Arrhythmias. Alex Nesbitt Marcus Warriner

Transcription

1 Arrhythmias Alex Nesbitt Marcus Warriner

2 Objectives To develop a system for approaching arrhythmias To be able to diagnose common arrhythmias by ECG To understand the management of common arrhythmias

3 What is an Arrhythmia? A disruption in the normal pattern of cardiac conduction Can be fast (tachyarrhythmias) or slow (bradyarrhythmias)

4 A System for Approaching Arrhythmias Is the rate fast or slow? What do the QRS complexes look like? Broad = Ventricular Narrow = Supraventricular Is the rhythm regular or irregular?

5 Mr A is a 62 year old man who was admitted to the coronary care unit yesterday with an anterior myocardial infarction. The alarm on his cardiac monitor alerts you to the following rhythm:

6 What is the single most appropriate action to take? A. Administer amiodarone B. Administer adrenaline C. Administer metoprolol D. Check Mr As pulse E. DC cardioversion

7 Remember your ABC!

8 Management of Sustained Ventricular Tachycardias How compromised is my patient? Moderately Severely Pulseless/Arrested Amiodarone IV & Magnesium Sulphate IV DC Cardioversion ALS Protocol

9 ALS Protocol

10 Miss B is a 19 year old medical student who has palpitations. She is asthmatic. Her ECG is below:

11 What is the single most appropriate intervention? A. Adenosine B. Amiodarone C. DC Cardioversion D. Metoprolol E. Verapamil

12 Supraventricular Tachycardias Regular Atrioventricular re-entrant tachycardia (AVRT) Atrioventricular nodal re-entrant tachycardia (AVNRT) Atrial Tachycardia Atrial Flutter Irregular Atrial Fibrillation

13 Managing AVRT and AVNRT Is my patient compromised? Yes No DC Cardioversion Vagal Manoeuvres Adenosine (6mg bolus) Verapamil Warn your patient: Nausea Flushing Chest Pain Limb heaviness Sense of impending doom

14 Mrs Smith is a 47 year old woman with palpitations, dyspnoea and chest pain. Her observations are as follows: HR 115, BP 120/80, T 38.4, RR 20, Sp02 92% (room air). Her ECG is below:

15 What is the single most likely cause for the rhythm shown on the ECG? A. Haemochromatosis B. Hypertension C. Infective Endocarditis D. Lower Respiratory Tract Infection E. Rheumatic Heart Disease

16 Causes of Atrial Fibrillation Common Ischaemic Heart Disease, Heart Failure, Thyrotoxicosis, Hypertension, LRTI, Mitral Valve Disease, Caffeine, Alcohol, PE, Low Potassium, Low Calcium, Post-op Less Common/Rare Cardiomyopathy, Sick Sinus Syndrome, Endocarditis, Constrictive Pericarditis, Sarcoid, Lung Cancer, Atrial Myxoma, Haemochromatosis

17 What is the single most appropriate intervention? A. DC Cardioversion & Heparin B. Digoxin C. Flecainide D. Metoprolol E. Verapamil

18 Management of Atrial Fibrillation Is my patient compromised? Yes DC Cardioversion & Heparin No Have their symptoms lasted for more than 48 hours? Is the arrhythmia related to an underlying condition? Rate Control Beta-blocker/CCB Or Digoxin/Amiodarone Rhythm Control Flecainide/Sotalol Or Amiodarone

19 Mr Jones, an 80 year old man presents with a three day history of palpitations. Seven years ago, he had a TIA. Observations are normal and physical examination reveals an irregularly irregular pulse. His ECG is below:

20 What is the single most appropriate intervention to control his heart rate? A. Amlodipine B. Flecainide C. Atenolol D. Digoxin E. Amiodarone

21 You have controlled Mr Jones heart rate successfully. What is the single most appropriate anticoagulation regimen for him? A. Aspirin B. Low Molecular Weight Heparin C. No anticoagulation D. Unfractionated Heparin E. Warfarin

22 Anticoagulation C Hx of congestive heart failure H Hx of hypertension A Age > 75 years D Diabetes? S2 - Prev Stroke/TIA 0 = Low Risk = None or Aspirin 1 = Moderate Risk = Aspirin or Warfarin 2+ = High Risk = Warfarin (INR 2-3)

23 Mrs D is a 70 year old lady who has collapsed at church. She has a history of ischaemic heart disease, hypothyroidism and depression. Her ECG is below:

24 Which single one of her medications resulted in her ECG findings? A. Amitriptyline B. Aspirin C. Clopidogrel D. Levothyroxine E. Simvastatin

25 Drugs that Prolong the QT Interval Amiodarone Macrolides Citalopram Amitriptyline Domperidone Haloperidol Chloroquine Flecainide

26 Torsades de Pointes

27 Mr S is a 63 year old man who presents to A&E having had an episode of syncope. Physical examination and blood tests are unremarkable. His ECG is below:

28 What is the single diagnosis on the ECG? A. First Degree Atrioventricular Block B. Mobitz Type II Atrioventricular Block C. Sinus Bradycardia D. Third Degree (complete) Atrioventricular Block E. Wenckebach Rhythm

29 Bradycardias

30 Causes of Different Bradycardias Sinus bradycardia Physical fitness, sick sinus syndrome, vasovagal attacks, acute MI, drugs, hypothyroidism, hypothermia, high intracranial pressure First/Second Degree Atrioventricular Block Normal variant, sick sinus syndrome, athletes, acute carditis, ischaemic heart disease, drugs (digoxin/beta blockers) Third Degree (Complete) Atrioventricular Block Idiopathic (fibrosis), congenital, ischaemic heart disease, aortic valve calcification, cardiac trauma/surgery, infiltration, digoxin toxicity

31

32 Objectives To develop a system for approaching arrhythmias To be able to diagnose common arrhythmias by ECG To understand the management of common arrhythmias

33 Any Questions?

34 Sources Oxford Handbook of Clinical Medicine