Lecture 2 : Peri Arrythmia
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U.M.F. “Gr. T. Popa” Iaşi Emergency Medicine
Peri-arrest arrhythmias Prof.Diana Cimpoeşu MD,PhD
2009
Reversible Causes
Hypoxia Hypovolemia Hypo/hyperkale mia Hypothermia
Tension Pneumotorax Tamponade cardiac Toxics Thrombosis (coronary or pulmonary)
Peri-arrest arrhythmias Principles of treatment
In all cases : -give oxygen -i.v acces -monitor - 12-lead ECG -electrolyte abnormalities - correct any abnormalities K, Mg, Ca
Treat the patient not the ECG monitor!
Cardiac arythmia Principles of treatment
How the pacient is feel? Stable or unstable haemodinamic? We see adverse manifestation ? Witch type of arythmia is present ?
Adverse signs (1)
Clinical signs of low cardiac output : -pallor, sweating , cold extremities , altered menthal status , hypotension (BP<90mmHg ) Excessve tachycardia >150/min.
Adverse signs (2)
Excessive Bradychardia -absolute< 40/min and relative< 60/min on pacients with low cardiac reserve
Signs of Heart Failure. -acute pulmonary oedema, raised jugulars venous pressure, hepatic engorgement
Chest pain
Treatment options Bradychardia
Pacing
Tachycardia
Cardioversion
All arrhythmias Anti-arrhythmic medication and other drugs
Cardiac Pacing
Safe method for treatment of bradychardia Required a skillfull person for transvenous pacing Required is there is a risk of asystola ; instable pacient ; not responding to atropine Transcutaneous pacing – initiate immediately , use analgesia and sedation Fist pacing- serial rhythmic blows 50- 70 / min
Cardioversion
Is used to convert atrial or ventricular tachyarrythmias
Is used when patient is unstable or deteriorating – Medication is ineffective
Risk of inducting Ventricular Fibrillation ! – Shock must be syncronised with R wave – Require analgesia and sedation
Cardioversion
First shock energies : - Start with 200 J monophasic (120-150 J biphasic ) – for broad complex tachycardia and AF -Start with 100 J monophasic (70-120 J biphasic ) – paroxysmal SVT and atrial flutter
Antiarrhythmic drugs Could convert tachyarrhytmia – Less secure then cardioversion – Used on patients without severity signs Used in first episode of bradychardia – Less eficients in case of low cardiac output All antiarrhytmic drugs can cause arrhytmia !
Bradycardia Adverse signs ? – Systolic BP < 90 mmHg – Heart rate < 40 b/min – Ventricular arrhytmias compromising BP – Heart failure If Yes – atropine 500 µ g i.v. and evaluate response DO NOT GIVE atropine to patients with cardiac transplants , it can cause a high degree AV block or even sinus arrest
Bradycardia IF
Satisfactory response NO adverse signs Evaluate risk of asystole: Recent asystole? Mobitz II AV block? Complete heart block with broad QRS ? Ventricular pause >3s ?
Bradycardia IF :
1. 2. 3. 4.
Risk of asystole or DOES NOT respond to atropine Repeat atropine 500 mcg to maximum 3 mg Transcutaneous pacing Adrenaline 2-10 µ g /min Arange transvenous pacing Seek expert help !
Bradycardia
Alternate drugs for pentru bradycardia : - dopamine - isoprenaline - aminophylline - glucagon iv – if beta-blocker or calcium channel blocker overdose
Bradycardia
IF does not responde to atropine and: NO risk of asystole ! Observe pacient
BRADYCARDIA
Tachyarrythmia Pacient unstable and deteriorating: - syncronised cardioversion, amiodarone 300 mg in 10-20min, repeta cardioversia, reattempt cardioversion, amiodarone 900 mg over 24 h Patient stable – antiarrythmics drugs
Tachyarrhytmia
Broad complex tachycardia QRS >0,12s: -Usually ventricular in origin but may be caused by supraventricular rhythms with aberrant conduction - regular rhythm – VT or SVT with bundle branch block -Irregular rhythm –VT polymorphic , AF with bundle branch block, Af with WPW
Broad complex tachycardia QRS >0,12s
Pulse? No! – VF/Vtah Yes! – stable/unstable?
