I.

II.
III.

IV.

Multifocal atrial tachycardia: irregular rhythm 100-180 see in COPD (acedimia)

a. 3 main criteria:
i. HR>100
ii. >=3 different p-wave morphologies
iii. PR interval will vary (3-5 boxes)
b. Perioperative managemet:
i. Mg Sulfate
ii. CCB

Atrial Flutter: an organized atrial rhythm 250-350 bpm with variying degrees of AV block
a. Ventricular rate 2:1 an atrial rate of 300 beats results in ventricular rate of 150
beats per minute.
b. Commonly associated to: pulmonary disease, ethanol
i. Ethanol intoxication,
ii. Thyrotoxicosis
iii. Acute MI
c. Perioperative management: if it occurs before induction postpone sx
i. Tx:
1. If present within 48 hours we give anticoagulants
2. If unstable
a. Cardioversion 50J (monophasic)
3. If stable:
a. Overdrive pacing
b. Control AV conduction (GOAL)!!!! These drugs control ventricular
rate.
i. Amiodorone
ii. Diltiazem
iii. Verapamil
Atrial fibrillation: no p waves. Occurs when multiple area of the atria continuously
depolarize and contract in a disorganized manner. There is no coordinated depolarization
or contraction, only a quivering of the atrial walls.
a. Occurs in association with atrial flutter
b. When extremely rapid ventricular response in excess of 180 bpm can cause VTACH
or V fib
c. CONDITIONS CAUSING THIS: BOLD MAIN CAUSE
i. Rheumatic heart disease, HTN
ii. Hyperthyroidism
iii. IHD
iv. COPD
v. ETOH
vi. Pericarditis

vii. PE
d. Symptomatic and vague: generalized weakness, fatigue, palpitations, angina, SOB,
orthopnea, hypotension.
e. Therapy goals for new-onset atrial fib include ventricular rate control and electrical
or pharmacologic cardioversion.
f. Control ventricular response
i. CCB (diltiazem and verapamil) reduce the ventricular rate during A FIB
ii. BB
iii. DIGOXIN monitor K and Mag lvls
g. Pharmacologic cardiovernsion is most effective if initiated within 7 days of the
onset
i. Amiodarone is best for patients with IHD and LV hypertrophy, HF
h. If appears before induction cancel sx
i. If during sx perform cardioversion at 100 to 200 J (biphasic)

VENTRICULAR DYSRHYTHMIAS
V.
PVC: that occur during approximately the middle of the third of the T wave may initiate
repetitive beats that can deteriorate into a sustained rhythm such as ventricular
tachycardia or V fib. This is known as RonT phenomenon.
a. Below AV node
b. !!!! Excessive caffeine, alcohol, and cocaine use can cause PVCs.
i. Also arterial hypoxemia, MI, cardiomyopathy, Dig toxicity low K and Low Mg
c. More than 3 PVCs= V tach
d. Common S/s: palpitations, fainting, syncome.
e. Tx: eliminate underlying cause. And have defib close by.
i. Beta blockers
ii. And AMIodarone only if Vtach
VI. Ventricular Tachycardia: HR is more than 120 bpm
a. TX with BB or CCB
b. Implantation of defibrillator for tx of drug-refractory V tach
c. Perioperative: VT or SVT need to undergo cardioversion immediatebly
i. 100 J (monophasic) and increase in increments of 50 to 100 J as necessary
d. Recurrent VT
i. Amiodarone 150 mg over 10 minutes.
ii. Can give as alternative drugs procainamide, sotalol, and lido
e. Pulseless VT requires CPR and immediate defib using 360 J
f. Torsade de pointes looks the same except change in amplitude
g. BEGIN READING AT PERIOPERATIVE MANAGEMENT
VII.
Ventricular fibrillation: most common cause of sudden death
a. Associated with IHD
b. Implant pacemaker

c. There is never a pulse or blood pressure with V fib if patient is awake.reevaluate.

There is no SV or CO
VENTRICULAR PREEXCITATION SYNDROMES
VIII.

IX.
X.
XI.
XII.
XIII.
XIV.
XV.

Wolff-parkinson-white syndrome HR 100-200 Can Cardiovert

a. Is a form of SVT heart doesnt work this way.the electrical signal reenters the
atria in an abnormal pathwayand this signal disturb timing of ventricles and atria
and beat too fast
b. There is a slurring upstroke at the beginning of of the QRS
c. Common with patients with ebstein malformation of the tricuspid valve.
d. S/S: Paroxysmal palpitations with or without dizziness, syncope, dyspnea, or angina
pectoris
e. Initial manifestion of WPW occurs during pregnancy in women.
f. Ventricular preexcitation causes an earlier than normal deflection of the QRS
complex called a delta wave. Delta waves mimic the Q waves of a myocardial
infarction.
g. Orthodromic (narrow QRS complex) impulse returns from accessory pathway
h. Antidromic (wide QRS complex) impulse returns from AV node
i. STABLE ORTHODROMIC: tx with vagal maneuvers such as carotid sinus massage or
valsalvas maneuver. Then Adenosine, verapamil BB, or amiodarone
i. Catheter ablation
j. Antidromic form of AVNRT, the cardiac impulse is conducted from the atrium to the
ventricle thorugh the accessory pathway and returns from the vetnricles to the
atria via the normal AV node.
i. Tx: procainamide which slows conduction through accessory pathway
k. TREATMENT/PERIOPERATIVE:
i. Electrical cadrioversion indicated if not controlled with drug therapy
ii. Long term treatment: radiofrequency catheter ablation of the accessory
pathway. The procedure is curative in 95% of patients and has a low
complication rate.
iii. GOAL OF ANESTHESIA: is to avoid any event (Increase HR) or drug (Dig,
verapamil) that could enhance anterograde conduction of cardiac impulses
through an accessory pathway.
Prolonged QT syndrome:
Sinus Bradydysrhythmias
Junctional rhythm
1st degree heart block
2nd degree heart block
a. Mobitz type I
b. Mobitz type II
rd
3 degree heart block
Bundle Branch Block
a. Right bundle branch
b. Left bundle branch