Professional Documents
Culture Documents
Arritmias en
Reanimacin
Jueves 11 de septiembre
SALONES 5 y 6
Objetivos
Contexto
Definiciones
Identificacin electrocardiogrfica
Manejo
Contexto
100
75
75-84%
54
ECGs
50
25
>50%
Asystole
3
59
Rate: None
TV Monomrfica
54
ECGs
57
Fibrilacin Ventricular
ECGs
amplitude
The
as a possible
Clinical Tip: Consider electrolyte abnormalitiesactivity
fibrillation as coarse, medium, or fine.
Torsade de Pointes
de Pointes
Torsade
or absence of pulses because
the presence
Clinical Tip: It is important to confirm
monomorphic VT may be perfusing or nonperfusing.
The QRS reverses polarity and the strip shows a spindle effect.
VF ororunstable
deteriorate
VT will
if sustained
Tip:isMonomorphic
This
Clinical
intervals.
long QTVT
normal
VT withinto
polymorphic
ofprobably
an unusual variant
rhythm
not treated.
the term means twisting of the points.
and
In French
56
55
ECGs
Monitor shows
and electrolyte
interval
QTpulse
that prolong
drugs rhythm,
causes are
Tip: Frequent
Clinical
atrial, junctional, or ventricular in origin.
be sinus,
abnormalities
Rhythm may such
as hypomagnesemia.
PEA is also called electromechanical dissociation (EMD).
Rate: Indeterminate
Rhythm: Chaotic
P Waves: None
PR Interval: None
QRS: None
AESP
Clinical Tip: There is no pulse or cardiac output. Rapid intervention is critical. The longer the
delay, the less the chance of conversion.
Asystole
Electrical activity in the ventricles is completely absent.
Rate, rhythm, P waves, P-R interval, and QRS: Reflect underlying rhythm.
ECGs
Clinical Tip: Potential causes of PEA are pulmonary embolism, MI, acidosis, tension
pneumothorax, hyper- and hypokalemia, cardiac tamponade, hypovolemia, hypoxia,
hypothermia, and drug overdose (i.e., cyclic antidepressants, beta blockers, calcium channel
blockers, digoxin).
59
Asistolia
ECGs
TV Polimrfica
58
1
Iniciar RCP
-Oxgeno
-Monitorizacin
Si
Ritmo desfibrilable?
No
FV/TVsP
Asistolia / AESP
Pulseless Electrical Activity (PEA)
-Acceso IV/IO
TVM
54
Ritmo desfibrilable?
RCP 2 min
10
Clinical Tip: Always confirm asystole by checking the ECG in two different leads. Also,
search to identify underlying ventricular fibrillation.
Clinical Tip: Seek to identify the underlying cause as in PEA.
RCP 2 min
Ritmo desfibrilable?
Si
Si
No
11
ECGs
57
Rate: None
Rhythm: None
P Waves: None
PR Interval: None
QRS: None
No
Clinical Tip: There is no pulse or cardiac output. Rapid intervention is critical. The longer the
delay, the less the chance of conversion.
Clinical Tip: Potential causes of PEA are pulmonary embolism, MI, acidosis, tension
pneumothorax, hyper- and hypokalemia, cardiac tamponade, hypovolemia, hypoxia,
hypothermia, and drug overdose (i.e., cyclic antidepressants, beta blockers, calcium channel
blockers, digoxin).
Ritmo desfibrilable?
Rate: Indeterminate
Rhythm: Chaotic
P Waves: None
PR Interval: None
QRS: None
ECGs
TdP
Rate, rhythm, P waves, P-R interval, and QRS: Reflect underlying rhythm.
Asistolia
Si
de Pointes
Torsade
or absence of pulses because
the presence
Clinical Tip: It is important to confirm
monomorphic VT may be perfusing or nonperfusing.
The QRS reverses polarity and the strip shows a spindle effect.
VF ororunstable
deteriorate
VT will
if sustained
Tip:isMonomorphic
This
Clinical
intervals.
long QTVT
normal
VT withinto
polymorphic
ofprobably
an unusual variant
rhythm
not treated.
the term means twisting of the points.
and
In French
Rate: 100250 bpm
Rhythm: Regular or irregular
P Waves: None or not associated with the QRS
PR Interval: None
QRS: Wide (!0.10 sec), bizarre appearance
Ventricular Fibrillation (VF)
Clinical Tip: It is important to confirm the presence or absence of pulses because
or nonperfusing.
perfusing
be
may
VT
polymorphic
no ventricular depolarization or contraction.
Chaotic electrical activity occurs with
fibrillatory activity
of the
used to define the type of
and frequency
can be etiology.
The amplitude
as a possible
abnormalities
electrolyte
Tip: Consider
Clinical
fibrillation as coarse, medium, or fine.
No
Asystole
Electrical activity in the ventricles is completely absent.
56
55
ECGs
TVP
FV
AESP
RCP 2 min
59
ECGs
ECGs
RCP 2 min
-Adrenalina 3-5 min
-Monitorizacin avanzada
RCP 2 min
-Adrenalina 3-5 min
-Monitorizacin avanzada
Ritmo desfibrilable?
