Arrhythmias FM Lecture Series

Alex Dworak July 2008

Needless photo of the author with his noponytails-until-youre-in-college son

The obligatory objectives slide

Review common and significant arrhythmias and EKG findings Focus on recognition, etiology, immediate and definitive management References: Uptodate, ECGlibrary.com

Basic principles of any arrhythmia

Is the patient stable or unstable? If unstable, call Code Blue and follow ACLS. If unsure, call a codeyoull get help fast, & the ICU team would rather have a fake code than a too-late code No palpable central pulse in the unstable patient means start CPR; a dopplerable pulse wont perfuse the brain If stable, stop and think. Call for help from your supervisor or staff. Check code labs (CBC, CMP, Mg/Phos, cardiac enzymes, blood cx) and get a 12 lead EKG. Consider calling Cards if appropriate. Make sure the wires are hooked up/its not artifact. The telemetry nurses usually recognize whats worth freaking out aboutdont tune them out.

VT (Ventricular Tachycardia)
A PVC is just a PVC, but 3 in a row is Vtach! Cause: MI, other structural disease, severe electrolyte change Immediate: If unstable, SHOCK! If stable (talking, maintaining BP), calmly call Cards while the pads are being attached; consider Amiodarone or Lidocaine bolus, head for the ICU or cardiac floor Definitive: May need AICD, especially if EF<35% to lower chance of sudden death

Normal/ Confidence Builder

Examine rate, rhythm (sinus or notP before every QRS?), axis (left thumb is I, right is AVFif both thumbs up, axis is normal, whereas a down thumb is deviated in the direction of that hand). Look at ST segments, width of QRS, check for Q waves, PR depression, weird P waves, flipped/peaked T waves or U waves, excess QT interval length Machine is good at rates and intervals; dont always trust its interpretation, though! We read the bottom of the EKG, not the top. Take advantage of Dr. ODells EKG sessions and practice on every EKG you get! (Same goes for Xrays!)

Too much digitalis

Atrial flutter
Cause: Non-conducted atrial beats, usually in structurally abnormal heart Characteristically 300 bpm Not always obvious; 2:1 aflutter (unlike the 16:1 previously) can be both occult and dangerous consider it with any narrow complex tachyarrhythmia with rate ~150 bpm Immediate: If unstable, shock. Otherwise, IV metoprolol 5 mg q5min x3 or IV diltiazem drip with bolus; esmolol gtt in ICU or verapamil are also considerations. Watch for hypotension. Definitive: Electric vs. drug cardioversion in consultation with Cards; may need clot prophylaxis

Ventricular Fibrillation
SHOCK! This and unstable VT should always be shocked. Make sure the leads are hooked up and the patient is actually unstable and pulseless before you hit the button Definitive: Let Cards and EP sort out the best management; stabilize and then get the patient to the ICU.

Torsades des pointes

Cause: MI, hypoK+, hypoMg++, long QT, drugs (antiarrhythmics, TCAs) Immediate: If unstable, shock! Empirically give 1-2 g IV Mg++ (careful if they have renal failurebut intubation is easier than reanimation) Definitive: Correct underlying cause, maybe ICD. Consult Cards.

Complete heart block with idioventricular escape rhythm

Cause: MI or other disruption of conducting system No relation of P to QRS Immediate: tele monitoring Definitive: Cards consult for EP workup and pacing

Acute anterior MI
Causes: thrombosis, drugs (cocaine, meth) Immediate: ACLS Definitive: Percutaneous stent vs. CABG depending on anatomy at cath and risk factors (i.e. DM) No beta blockers for coke abusers

Look for the P waves

2:1 AV block
Could be either Mobitz I (Wenke walks away) or Mobitz II (Moby falls down like he got kicked in the head?) Mobitz I has repetitively lengthening PR until the dropped beat, then resets Mobitz II just drops a beat suddenly; unstable and needs pacing Cant tell if its 2:1; assume its Mobitz II, put on telemetry and get Cards eval

Chest pain, got hypotensive with NTG in the ambulance.

Posterior MI
Usually not isolated; lateral involvement common ST depression in V1, V2 is actually inverted STEMI on the back of the heart in the RV Immediate: PRELOAD dependent, give lots of fluids (may need to intubate if theyve got LV involvement too) and the usual ACLS Definitive: same as any MI

Afib with RVR

Usually in the context of known afib Treatment is same as for aflutter: Immediate: If unstable, shock. Otherwise, IV metoprolol 5 mg q5min x3 or IV diltiazem drip with bolus; esmolol gtt in ICU or verapamil are also considerations. Watch for hypotension. Definitive: Electric vs. drug cardioversion in consultation with Cards; definitely needs clot prophylaxis unless a good reason not to

Credits, Suggested Reading

www.ecglibrary.com www.uptodate.com Pocket ACLS survival guide (must have, <$10 at bookstore) Pocket EKG survival guide Hursts The Heart or Braunwald if youre really gung-ho

Cake is the best!

Torsades des feet.

Completely unrelated video of (Christian) Taekwondo practitioners doing 540 tornado kicksyes, its totally useless in a real fight, but Id like to see any haters try one and not land on their faces. Separate (techno!) video of two credible Darth Maul impersonators