HANDOUT STUDY UNIT 2 ARRHYTHMIA MANAGEMENT (BRADYCARDIA)

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1 HANDOUT STUDY UNIT 2 ARRHYTHMIA MANAGEMENT (BRADYCARDIA) Bradycardia is defined conservatively as a heart rate below 60 beats per minute, but symptomatic bradycardia generally entails rates below 50 beats per minute. A bradycardia is only significant when the patient is symptomatic due to the rate itself. Absolute bradycardia: o HR < 60bpm may not be abnormal, e.g. athlete Relative bradycardia: o HR is less than expected for the patient s clinical condition, e.g. HR of 70bpm for a patient that is in hypotensive septic shock Symptomatic bradycardia: o HR is slow o Patient is symptomatic o Symptoms are due to the slow HR The American Heart Association, ACLS Guidelines recommend that clinicians not intervene unless the patient exhibits evidence of inadequate tissue perfusion thought to result from the slow heart rate. Signs and symptoms of inadequate perfusion include: o Hypotension o Altered mental status o Signs of shock o Ongoing ischemic chest pain o Evidence of acute heart failure Management: o Essential to identify and treat underlying cause!!! o ABCs o Oxygen prn o ECG (3-lead); BP; Sats o Establish IV access o 12-lead ECG if available o Is the patient symptomatic (signs of inadequate perfusion)? o Asymptomatic: Monitor and observe o Symptomatic: Atropine Transcutaneous pacing Adrenaline Atropine: o First line drug (ClassIIa, LOE B). o Reverses the cholinergic mediated decreases in HR. o Used to treat sinus bradycardia and AV Blocks at the nodal level. o The SA and AV nodes are innervated by the vagus nerve and Atropine blocks the effects of vagal nerve discharge on the SA and AV node. o The initial dose of atropine is 0.5 mg IV bolus. o Repeat every 3-5 minutes to a maximum of 3mg. 1

2 o Dosages < 0.5mg cause a paradoxical slowing of the HR. o Use with caution in the presence of coronary ischemia or MI as the increase in HR may worsen the ischaemia or zone of infarction. o Avoid in Second Degree Type II or Third Degree AV Blocks as Atropine exerts its antibradycardiac effects at the AV node and is unlikely to be effective if a conduction block exists at or below the Bundle of His. o Atropine is ineffective in transplanted hearts due to lack of vagal innervation. Transcutaneous Pacing (TCP): o Second line intervention (Class IIa, LOE B). o First line intervention in high-degree AV Blocks when IV access is not available (Class IIb, LOE C). o The goal of TCP is not to target a specific HR but rather ensure an improvement in the patient s clinical condition. o Start TCP immediately in unstable patients, if there is no response to Atropine and if Atropine is unlikely to be effective. o An impulse is conducted through the chest wall to activate the myocardium resulting in depolarization. o Used to increase HR (and CO) when the patient s intrinsic pacemaker becomes insufficient. o Check femoral pulse for mechanical capture (not carotid). o Consider sedation & analgesia for conscious patients. Assess whether the patient can perceive the pain associated with this procedure and if so provide appropriate sedation and analgesia whenever possible. o In cardiovascular collapse / rapidly deteriorating patient, start pacing without sedation. o Aeromedical environment Safety? o Physiological effects: mean O2 consumption HR MAP CO total peripheral vascular resistance Skeletal muscle contraction Pain o Permanent Pacemaker: A pacemaker is surgically implanted into the myocardium and connected to a pulse generator placed subcutaneously because of a permanent myocardial conduction disorder. o Temporary Pacemaker: Used in emergencies for transient conduction disturbances or prophylactically for arrhythmias (<72 hours). o Pacing Modes: Asynchronous / Fixed / Non-Demand: Timed electrical stimuli at selected rate regardless of the patient s intrinsic cardiac activity. May induce VF (R on T) or VT. 2

3 Useful for motion artefact (but mostly outdated mode) Synchronous / Demand: Better option. Delivers impulse when needed. Pulse generator designed to sense intrinsic QRS complexes. When an intrinsic beat is sensed the pacemaker is inhibited. If no beat is sensed the pacemaker discharges at the prescribed rate. VF risk excluded. o Advantages of TCP: Easy skill (limited training needed) Rapid application Cost effective Limited risks o Contra-indications of TCP: Severe hypothermia Failure to exclude treatable causes of a bradycardia Haemodynamically stable patient o Complications of TCP: Failure to recognize underlying VF Failure to recognize non-mechanical capture Loss of capture due to altered pacing thresholds Localised skin irritation o Mechanical capture manifests as: Palpable HR corresponding to pre-selected HR Increase in BP Improved LOC Improved skin colour and temperature o Initiate pacing at a rate of 70bpm and 30mA, increasing the energy until electrical and mechanical capture is noted. o If no improvement in blood pressure, increase the rate up to a maximum of bpm. If pacing fails to improve the blood pressure consider inotropic / chronotropic as above. Adrenaline: o Not a first line agent (Class IIb, LOE B) o Catecholamine with α- and β-adrenergic actions. o α- effects: Vasoconstriction o Β1-effects: Positive inotrope Positive chronotrope Positive dromotrope o Alternate if Atropine fails. o Considered equal alternate to TCP. o Adrenaline is given at 2 to 10 mcg per minute, titrated to the patient's response. 3

4 Glucagon: o Give to drug induced bradycardia (β-blocker / Calcium Channel Blocker OD) which is not responsive to Atropine or Adrenaline. o 1mg / vial freeze-dried glucagon plus syringe containing 1ml H2O for injection o Reconstitute with provided solution: Inject 1ml H2O for injection into vial, shake to dissolve, then draw up solution. Do NOT mix with saline. o Administer 3mg IV initially as adjuvant treatment of calcium channel blocker or beta blocker OD, followed by 3mg/hour infusion 4

5 Classification of Recommendations: Class I: o Conditions for which there is evidence, general agreement, or both that a given procedure or treatment is useful and effective. Class II: o Conditions for which there is conflicting evidence, a divergence of opinion, or both about the usefulness/efficacy of a procedure or treatment. Class IIa: o Weight of evidence/opinion is in favor of usefulness/efficacy. Class IIb: o Usefulness/efficacy is less well established by evidence/opinion. Class III: o Conditions for which there is evidence, general agreement, or both that the procedure/treatment is not useful/effective and in some cases may be harmful. Level of Evidence: Level of Evidence A: Data derived from multiple randomized clinical trials Level of Evidence B: Data derived from a single randomized trial or nonrandomized studies Level of Evidence C: Consensus opinion of experts References: 1. American Heart Association; ACLS for Experienced Providers; American Heart Association; Guidelines CPR ECC 2015; ACLS for Experienced Providers 5

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