1 Cardiology Acute Care Day 22 April 2013 Arrhythmia Tutorial Course Material
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1 1 Cardiology Acute Care Day 22 April 2013 Arrhythmia Tutorial Course Material Arrhythmia recognition This tutorial builds on the ECG lecture and provides a framework for approaching any ECG to allow the rhythm to be determined. The tutorial also provides a simple classification of common arrhythmias. During the tutorial examples of each rhythm will be broken down using the same approach and the basis of the ECG appearances will be explained. The tutorial will also introduce a treatment strategy for arrhythmias. 1) An approach to the diagnosis of an arrhythmia from the ECG Any rhythm can be determined by asking five simple questions: Are the QRS complexes NARROW or BROAD? If so, what is the P: QRS relation? By systematically applying this approach to each ECG you see, you will: Reduce the chances of missing something important Get good at ECGs more quickly Count the number of large boxes between each R wave 300/ this number = rate in bpm Normal bpm Fast > 100bpm Slow < 60bpm Are the QRS complexes NARROW or BROAD? Narrow 120ms (three small squares) A narrow QRS complex means that ventricular activation has occurred using the normal specialised conducting system (His-Purkinje system) Broad > 120ms A broad QRS complex means either: There is an abnormality in the His-Purkinje system (e.g. bundle branch block) or
2 2 Cardiology Acute Care Day 22 April 2013 Arrhythmia Tutorial Course Material P waves = atrial activation If so, what is the P: QRS relation? 2) Normal sinus rhythm Activation of the ventricle did not occur using the His-Purkinje system (e.g. accessory pathway, ventricular origin) One P wave for each QRS complex implies normal conduction of the impulse from atrium (A) to ventricle (V) If there are P waves, but the relation to the QRS complexes is not 1:1 then there is some abnormality of AV conduction (e.g. heart block, AV dissociation) Impulse arises in SAN, where the cells have intrinsic regular automaticity at bpm Impulse spreads through the atria, producing a P-wave Impulse is delayed at the AVN, producing the PR interval Impulse is conducted through the AVN, Bundle of His, L/R bundle branches and Purkinje fibres to depolarise the ventricular tissue efficiently, giving a narrow QRS complex Each atrial activation is conducted to the ventricle, meaning that the P: QRS is 1: bpm Are the QRS complexes NARROW or BROAD? Narrow If so, what is the P: QRS relation? 1:1
3 3 Cardiology Acute Care Day 22 April 2013 Arrhythmia Tutorial Course Material 3) Bradyarrhythmias Classification of bradyarrhythmias is according to origin: i) Sinus bradycardia ii) Junctional bradycardia iii) Heart block or atrioventricular block Arises from AV node (sometimes called AV junction) Delay or failed conduction at AVN causes slow heart rate Categories of AV block (in order of increasing severity) First degree AV block Second degree AV block Mobitz type I (Wenckebach) Mobitz type II Third degree (complete) AV block Understanding of bradyarrhythmias requires understanding of the pacemaker hierarchy in the heart. Most cardiac cells are capable of intrinsic automaticity, but some (SAN cells) are better (faster) than others (V cells). Essentially, the fastest impulse will dominate. Under normal circumstances, the SAN has the fastest intrinsic automaticity and so suppresses the activity of other cells (which never get long enough to generate an AP of their own as they are conducting SAN derived APs) BUT if something happens to the SAN impulse, then the next fastest will take over (an escape rhythm). As non-san cells are not specialised pacemaker cells, this is not a perfect safety net, meaning that the escape rhythm can be very slow. i) Sinus bradycardia Impulse arises in SAN, where the cells have decreased automaticity at < 60bpm Impulse spreads through the atria, producing a P-wave Impulse is delayed at the AVN, producing the PR interval
