxin can be used as well – especially if evidence of HF ANTICOAGULATION ¡ Decision about anticoagulation is made after CHADVASC and ORBIT (or HASBLED) scores ¡ DOACs egApixaban ,Edoxaban ,Rivaroxaban ,Dabigatran are usually used .Or Warfarin when indicated (on end stage renal failure)REFERENCES ¡ https://elentra.healthsci.queensu.ca/assets/modules/ts- • https://rebelem.com/bundle-branch-blocks101/ ecg/ventricular_tachycardia.html ¡ https://my.clevelandclinic.org/health/diseases/21692-right-bundle-branch-block • https://ecglibrary.com/af_lbbb.html • https://resus.com.au/vt-vs-svt-aberrancy/ ¡ causes/syc-20370514nic.org/diseases-conditions/bundle-branch-block/symptoms- • https://emergencycarebc.ca/clinical_resource/clinical-summary/bundle-branch-blocks- lbbb-lafb-rbbb-trifascicular-block/ ¡ RESUS COUNCIL UK https://www.resus.org.uk/library/2021-resuscitation- guidelines • https://bmcemergmed.biomedcentral.com/articles/10.1186/s12873-020-00390- 3/figures/2 ¡ https://www.mdcalc.com/ ¡ https://youtu.be/bDyZ76QzA9s?si=aG4LBsPsfYArBSrA ¡ https://youtube.com/shorts/2ahq8r-S-hQ?si=g1RymK77mXHtD9Zp ¡ https://youtu.be/UOkseyF-wrA?si=ku1ejAGjQu1Bm9V8 ¡ https://youtu.be/6LrptveKYus?si=tWbgRoeZm2qgIypt ¡ https://youtu.be/gCCTgMc2E8Q?si=fFiin0xLUxoED6BC ¡ https://youtube.com/shorts/osA1Wtjb1yo?si=Wc-mkWKOppXeb5qz ¡ https://youtu.be/jOCevXmKmK0?si=SYVV0Efn2wi57WRw ¡ https://youtube.com/shorts/4AUkZ8GFZF0?si=h_gFIM9oFAvQZtD7 ¡ https://www.ncbi.nlm.nih.gov/books/NBK519049/ ¡ https://www.osmosis.org/THANKYOUVERY MUCH ANY QUESTIONS?