12
No
No hay ROSC? Pasar a 10 u 11
Hay ROSC ? Cuidados post RCP
Si
Pasar a 5 7
Definiciones
Taquicardia Ventricular
15%
<5%
Preexcitacin
<1%
Marcapaso ventricular
Antiarrtmicos, Hiperkalemia
Wellens
criteria of BCT
E 100% S
E 100% S
Diagnsticos
R monofsica V1
QS V6
RS 100 ms
R monofsica V1
S mayor que R en V6
Sin pulso
Debo asumir TV
(a)
TVm
(b)
TVp
(c)
TdP
Figure 30.9 (a) Monomorphic VT. (b) Polymorphic VT. (c) Polymorphic
VT with undulating pattern, suggestive
of torsade
deAcute
pointes.
Brady. Critical Decisions
in Emergency and
Care Electrocardiography 2009
Reprinted from Hudson KB et al. Electrocardiographic manifestations:
This EGG was recorded in a coronary care unit from a patient admitted 2 h previously with an acute anterior
myocardial infarction. The patient was cold and clammy, and confused, and his blood pressure was unrecordable. What
does the ECG show and what would you do?
TDP
FIGURE 26-13 Torsades des pointes. This rhythm strip demonstrates the initiation of
torsadesECG
des pointes
by a series ofMEDICINE
ectopic beatsAND
that begin
withCARE 2005
ROSEN.
IN EMERGENCY
ACUTE
a premature ventricular beat or salvo of ventricular beats, followed by a pause, and then a supraventricular beat. Another premature ventricular beat arrives at
a relatively short coupling interval and falls on the preceding T wave, precipitating the rhythm. The baseline corrected QT interval was 0.64 sec.
126
FIGURE 26-14 Polymorphic ventricular tachycardias with hypokalemia. Paroxysms of multifocal ventricular ectopy are seen in this ECG from a patien
with a serum potassium of 1.9 mEq/dL. Note the ST segment depression and giant U waves (arrows).
ROSEN. ECG IN EMERGENCY MEDICINE AND ACUTE CARE 2005
TVP
V5
FIGURE 8-11 Irregular tachydysrhythmias with aberrancy. Atrial fibrillation with left bundle branch block demonstrating an irregular, wide-complex
tachycardia.
FIGURE 8-12 Preexcited atrial fibrillation (AF). ECG and rhythm strip demonstrate AF with preexcitation and conduction down the accessory pathway, pro-
ducing runs of rapid, irregular, wide-complex tachycardia. Note the intermittent narrow QRS complexes resulting from occasional normal AV conduction (arrows).
FA Y WPW
FIGURE 25-6 Orthodromic reentry tachycardia. This electrocardiogram shows orthodromic reentry tachycardia with a rate of approximately 250 bpm.
This rhythm exhibits regular, narrow complexes and the absence of discernible P waves.
FIGURE 25-7 Antidromic reentry tachycardia. This electrocardiogram shows antidromic reentry tachycardia with a rate of approximately 300 bpm. Note
the wide-complex regular tachycardia.
TMCA
FIGURE 26-11 Ventricular tachycardia. The QRS complex width is greater than 140 msec in lead V1, which is positive. The axis is superior with no
RS complexes seen in the precordial leads.
FIGURE 26-12 Right ventricular outflow tract ventricular tachycardia (VT). This rhythm strip demonstrates right ventricular outflow tract VT with
typical left bundle branch block morphology and right inferior axis.
TV TSVD
Definiciones
Fibrilacin Ventricular
BOX 19-2
A 50-year-old man who had come to the A & E department with chest pain, collapsed while his EGG was
being recorded. What happened and what would you do?
Hampton. ECG problems 2003
Figure 16-20. Accelerated idioventricular rhythm (AIVR) in a patient with an acute inferior wall infarction. The first four beats
show the typical pattern, followed by a return of sinus rhythm, then the reappearance of the AIVR. Notice that the fifth, sixth, twelfth,
and thirteenth QRS complexes are fusion beats because of the nearly simultaneous occurrence of a sinus beat and a ventricular
beat.
78
VT
AIVR
II
Figure 16-21. Accelerated idioventricular rhythm (AIVR) and nonsustained polymorphic ventricular tachycardia (VT) occurring
together. Notice the VPB on T beats that initiate both the AIVR and the VT episodes. VPB, ventricular premature beat.
VT
VF
Ventricular Fibrillation
gure 19-2. Ventricular tachycardia (VT) and ventricular fibrillation (VF) recorded during cardiac arrest. The rapid sine wave typ
Coarse VF
Fine VF
Coarse VF
Figure
16-22.
Ventricular
fibrillation
(VF)
may produce
both
coarse and
fine waves. pattern
Immediate
defibrillation
should be
Figure
19-3.
Complete
ventricular
standstill
(asystole)
producing
a straight-line
during
cardiac arrest.
performed.
ECG148The houseofficer from the health care of the elderly ward is puzzled by this ECG and asks for your help.
What questions would you ask him?
