Arrhythmias

ECG Diagnosis Clinical Diagnosis

Diagnosis

Tachyarrhythmia Bradyarrhythmia Stable Unstable

Easy
Narrow, regular
Wide, regular
Narrow, irregular Complexicity of treatment
Wide, irregular
Hard
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Clinical Diagnosis
- Unstable when there is sign of shock.

Assess and look for signs of shock Example:

Brain: Altered mental status Unstable SVT
Heart: Ischemic chest discomfort Unstable Atrial
Lung: Bibasal crepitations dt HF Synchronised
fibrillation
Systemic: Hypotension Unstable Atrial flutter cardioversion
Extremities: Cold, clammy skin Unstable regular
: Capillary refilling(>2sec) monomorphic tachy with
: Weak, thready pulse pulses

Synchronised cardioversion
Narrow, regular : 50 J (eg Supraventricular tachycardia, atrial flutter)
Wide, regular : 100 J (eg Ventricular tachycardia)
Narrow, irregular : 120-150 J (eg Atrial fibrillation)
Wide, irregular: unsynchronized defib. 200 J (eg Ventricular fibrillation,
polymorphic VT)
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 Tachyarrhythmia

Wide Narrow

Regular Irregular Regular Irregular

Monomorphic Polymorphic VT
VT Torsades de pointes
Atrial
Sinus tachy Ventricular fibrillation
Sinus tachycardia fibrillation
with aberrant AF with BBB
Supraventricular Atrial flutter
conduction Atrial flutter with BBB &
tachycardia (SVT) with variable block
SVT with aberrant conduction
Atrial flutter Multifocal
aberrant conduction Multifocal AT with
atrial tachycardia
aberrant conduction
AF with aberrancy

*Differences between polymorphic VT and Torsades de pointes is the presence of 180º axis in Torsades.

Anti-arrhythmic infusion for STABLE WIDE-QRS If unstable, synchronized cardioversion

If regular, narrow complex, consider adenosine
Procainamide IV Dose (61212mg)
20-50mg/min until suppressed/hypotension/QRS Consult expert after third dose.
increase >50% (Max. 17mg/kg)
Maintenance infusion: 1-4mg/min
Atrial fibrillation
Avoid if prolonged QT or CHF
 Amiodarone
Amiodarone IV Dose
150mg over 10mins; repeat as needed if VT occurs  Must know duration of AF(> 48 hours)
Maintenance: 1mg/min over first 6 hours *pooling of blood in atriumclot atrial
Sotalol IV Dose contraction return emboli
100mg (1.5mg/kg) over 5 mins  Give IV heparin
Avoid if prolonged QT  Unstable AF cardioversion but must give IV
heparin if more than 48 hours; assess risk of
bleeding
ONLY SVT Risk of Bleeding (HASBLED)
Non-pharmacological  Hypertension(SBP>160)
 Valsava maneouvre via vagal activation  Abnormal RFT/LFT
 Carotid massage: Auscultate for carotid bruit first  Stroke
*TRO artherosclerosis  emboli  stroke  Bleeding tendencies/predispose
*Compress with thumb from angle of mandible  Labile INR
downwards along carotid artery against cervical spine  Elderly > 65 yrs old
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Pharmacological  Drugs/alcohol
 Adenosine (6mg  12mg  12mg )
*explain regarding possible chest pain,faint,heart block
After 3 doses, consult expert
Prepared by Leow Zhe Eu Group 4 Year 5 2014/2015
 Bradyarrhythmia

Wide Narrow

Regular Irregular Regular Irregular

Complete 2nd degree Sinus

Sinus bradycardia arrhythmia
AV block (with AV block
Junctional Sinus arrest
ventricular Morbitz I &
bradycardia Atrial
escape rhythm) II
Complete AV
Sinoventric Irregular fibrillation with
block (junctional slow ventricular
ular rhythm brady with BBB
escape rhythm) response
Regular Sinoatrial
Atrial flutter with
brady with exit block with BBB Atrial
high degree block fibrillation with
aberrancy/ BBB
variable block
*Any patient with sinus bradycardia and junctional bradycardia are hyperkalemia until proven otherwise

If stable, monitor and observe.

If unstable start atropine sulphate 0.5mg every 3-5 mins until a maximum of 3mg.
If ineffective, consider :- Transcutaneous pacing
- Dopamine infusion (2-10mcg / kg / min)
- Adrenaline infusion (2-10mcg / min)

Cardioversion and Defibrillation

Defibrillation: process of stunning the heart and restart the cardiac rhythm
: treatment of life-threatening arrhythmias with which patient does not have a pulse

Cardioversion: process to convert arrhythmia back to sinus rhythm

: delivered shock at lowest joule depending on each machine
: two types: Chemical and Electrical

Defibrillation Cardioversion
High dose of shock Lose dose of shock
Not synchronised Synchronised
Direct delivery of shock Wait for R-wave
High risk of injury Low risk of injury
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Prepared by Leow Zhe Eu Group 4 Year 5 2014/2015

 Monophasic and biphasic

Monophasic Biphasic
Current travel in one direction Current moves to +ve paddle and return
Once Occur several times
1 cycle every 10 millisecond
More burns Less burn
More myocardial injury Less myocardial injury
Single shock start at and repeat at 360 J Initial dose at 150-200 J and repeated at 150-360 J

Paddles vs Patches

Paddles Adhesive patches

Anterior patch/paddle placed below Right clavicle
Apical patch at the apex of the heart
Gels required Stick to the wall; no gels required
Requires at least 25lbs/11kg of pressure No pressure required
Poor ECG tracing Good ECG tracing

Type of defibrillators
1) Automated external defibrillator – No special training required
- Found in public places
- Analyse and deliver shock
- Cannot be override manually
- 10-20 second to determine arrhythmia
2) Semi-automated external defibrillator – Can be override and has ECG display
- Use by paramedics
- Ability to pace
3) Standard defibrillator with monitor
4) Transcutaneous or implanted

CREDITS
I would like to express our gratitude and appreciation to Dr Junainah for her guidance
and teachings throughout resuscitation week for Year 5 2014/2015.
Thanks to all who had assisted directly and indirectly.
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Prepared by Leow Zhe Eu Group 4 Year 5 2014/2015