Jordan M. Prutkin, MD, MHS Assistant Professor University of Washington 7/18/2013

Transcription

1 Jordan M. Prutkin, MD, MHS Assistant Professor University of Washington 7/18/2013

2 What to do Check the patient s pulse Get an ECG Unless there s no pulse. Then call a code and do ACLS

3 Approaching an EKG Eyeball Rate Rhythm Axis Intervals P waves QRS ST-T waves Overall appearance

4 Approach to Arrhythmias Do you have calipers? Are there P waves? Are the P waves and QRS s regular? Are there more P waves than QRS complexes? Are there more QRS complexes than P waves? Is there a constant relationship between the P waves and QRS complexes (constant PR)? Do the QRS complexes look like the baseline QRS (if known)? Are they wider? Narrower?

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6 Regular Irregular Narrow Wide Sinus Tach AVNRT Orthodromic AVRT Atrial Tach Junctional Tach Atrial Flutter Monomorphic VT Antidromic AVRT SVT with: BBB Bypass pathway Ventricular pacing Afib MAT Frequent PACs Rarely SVT Atrial Flutter Wenckebach Polymorphic VT VFib Afib, MAT, PACs with: BBB Bypass pathway Ventricular pacing

7 Delacretaz. NEJM 2006;354:

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9 Case 1 73 year old female admitted with pneumonia, reports acute onset of shortness of breath

10 Case 1

11 What does this EKG show? 1. Sinus rhythm 2. Atrial fibrillation 3. Atrial flutter 4. Atrial tachycardia

12 What does this EKG show? 1. Sinus rhythm 2. Atrial fibrillation 3. Atrial flutter 4. Atrial tachycardia

13 Case 2 61 year old male presents to the ED with palpitations HR 155bpm, BP 122/76

14 Case 2

15 What does this EKG show? 1. Sinus tachycardia 2. Atrial fibrillation 3. Atrial flutter 4. Atrial tachycardia 5. Artifact

16 What does this EKG show? 1. Sinus tachycardia 2. Atrial fibrillation 3. Atrial flutter 4. Atrial tachycardia 5. Artifact

17 Slower heart rate

18 Management of Afib/flutter Is the patient hemodynamically stable? If there s hypotension, acute heart failure, mental status change, ischemia, or angina, then cardiovert

19 If stable, then what? About 1/2 to 2/3 will terminate spontaneously within 24 hours Do you need to do anything then? If rapid or mildly/moderately symptomatic, yes. Asymptomatic, HR <110bpm Otherwise, maybe not.

20 Rate control IV PO Metoprolol 5mg IV Q5min x 3 Diltiazem 5-20mg IV, then 5-20mg/hr Esmolol gtt, if in ICU Metoprolol 25mg Q6-8H Metoprolol XL 25-50mg Q12-24H Atenolol mg Q24H Diltiazem 30-60mg Q6H Diltiazem CD mg Q24H Verapamil mg Q24H Digoxin?

21 Rhythm Control Amiodarone 150mg IV, then mg/min gtt Should really have a central line Don t use if afib >48 hours and no anticoagulation Flecainide Propafenone Ibutilide Call cardiology

22 Anticoagulation/DCCV for AF Increased risk of stroke after DCCV If >48 hours, need three weeks of weekly therapeutic coumadin levels, or TEE first If >48 hours and acute DCCV, give heparin bolus, then infusion and anticoagulate for 4 weeks If <48 hours, don t need anticoagulation necessarily If on heparin, if PTT <60 for >48 hours, then clock restarts. LMWH, dabigatran, rivaroxaban, apixiban okay

23 Case 3

24 Treatment for the person here: 1. Metoprolol 2. Diltiazem 3. Digoxin 4. Procainamide

25 Treatment for the person here: 1. Metoprolol 2. Diltiazem 3. Digoxin 4. Procainamide

26 Sinus tachycardia 78 year old admitted with pyelonephritis HR 120bpm ECG shows sinus tachycardia

27 Causes of sinus tach Fever Infection/Sepsis Volume depletion Hypotension/shock Anemia Anxiety Pulmonary embolism MI Heart failure COPD Hypoxia Hyperthyroid Pheochromocytoma Stimulants/Illicit substances