Broad complex tachycardia QRS >0,12s
Is patient stable? – – – – –
Sistolic BP< 90 mmHg Chest Pain Heart Failure Heart Rate > 150 /min Reduced Conscious level
No •Amiodarone 300mg iv over 10-20 min •Expert cardiology •Cardioversion • Amiodarone 900 mg over 24 h
Yes •Seek expert help • cardioversion 200J(120-150) synchronised DC Shock up to 3 attempts •Amiodarone 900 mg over 24 h
correct HipoK, give magnesium 2g over 10 min
Tachyarrythmia
Narow complex tachycardia : - regular rhythm : - sinus ,AV nodal re-entry tachycardia , AV re-entry tachycardia (AVRT), atrial flutter with regular AV conduction - Irregular rhythm – AF , atrial flutter with variable AV conduction
Narrow complex tachycardia (PSVT)-Regular Use vagal manoeuvres
1.
– –
Valsalva manoeuvre (forced expiration against a closed glottis) Carotid sinus massage
Adenosine i.v.
1.
– –
6 mg bolus 12 mg bolus, (repeat 12 mg)
Failure to terminate a regular narrow-tach: Seek expert help!
Narrow complex tachycardia (PSVT)Regular Is patient stable? Sistolic BP< 90 mmHg Chest Pain Heart Failure Heart Rate > 200 /min Reduced Conscious level
No Antiarrythmics
Yes Cardioversion 100J (70-120J) Amiodarone 300 mg iv 20-60 min
Narrow complex tachycardia (PSVT)-Regular Seek help
N o
Is patient stable? Sistolic BP< 90 mmHg Chest Pain Heart Failure Heart Rate > 200 /min Reduced Conscious level
•Esmolol: 40 mg 1 min + piv 4 mg /min or
•Verapamil 5-10 mg i.v. or •Amiodarone: 300 mg 20-60 min or •Digoxin: iv maximum 500 µg in 30 min x2
ye s
Cardioversion 100 J, biphasic(70-120J)
Amiodarone 300 mg in 20 min 900 mg in 24h •Repeat cardioversion
Post-resuscitation care
Return of spontaneos circulation ROSC Hypoxia and hypercarbia –contribute to secondary brain injury Tracheal intubation, sedation and controlled ventilation Normocarbia Pa CO2 Normal PaO2
1. Australia Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-ofhospital cardiac arrest with induced hypothermia. N Engl J Med 2002;346:557-63. 2. Europa The Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002;346:549-56. Mild therapeutic hypothermia (33°C in the first study and 32°C to 34°C in the second) in survivors of out-of-hospital cardiac arrest.
Questions?
Peri-arrest arrhythmias Prof.Diana Cimpoeşu MD,PhD
2009
Reversible Causes
Hypoxia Hypovolemia Hypo/hyperkale mia Hypothermia
Tension Pneumotorax Tamponade cardiac Toxics Thrombosis (coronary or pulmonary)
Peri-arrest arrhythmias Principles of treatment
In all cases : -give oxygen -i.v acces -monitor - 12-lead ECG -electrolyte abnormalities - correct any abnormalities K, Mg, Ca
Treat the patient not the ECG monitor!
Cardiac arythmia Principles of treatment
How the pacient is feel? Stable or unstable haemodinamic? We see adverse manifestation ? Witch type of arythmia is present ?
Adverse signs (1)
Clinical signs of low cardiac output : -pallor, sweating , cold extremities , altered menthal status , hypotension (BP<90mmHg ) Excessve tachycardia >150/min.
Adverse signs (2)
Excessive Bradychardia -absolute< 40/min and relative< 60/min on pacients with low cardiac reserve
Signs of Heart Failure. -acute pulmonary oedema, raised jugulars venous pressure, hepatic engorgement
Chest pain
Treatment options Bradychardia
Pacing
Tachycardia
Cardioversion
All arrhythmias Anti-arrhythmic medication and other drugs
Cardiac Pacing
Safe method for treatment of bradychardia Required a skillfull person for transvenous pacing Required is there is a risk of asystola ; instable pacient ; not responding to atropine Transcutaneous pacing – initiate immediately , use analgesia and sedation Fist pacing- serial rhythmic blows 50- 70 / min
Cardioversion
Is used to convert atrial or ventricular tachyarrythmias
Is used when patient is unstable or deteriorating – Medication is ineffective
Risk of inducting Ventricular Fibrillation ! – Shock must be syncronised with R wave – Require analgesia and sedation
Cardioversion
First shock energies : - Start with 200 J monophasic (120-150 J biphasic ) – for broad complex tachycardia and AF -Start with 100 J monophasic (70-120 J biphasic ) – paroxysmal SVT and atrial flutter
Antiarrhythmic drugs Could convert tachyarrhytmia – Less secure then cardioversion – Used on patients without severity signs Used in first episode of bradychardia – Less eficients in case of low cardiac output All antiarrhytmic drugs can cause arrhytmia !
