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Emergency Med: Lecture 5: Cardiovascular Emergencies

Dr. Agostini
8/24/2009 9:30am

First degree AV Block


• Rhythm: Regular
• P waves: Each P followed by QRS
• PR
– Prolonged (> 0.20 sec)
– Usually constant
QRS: Normal

Second degree AVB, Type I (Wenkebach)


• Rate
– Atrial: Unaffected
– Ventricular: Less than atrial  the QRS is dropped eventually
• Rhythm
– Atrial: Regular
– Ventricular: Irregular, progressive shortening of R – R before pause
• P waves: Normal
• PR: Progressive increase until P dropped
• QRS: Normal

Second degree AVB, Type II


• Rate
– Unaffected
– Ventricular: < atrial rate
• Rhythm
– Atrial: Regular
– Ventricular: Usually irregular, except with constant conduction ratio
• P waves: Normal
• PR: Normal or prolonged, but constant
• QRS
– Normal when at Bundle of His
– Wide when at bundle branch level

Second degree AVB, Type II w/ 2:1 conduction


Second Degree AVB, Type II w/ variable conduction  High grade block w/ 2 dropped
QRS complexes in a row. pt will be symptomatic, prob feeling like they are going to pass out

Third degree AV block (complete AVB)  atrial rate and ventricular rate are both constant but separate
• Rate
– Atrial: Unaffected
– Ventricular: < atrial rate
• AV nodal level block (40-60)
• Infranodal block (< 40)
• Rhythm
– Atrial: Usually regular
– Ventricular: Regular
• P waves: Normal
• PR: Will vary  varying, random lengths
• QRS
– AV node or Bundle of His: narrow QRS
– Bundle branch level: Wide QRS

P to P is constant and the distances b/w QRS complexes are constant


Pts will be symptomatic (light headed)

Treatment for AV blocks


• First degree: Symptomatic
• Second degree Type I: Symptomatic
• Second degree Type II: Pacemaker
• Third degree: Pacemaker
Atropine (max. 0.04 mg/kg) may be used (not usually for second degree type II)

PSVT (Paroxysmal supraventricular tachycardia)


Reentry mechanism, most often involving AV node alone or the AV node and an extra AV nodal bypass
tract. Can affect younger people and not last long, but can also be pathologic and require treatment. Pt will
complain of palpitations.
• Rate: Usually > 150
• P waves: Variable, but not discerned if they occur during QRS
QRS: Usually narrow
Can’t see the P waves  only T waves are shown
PSVT Treatment
• Stable: Vagal stimulation, adenosine, diltiazem, beta-blockers, cardioversion
• Vagal stimulation  lean forward and simulate bowel movement; dip head in ice water
• Adenosine will put back into sinus rhythm in a few seconds
• Cardioversion is used in stable pts when all other options fail
• Unstable: Cardioversion

Wide Complex Tachycardia


Diagnostic Considerations with Wide Complex Tachycardia
• VT vs. PSVT with aberrancy
• Improper treatment can complicate management
• Ventricular tachycardia has a grim prognosis
**It may look like Ventricular tachycardia or PSVT…if you don’t know what to call it, its wide complex
tachycardia
Treat all wide complex tachycardia like its V-tac because it has a much worse prognosis
Wide Complex Tachycardia Treatment
• Stable
– DC cardioversion or Amiodarone
• Unstable
– DC cardioversion

Wide Complex Tachycardia


Sinus Tachycardia
• Rate: > 100
• Rhythm: Regular
• P waves: Upright in 1, 2, aVF

Sinus tachycardia is VERY common  from exercise, medicine, acute injury, anxiety, etc.
Symptoms & Treatment ***Treat the underlying cause
• Pain: Analgesics
• Anxiety: Sedation
• Hemodynamic state: Beta blockers
• Hypovolemia: Volume replacement
• Myocardial damage: Hemodynamic monitoring and drug therapy

Sinus bradycardia
• Rate: < 60
• Rhythm: Regular
• P waves: Upright in 1, 2, aVF

Treatment
• If symptomatic, treat with atropine
• May need pacemaker

Pulseless Electrical Activity


• PEA is the presence of some type of electrical activity (other than VT or VF), but a pulse cannot be
detected by palpation of any artery.
• Any rhythm or electrical activity that fails to generate a pulse is PEA.
• Pt will be symptomatic  close to death
Treatment
• Search for and treat identified reversible causes
• Epinephrine 1 mg IVP, repeat q 3-5 min.
• Or vasopressin 40 U (1 dose to replace 1st or 2nd epi dose)
• Atropine 1 mg IV , repeat q 3-5 min. (3 doses)
• Use atropine if you think there may be a faint pulse
Causes of Pulseless Electrical Activity = H and Ts:
• Hypovolemia
• Hypoxia
• Hydrogen ion (acidosis)
• Hyper/hypokalemia
• Hypothermia
• Tablets (drug OD, accidents)
• Tamponade, cardiac
• Tension pneumothorax
• Thrombosis, coronary = MI
• Thrombosis, pulmonary (embolism)
A patient presents complaining of being lightheaded. You decide to administer an EKG. Based on the results,
which of the following would be the proper treatment?

Atropine
Epinephrine
Fluid replacement
Pacemaker
Adenosine

A 60 year old female presents complaining of heart palpitations and becomes unstable. Based on the following
EKG, which treatment would you administer?

Vagal stimulation
Adenosine
Diltiazem
Beta-blockers
Cardioversion

A 74 year old male presents to the ED and is unresponsive. An EKG was administered and showed a rhythm
but a pulse is unable to be palpated anywhere. You decide that the patient has pulseless electrical activity and
you are unable to identify a reversible cause. What would be your next course of treatment?
Epinephrine
Dilitazem
Vagal stimulation
Cardioversion
Defibrillation