4 4 Cardiology Acute Care Day 22 April 2013 Arrhythmia Tutorial Course Material Impulse is conducted through the AVN, Bundle of His, L/R bundle branches and Purkinje fibres to depolarise the ventricular tissue efficiently, giving a narrow QRS complex Each atrial activation is conducted to the ventricle, meaning that the P: QRS is 1:1 < 60bpm Are the QRS complexes NARROW or BROAD? Narrow If so, what is the P: QRS relation? 1:1 ii) Junctional bradycardia There is no impulse arising from the SAN There is therefore no impulse spreading through the atria, so no P-wave The AVN cells also have intrinsic automaticity, but at a slower rate than SAN cells (~40-50bpm). In the absence of the normal overdrive (faster) impulse from the SAN, the AVN cells are spontaneously active. The impulse is conducted through the AVN, Bundle of His, L/R bundle branches and Purkinje fibres to depolarise the ventricular tissue efficiently, giving a narrow QRS complex < 60bpm Are the QRS complexes NARROW or BROAD? Narrow No If so, what is the P: QRS relation? N/A no P-waves iii) AV block a) First degree AV block This does not cause bradycardia in itself, but will be considered here as when first degree AV block is seen with other conduction abnormalities it indicates a higher chance of progression to more severe AV block Impulse arises in SAN Impulse spreads through the atria, producing a P-wave
5 5 Cardiology Acute Care Day 22 April 2013 Arrhythmia Tutorial Course Material Impulse is delayed for longer than normal at the AVN, producing a prolonged PR interval Impulse is conducted through the AVN, Bundle of His, L/R bundle branches and Purkinje fibres to depolarise the ventricular tissue efficiently, giving a narrow QRS complex Each atrial activation is conducted to the ventricle, meaning that the P: QRS is 1:1 Usually normal Are the QRS complexes NARROW or BROAD? Narrow If so, what is the P: QRS relation? 1:1 but PR interval > 200ms b) Second degree AV block Mobitz type I / Wenckebach Impulse arises in SAN and spreads through the atria, producing a P-wave On consecutive beats the impulse is delayed for increasing periods of time producing a progressive prolongation of the PR interval Periodically the AV delay is so profound that impulse conduction through the AVN fails completely and no QRS complex follows that P-wave < 60bpm No Are the QRS complexes NARROW or BROAD? Narrow If so, what is the P: QRS relation? PR interval prolongs before a dropped beat Mobitz type II AV block Impulse arises in SAN and spreads through the atria, producing a P-wave Some beats conduct normally but intermittently AV conduction fails completely and no QRS complex follows that P-wave (the severity is determined by the number of non conducted beats for each conducted beat)
6 6 Cardiology Acute Care Day 22 April 2013 Arrhythmia Tutorial Course Material < 60bpm No Are the QRS complexes NARROW or BROAD? Narrow If so, what is the P: QRS relation? Not 1:1 c) Third degree AV block / complete heart block Impulse arises in SAN and spreads through the atria, producing a P-wave AV conduction fails completely and so there is no QRS complexes related to the P-wave In the absence of overdrive suppression from a supraventricular rhythm, tissues distal to the AVN become spontaneously active, producing an escape rhythm, which is seen as QRS complexes which are not related to the P-waves The rate and appearance of the escape rhythm depends on its origin: AVN (junctional) = Narrow ~ 40-55bpm His/bundle branch = BBB pattern ~ 40-50bpm Ventricular = Broad ~ 30-40bpm Are the QRS complexes NARROW or BROAD? If so, what is the P: QRS relation? < 60bpm No Either (usually broad) No relation
7 7 Cardiology Acute Care Day 22 April 2013 Arrhythmia Tutorial Course Material 4) Tachyarrhythmias The most practical classification of tachyarrhythmias is ECG appearance: Narrow complex Regular Irregular Broad complex Regular Irregular Sinus tachycardia Supraventricular tachycardia Atrial flutter Atrial tachycardia Atrio-ventricular re-entrant tachycardia (AVRT) Atrio-ventricular nodal re-entrant tachycardia (AVNRT) Atrial fibrillation with rapid ventricular response Ventricular tachycardia SVT with aberrant conduction (i.e. BBB) AF with rapid ventricular response and aberrant conduction (BBB) i) Regular narrow complex tachycardias a) Sinus tachycardia Impulse arises in SAN, where the cells have increased automaticity at > 100bpm Impulse spreads through the atria, producing a P-wave Impulse is delayed at the AVN, producing the normal PR interval Impulse is conducted through the AVN, Bundle of His, L/R bundle branches and Purkinje fibres to depolarise the ventricular tissue efficiently, giving a narrow QRS complex Each atrial activation is conducted to the ventricle, meaning that the P: QRS is 1:1 >100bpm Are the QRS complexes NARROW or BROAD? Narrow If so, what is the P: QRS relation? 1:1