Bradycardia Adverse signs ? – Systolic BP < 90 mmHg – Heart rate < 40 b/min – Ventricular arrhytmias compromising BP – Heart failure If Yes – atropine 500 µ g i.v. and evaluate response DO NOT GIVE atropine to patients with cardiac transplants , it can cause a high degree AV block or even sinus arrest
Bradycardia IF
Satisfactory response NO adverse signs Evaluate risk of asystole: Recent asystole? Mobitz II AV block? Complete heart block with broad QRS ? Ventricular pause >3s ?
Bradycardia IF :
1. 2. 3. 4.
Risk of asystole or DOES NOT respond to atropine Repeat atropine 500 mcg to maximum 3 mg Transcutaneous pacing Adrenaline 2-10 µ g /min Arange transvenous pacing Seek expert help !
Bradycardia
Alternate drugs for pentru bradycardia : - dopamine - isoprenaline - aminophylline - glucagon iv – if beta-blocker or calcium channel blocker overdose
Bradycardia
IF does not responde to atropine and: NO risk of asystole ! Observe pacient
BRADYCARDIA
Tachyarrythmia Pacient unstable and deteriorating: - syncronised cardioversion, amiodarone 300 mg in 10-20min, repeta cardioversia, reattempt cardioversion, amiodarone 900 mg over 24 h Patient stable – antiarrythmics drugs
Tachyarrhytmia
Broad complex tachycardia QRS >0,12s: -Usually ventricular in origin but may be caused by supraventricular rhythms with aberrant conduction - regular rhythm – VT or SVT with bundle branch block -Irregular rhythm –VT polymorphic , AF with bundle branch block, Af with WPW
Broad complex tachycardia QRS >0,12s
Pulse? No! – VF/Vtah Yes! – stable/unstable?
Broad complex tachycardia QRS >0,12s
Is patient stable? – – – – –
Sistolic BP< 90 mmHg Chest Pain Heart Failure Heart Rate > 150 /min Reduced Conscious level
No •Amiodarone 300mg iv over 10-20 min •Expert cardiology •Cardioversion • Amiodarone 900 mg over 24 h
Yes •Seek expert help • cardioversion 200J(120-150) synchronised DC Shock up to 3 attempts •Amiodarone 900 mg over 24 h
correct HipoK, give magnesium 2g over 10 min
Tachyarrythmia
Narow complex tachycardia : - regular rhythm : - sinus ,AV nodal re-entry tachycardia , AV re-entry tachycardia (AVRT), atrial flutter with regular AV conduction - Irregular rhythm – AF , atrial flutter with variable AV conduction
Narrow complex tachycardia (PSVT)-Regular Use vagal manoeuvres
1.
– –
Valsalva manoeuvre (forced expiration against a closed glottis) Carotid sinus massage
Adenosine i.v.
1.
– –
6 mg bolus 12 mg bolus, (repeat 12 mg)
Failure to terminate a regular narrow-tach: Seek expert help!
Narrow complex tachycardia (PSVT)Regular Is patient stable? Sistolic BP< 90 mmHg Chest Pain Heart Failure Heart Rate > 200 /min Reduced Conscious level
No Antiarrythmics
Yes Cardioversion 100J (70-120J) Amiodarone 300 mg iv 20-60 min
Narrow complex tachycardia (PSVT)-Regular Seek help
N o
Is patient stable? Sistolic BP< 90 mmHg Chest Pain Heart Failure Heart Rate > 200 /min Reduced Conscious level
•Esmolol: 40 mg 1 min + piv 4 mg /min or
•Verapamil 5-10 mg i.v. or •Amiodarone: 300 mg 20-60 min or •Digoxin: iv maximum 500 µg in 30 min x2
ye s
Cardioversion 100 J, biphasic(70-120J)
Amiodarone 300 mg in 20 min 900 mg in 24h •Repeat cardioversion
Post-resuscitation care
Return of spontaneos circulation ROSC Hypoxia and hypercarbia –contribute to secondary brain injury Tracheal intubation, sedation and controlled ventilation Normocarbia Pa CO2 Normal PaO2
1. Australia Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-ofhospital cardiac arrest with induced hypothermia. N Engl J Med 2002;346:557-63. 2. Europa The Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002;346:549-56. Mild therapeutic hypothermia (33°C in the first study and 32°C to 34°C in the second) in survivors of out-of-hospital cardiac arrest.
Questions?
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