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Emergency Medicine
Peri-arrest arrhythmias
Principles of treatment
Excessive Bradychardia
-absolute< 40/min and relative< 60/min on
pacients with low cardiac reserve
Signs of Heart Failure.
-acute pulmonary oedema, raised jugulars
venous pressure, hepatic engorgement
Chest pain
Treatment options
Bradychardia
Pacing
Tachycardia
Cardioversion
All arrhythmias
Anti-arrhythmic medication and other drugs
Cardiac Pacing
Safe method for treatment of bradychardia
Required a skillfull person for transvenous
pacing
Required is there is a risk of asystola ; instable
pacient ; not responding to atropine
Transcutaneous pacing – initiate immediately ,
use analgesia and sedation
Fist pacing- serial rhythmic blows 50- 70 / min
Cardioversion
Is used to convert atrial or ventricular
tachyarrythmias
Is used when patient is unstable or
deteriorating
– Medication is ineffective
Risk of inducting Ventricular Fibrillation !
– Shock must be syncronised with R wave
– Require analgesia and sedation
Cardioversion
First shock energies :
- Start with 200 J monophasic
(120-150 J biphasic ) – for broad
complex tachycardia and AF
-Start with 100 J monophasic (70-
120 J biphasic ) – paroxysmal SVT and
atrial flutter
Antiarrhythmic drugs
Could convert tachyarrhytmia
– Less secure then cardioversion
– Used on patients without severity signs
Used in first episode of bradychardia
– Less eficients in case of low cardiac output
All antiarrhytmic drugs can cause arrhytmia !
Bradycardia
Adverse signs ?
– Systolic BP < 90 mmHg
– Heart rate < 40 b/min
– Ventricular arrhytmias compromising BP
– Heart failure
If Yes – atropine 500 g i.v. and evaluate response
DO NOT GIVE atropine to patients with cardiac
transplants , it can cause a high degree AV block
or even sinus arrest
Bradycardia
IF
Satisfactory response -
NO adverse signs
Observe pacient
BRADYCARDIA
Tachyarrythmia
Yes! – stable/unstable?
Broad complex tachycardia
QRS >0,12s
Is patient stable?
– Sistolic BP< 90 mmHg
– Chest Pain
– Heart Failure
– Heart Rate > 150 /min
– Reduced Conscious level
No Yes
•Amiodarone 300mg iv •Seek expert help
over 10-20 min
• cardioversion 200J(120-150)
•Expert cardiology synchronised DC Shock up to
3 attempts
•Cardioversion
•Amiodarone 900 mg over 24 h
• Amiodarone 900 mg over
24 h
correct HipoK, give magnesium 2g over 10 min
Tachyarrythmia
No Yes
Antiarrythmics Cardioversion 100J (70-120J)
Amiodarone 300 mg iv 20-60 min
Narrow complex tachycardia
(PSVT)-Regular Seek help
Is patient stable?
Sistolic BP< 90 mmHg
No Chest Pain yes
Heart Failure
Heart Rate > 200 /min
Reduced Conscious
level
•Esmolol: 40 mg 1 min + piv 4 mg /min
or Cardioversion 100 J,
biphasic(70-120J)
•Verapamil 5-10 mg i.v.
or
•Amiodarone: 300 mg 20-60 min
or Amiodarone 300 mg in 20 min
•Digoxin: iv maximum 500 µg in 30 min x2 900 mg in 24h
•Repeat cardioversion
Post-resuscitation care
Return of spontaneos circulation ROSC
Hypoxia and hypercarbia –contribute
to secondary brain injury
Tracheal intubation, sedation and
controlled ventilation
Normocarbia Pa CO2
Normal PaO2
1. Australia
Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-
hospital cardiac arrest with induced hypothermia. N Engl J Med 2002;346:557-63.
2. Europa
The Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia
to improve the neurologic outcome after cardiac arrest. N Engl J Med
2002;346:549-56.
Mild therapeutic hypothermia (33°C in the first study and 32°C to 34°C in the
second) in survivors of out-of-hospital cardiac arrest.
Questions?