8 8 Cardiology Acute Care Day 22 April 2013 Arrhythmia Tutorial Course Material b) Supraventricular tachycardia Impulse arises above the AVN at an increased rate either due to: An abnormally fast atrial focus (atrial tachycardia) An atrial re-entry circuit (atrial flutter) An atrio-ventricular re-entry circuit (via an accessory pathway, AVRT) An AVN re-entry circuit (ANVRT) Impulse spreads through the atria, producing a P-wave, which sometimes cannot be seen due to the fast QRS rate Impulse is conducted through the AVN, Bundle of His, L/R bundle branches and Purkinje fibres to depolarise the ventricular tissue efficiently, giving a narrow QRS complex >100bpm Are the QRS complexes NARROW or BROAD? Narrow If so, what is the P: QRS relation? 1:1 ii) Irregular narrow complex tachycardias Atrial fibrillation with a rapid ventricular response Atrial activation is completely uncoordinated, so there are no P waves Multiple impulses reach the AVN at random intervals at very fast rates, when it has recovered from refractoriness the AVN conducts one of these impulses, the rate therefore depends on the AVN Impulse is conducted through the AVN, Bundle of His, L/R bundle branches and Purkinje fibres to depolarise the ventricular tissue efficiently, giving a narrow irregular QRS complex >100bpm No
9 9 Cardiology Acute Care Day 22 April 2013 Arrhythmia Tutorial Course Material Are the QRS complexes NARROW or BROAD? If so, what is the P: QRS relation? Narrow No No P waves Any type of narrow complex tachycardia can be aberrantly conducted (i.e. with bundle branch block) which will produce a broad complex tachycardia. If in doubt, or in an emergency, any broad complex tachycardia should be treated as VT. iii) Regular broad complex tachycardias Ventricular tachycardia Impulse arises from the ventricle at an increased rate usually due to a re-entrant circuit, this gives a regular, broad complex tachycardia These impulses are conducted retrogradely through the AVN, leaving it refractory to impulses from the atrium, which are not conducted P waves may be visible and are unrelated to the QRS (AV dissociation) >100bpm Are the QRS complexes NARROW or BROAD? Broad but they are hard to see If so, what is the P: QRS relation? No relation VT is associated with a high risk of cardiac arrest In patients with coronary heart disease or left ventricular dysfunction, a regular broad complex tachycardia is highly likely to be VT Any regular broad complex tachycardia in such patients should be assumed to be VT and treated as such until proven otherwise
10 10 Cardiology Acute Care Day 22 April 2013 Arrhythmia Tutorial Course Material Arrhythmia Treatment This part of the tutorial will outline a general approach to the treatment of arrhythmias which focuses on the safe assessment of the unwell patient with an abnormal heart rate. The group will then work through a number of cases, applying the treatment strategy to determine best management. Important points to remember: When assessing an unwell patient with a possible arrhythmia ALWAYS check for a pulse Recheck pulse with any clinical deterioration If you are faced with an unwell patient with an abnormal heart rate and you are unsure CALL for help A cardiac arrest call may be the quickest way to get experienced medical staff to the patient When faced with an unwell patient with an arrhythmia, ABC assessment principles apply: If you do not have someone else with you, make sure help is coming Check airway, for breathing and a pulse Assuming A and B are ok and the patient has a pulse Get the patient on a cardiac monitor Check and monitor BP Establish IV access Then assess the ECG In all cases in this tutorial the patient will have an intact airway, be breathing and have a pulse so that we can concentrate on arrhythmia management, but the importance of the ABC approach to any unwell patient cannot be emphasised enough.
