Professional Documents
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Rhythm Disorders
Regular
Iregular
Regular
Iregular
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Irregular
Atrial fibrillation Atrial flutter with variable block.
Investigations:
12 lead ECG with rhythm strip BU/SE CXR Thyroid function 2DEcho ECG during sinus rhythm (atrial ectopics, short PR and Delta waves).
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Management
Compromised patient
Immediate Synchronized DC shock with 50J,100J, 200J, 360J (IV Diazepam 10 mg, under general anesthesia) If arrhythmia recurs consider anti- arrhythmic agents (IV Amiodarone).
Run continuous rhythm strip Insert 18 G venous cannula Keep ready a 20 ml syringe filled with normal saline. Give IV Adenosine through the cannula followed by normal saline flush. Dose: 3mg, 6 mg, 9mg, 12 mg , 15 mg,18mg Can be given using 3 way tap as well. Action:AV block.
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4. AV node blockers( oral or IV Digoxin) 5.Anti-Arrhythmic(IV Amiodarone) 6. Over drive pacing 7.Cardioversion
Management Objectives
Prevention of thrombo-embolic complications Rate control or Restoration of sinus rhythm.
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Chronic AF
Restoration of sinus rhythm(at least one attempt) by elective Cardioversion . Using:
Electrical Cardioversion (D.C. shock) Chemical Cardioversion.
Preparation:
4 weeks of prior anti- coagulation with Warfarin (INR-2-3.5)
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Electrical cardioversion
Synchronized D.C. shock at 100J, 200J, 360J. Under GA. Continue Warfarin for 4 more weeks. If D.C. shock unsuccessful give antiarrhythmics (Amiodaron,Sotalol),second attempt of D.C. shock later.
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Chemical Cardioversion.
If AF is more than 48 hours,consider anticoagulation for 4 weeks before and after CCV.Drug:IV Flecanide 2 mg /KG iv Advantages of CV:No long term anticoagulation,preserve atrial contribution to Ventricular filling. Failed CV: consider anticoagulation with rate or rhythm control drugs.
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Intermittent A.F.
Long term anticoagulation
for high risk patients (patients with a high risk of stroke: hypertension, DM, IHD, TIA, h/o. stroke, thromboembolism, >65 years, cardiac failure, significant valvular heart disease).
Warfarin (INR-2-3.5)
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Management
if compromised, D.C. shock indicated if not compromised: regular narrow/broad T.C.
I.V. Adenosine to block AV node I.V. Amiodarone to block AP.
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SVT
Slowed by vagal maneuvers Slowed or terminated by Adenosine Initiated by AE. P>V
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SVT
LBBBor RBBB Wolf-Parkinson-White (WPW) Syndrome
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Management
If compromised and arrhythmia continues
Immediate precordial thump / synchronized DC cardioversion (100J,200J,360J). Resuscitation if patient has cardiac arrest If no response
Antiarrhythmic drugs, over drive pacing,IV Mg
If recurs
consider antiarrhythmics, treat the cause if any.
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Not compromised
Good LV function-IV Lignocaine 100mg(50 mg if <50 kg) followed by infusion of Lignocaine
4mg /min for 30 min 2 mg/min for 2 hours 1mg/min for upto24 hours
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If episodes are brief and self terminated antiarrhythmic treatment is not indicated. Treat correctable factors if any (acute ischemia, electrolytes imbalance).
Ischemic VT
Consider prophylaxis if VT occurs after 48 hrs of MI. Beta blockers
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Investigations:
ECG after cardioversion, Cardiac enzymes, CXR, Holter monitoring, exercise testing, Echo, Serum K+, Mg++
Follow up
Treat correctable causes e.g For IHD revascularization. Long term prophylaxis if indicated EPS,Implantable Defibrillators Correct risk factors (DM,hypertension,Hyperlipidaemia)
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Ventricular Fibrillation
Leads to cardiac arrest
Immediate cardioversion and resuscitation Treat correctable causes Long term prophylaxis as in case of VT
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Torsades Pointes
Polymorphic VT, Axis twist around the base line, usually non- sustained and repetitive, can degenerate in to VF During SR- prolonged QT Causes:
Antiarrhythmic drugs(1a,1c,111) Elytes disturbances: K+, Mg++, Ca++ Antibiotics: Erythromycin Congenital long QT syndrome
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Management
Remove offending agent,
Temporary pacing,
Isopreneline IV (0.5-10 g/min) IV Mg
8 mmol over 15 min, 72 mg over 24 hours
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Non sustained VT
minimum of 3 beats reverted back spontaneously within 30 s. If symptomatic: Beta blockers, Amiodarone
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Bradyarrhythmias
Ventricular rate < 60 bpm. Categories of Bradyarrhythmias:
Sinus bradycardia, Sinus arrest/block, AV block (2nd, 3rd degree)
Causes:
Drugs, IHD, hypothyroidism
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Investigations
ECG with long rhythm strip,CXR,Thyroid function,Digoxin level,Cardiac enzymes.
Management:
Withhold offending drug, if any Asystole/pulseless bradycardiaresuscitation Sinus bradycardia ,AV block:IV atropin,IV Isoprenelin,Salbutamol compromised:Temporary pacing ,plan for permanent pacing
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