Interferencia
Monitor lead
T-U
T-U
Figure 30.5 Polymorphic ventricular tachycardia. The rate is extremely rapid, with changing QRS morphologies and axis.
Monitor lead
155
Torsades de pointes
Torsades
de Pointes: Nonsustained
Figure 16-17. Notice the shifting polarity and amplitude of the QRS complexes during an episode of nonsustained torsades de
pointes. QT(U) prolongation (0.52 sec) is also present in the supraventricular beats (possible underlying atrial fibrillation).
T-U
T-U
Monitor lead
Torsades
de Pointes:
Sustained
Torsades
de pointes
Figure 16-17. Notice the shifting polarity and amplitude of the QRS complexes during an episode of nonsustained torsades de
pointes. QT(U) prolongation (0.52 sec) is also present in the supraventricular beats (possible underlying atrial fibrillation).
Figure 30.6
Torsade de pointes. The rhythm is initiated by an R-on-T phenomenon. The rate is extremely fast, with changing QRS morphologies and
Monitor
lead
axis. The QRS complexes change smoothly in amplitude, giving the appearance they are twisting around a central axis.
Figure 16-18. Classic pattern of the sustained torsades de pointes type of ventricular tachycardia. Notice the pattern of beats in
which the QRS axis appears to rotate or turn in a systematic way. Figure 16-17 shows a short, nonsustained run of the same arrhythmia, which occurs in the setting of QT(U) prolongation.
Definiciones
15:20:27
HR 160
ms 375
V
160
375
V
:
156
382
V
163
367
V
163
367
V
160
375
163
367
V
160
375
V
166
359
163
367
V
163
367
V
166
359
166
359
V
166
359
V
166
359
V
166
359
166
359
V
166
359
V
102
585
137
437
V
128
468
V
15:21:23
HR 103
ms 578
102
585
70
851
72
828
76
781
99
601
108
554
103
578
76
781
76
789
76
789
85
703
Definiciones
Asistolia
Asystole
R
179
B
C
DC shock given
D
R
1 sec
5H!
5T!
Hipovolemia
Hipoxemia
Hiperkalemia
Hipotermia
Hidrogeniones
Trombosis miocrdica
TEP
Taponamiento
Tensin Neumo
Txicos /Tablets
aVF
III
V3
V6
5H!
Hipovolemia
V1
Hipoxemia
Hiperkalemia!
Hipotermia
II
Hidrogeniones
Figure 35.6 Mild hyperkalemia. Peaked T waves are present, but the P waves and intervals are normal.
aVR
V1
V4
II
aVL
V2
V5
III
aVF
V3
V6
Figure 35.7 Severe hyperkalemia. Peaked T waves, flattened P waves with PR segment prolongation, and marked QRS widening are all evident.
5H!
Hipovolemia
35.qxd 10/17/08 7:08 PM
Hipoxemia
Hiperkalemia!
Hipotermia!
Hidrogeniones
Page 309
aVR
V1
V4
II
aVL
V2
V5
III
aVF
V3
V6
| 309
Figure 35.8 Hypothermia. Upward deflections at the terminal portion of the QRS complexes, termed Osborn waves or J waves, are noted. These
5T!
Trombosis miocrdica!
TEP
Taponamiento
Tensin Neumo
Txicos /Tablets
aVR
V1
V4
II
aVL
V2
V5
III
aVF
V3
V6
Figure 37.2 ECG demonstrating significant ST segment elevation in leads I, aVL, and V2V5 with reciprocal ST segment depression in leads III and
aVF consistent with a large anterior MI.
FIGURE 59-4 Global T wave inversion. This patient was thought to have had a nonQ wave myocardial infarction because of the presence of this pattern
along with elevated troponin levels. Pulmonary embolism turned out to be the lone culprit.
Txicos /Tablets
aVR
V1
V4
II
aVL
V2
V5
III
aVF
V3
V6
Figure 35.11 Electrical alternans in a patient with a large pericardial effusion. Beat-to-beat variation in the amplitude of the QRS complexes is
5T!
Trombosis miocrdica
TEP
Taponamiento
Tensin Neumo
Txicos /Tablets
aVR
V1
V4
II
aVL
V2
V5
III
aVF
V3
V6
V1
II
V5
Figure 35.9 Tricyclic antidepressant overdose. The classic findings of tachycardia, rightward axis, prominent S wave in lead I (large arrow) and tall R
1
Iniciar RCP
-Oxgeno
-Monitorizacin
Si
Ritmo desfibrilable?
FV/TVsP
3
4
No
Asistolia / AESP
RCP 2 min
-Acceso IV/IO
Ritmo desfibrilable?
No
Si
5
6
10
RCP 2 min
RCP 2 min
No
Ritmo desfibrilable?
Ritmo desfibrilable?
Si
Si
No
11
8
RCP 2 min
-Adrenalina 3-5 min
-Monitorizacin avanzada
RCP 2 min
-Adrenalina 3-5 min
-Monitorizacin avanzada
Ritmo desfibrilable?
12
No
No hay ROSC? Pasar a 10 u 11
Hay ROSC ? Cuidados post RCP
Si
Pasar a 5 7
Conclusiones