28 Treatment for Sinus Tach In general, don t treat heart rate Treat underlying cause Exception for acute MI, use beta-blockers

29 Case 4 63 year old male is admitted with chest pain to 5NE While waiting for a stress test, he reports abrupt onset of palpitations and mild chest discomfort to his nurse. Pulse 150, blood pressure 132/88 The nurse gets an ECG while you come to evaluate the patient

30 Case 4-Presenting EKG

31 What do you do? 1. Cry? 2. Call your senior resident/fellow? 3. Give metoprolol? 4. Give adenosine? 5. All of the above?

32 What do you do? 1. Cry? 2. Call your senior resident/fellow? 3. Give metoprolol? 4. Give adenosine? 5. All of the above?

33 Case 4-Adenosine

34 SVT

35 SVT-Retrograde P waves

36 WPW

37 SVT treatment Vagal maneuvers (with ECG) Adenosine (with ECG) 6mg, 12mg, central line if possible Beta-blockers/Ca channel blockers (on telemetry) Should use even if WPW known on baseline ECG Amiodarone (on telemetry) Procainamide (on telemetry) DCCV

38 Case 5-Two patients, same diagnosis

39 What is the diagnosis? 1. Artifact 2. Atrial flutter 3. Atrial tachycardia 4. Ventricular tachycardia

40 What is the diagnosis? 1. Artifact 2. Atrial flutter 3. Atrial tachycardia 4. Ventricular tachycardia

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42 Case 6 35 year old male with a history of nonischemic cardiomyopathy Presents with palpitations

43 Case 6

44 What is the diagnosis? 1. Atrial fibrillation 2. Atrial flutter 3. Sinus Tachycardia 4. Ventricular Tachycardia

45 What is the diagnosis? 1. Atrial fibrillation 2. Atrial flutter 3. Sinus Tachycardia 4. Ventricular Tachycardia

46 Case 6

47 Fusion beat

48 VT-Concordance

49 Fast VT

50 Paroxysmal RVOT VT

51 What to do? If hemodynamically unstable, ACLS/shock If hemodynamically stable, don t shock Call cardiology Amiodarone 150mg IV, then mg/min gtt Lidocaine 100mg IV, 1-4mg/min gtt Beta-blocker IABP Intubate/paralyze

52 PVCs

53 What to do? Most times, nothing if asymptomatic Beta-blocker first line if symptomatic Check labs? Usually normal Turn off telemetry? Reasonable

54 Polymorphic VT

55 Polymorphic VT Shock/ACLS Magnesium Get an ECG when not in VT Call cardiology Beta-blocker Isoproterenol Pacing Ischemia evaluation Avoid QT prolonging drugs (

56 VF

57 VF Shock Do chest compressions ACLS drugs Don t bother with an ECG

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59 Sinus bradycardia

60 Type I, 2 nd degree AV block (Wenckebach)

61 Case 7

62 This person should get a pacemaker 1. True 2. False

63 This person should get a pacemaker 1. True 2. False

64 2:1 AV block

65 Complete heart block

66 Slow escape rhythm

67 Regularized atrial fibrillation

68 Bradycardia Management Usually, HR <40bpm Is the patient symptomatic? Mental status changes, hypotension, angina, shock, heart failure Acute or chronic Are they sleeping? Do they have sleep apnea? Not everyone with bradycardia, even complete heart block, needs acute treatment if stable

69 Management Trancutaneous pacing (sedate) Atropine 0.5mg Q3-5min, max 3mg Avoid if cardiac transplant (may worsen block) Dopamine infusion Epinephrine infusion Isoproterenol infusion Glucagon if beta-blocker overdose Transvenous pacing (call cardiology)

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71 Conclusions You will be called (frequently) about arrhythmia issues Get an ECG If tachycardia, don t use hemodynamics to diagnose Wide or narrow, regular or irregular Cardioversion Beta-blockers, calcium channel blockers Amiodarone If bradycardia, where is the level of block? Are they symptomatic? Call cardiology for transvenous pacing

72 EKG's or other questions:

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