11 11 Cardiology Acute Care Day 22 April 2013 Arrhythmia Tutorial Course Material 1. A treatment strategy for arrhythmias First assess the patient Are they compromised? Then assess the ECG Low BP o Look for signs of systemic hypoperfusion o Impaired conciousness (cerebral hypoperfusion) Heart failure o Pulmonary oedema o Signs of chronic CHF Chest pain Is there a high risk of arrest? Ventricular rate very high (> 180bpm) or very low (< 35bpm)? Ventricular tachycardia Complete heart block If the patient is compromised or there is a high risk of arrest Treat as an emergency with electricity Tachyarrhythmias Synchronised DC cardioversion Bradyarrhythmias Temporary pacing If the patient is not compromised or there are no high risk features for cardiac arrest Treat with appropriate drugs ALWAYS look for and address reversible causes
12 12 Cardiology Acute Care Day 22 April 2013 Arrhythmia Tutorial Course Material 2. Treating arrhythmias with electricity 2.1 Tachyarrhythmias Synchronised DC cardioversion In the emergency setting this should be performed under conscious sedation with an anaesthetist present to manage the patient s airway If you think your patient requires this treatment as an emergency you should immediately call the on-call medical or cardiology registrar Synchronisation is important as it times the shock according to the QRS complexes: An unsynchronised shock could be delivered on the T- wave and induce VF or VT Unsynchronised shocks should only be used during cardiac arrest as part of the ALS protocol There is a Synch button on all defibrillators, and when engaged, a dot appears on each monitored QRS, showing you that the defibrillator knows when each QRS occurs The full cardiac arrest trolley and experienced nursing and medical staff should be present before this is undertaken Remember to anticoagulate (IV heparin) patients with AF/A flutter 2.2 Bradyarrhythmias Temporary pacing There are two types of temporary pacing Transcutaneous Transvenous Transcutaneous pacing is available through some (but not all) defibrillators Adhesive pads are applied to the chest and the Pacer function is selected
13 13 Cardiology Acute Care Day 22 April 2013 Arrhythmia Tutorial Course Material An appropriate HR is selected and the output (voltage) is increased until Electrical capture i.e. paced beats on the monitor AND Mechanical capture i.e. a pulse with each paced beat Transcutaneous pacing is painful and unpleasant for patients All patients undergoing transcutaneous pacing MUST be given analgesia and sedation This is a temporising measure ONLY until transvenous pacing can be instituted Temporary transvenous pacing places a pacing wire in the right ventricular apex, and is carried out by the cardiology registrar
14 14 Cardiology Acute Care Day 22 April 2013 Arrhythmia Tutorial Course Material 3. Medical treatment of arrhythmias 3.1 Bradyarrhythmias Not usually amenable to drug treatment IV atropine can be used when there is imminent or actual cardiac arrest Repeated IV atropine (> 3mg) in the non-arrest situation is unlikely to be helpful The cause is often conducting system disease which requires pacing in the long term It is important to always consider reversible causes: Myocardial ischaemia/infarction Drugs β-blockers, rate limiting calcium channel blockers, digoxin Hypothermia Hypothyroidism Raised intracranial pressure 3.2 Tachycardias (a) Narrow complex irregular tachycardia If the patient is not compromised, you need to decide on the treatment strategy: Rate control vs. rhythm control Rhythm control This means the conversion to, and maintenance of sinus rhythm Because of the risk of acute stroke at the time of cardioversion this strategy requires: OR Clear onset of palpitations < 48 hours At least one month of therapeutic anticoagulation Chemical cardioversion using antiarrhythmic drugs IV flecainide - contraindicated in heart failure, coronary heart disease or LV dysfunction IV amiodarone
15 15 Cardiology Acute Care Day 22 April 2013 Arrhythmia Tutorial Course Material Rate control This means the control of the ventricular rate Patients having a rate control strategy still require anticoagulation, due to the long term risk of CVA in AF Rate control with AV nodal blockers Calcium channel blocker β-blocker - contraindicated in acute heart failure, where BP is low or in patients on verapamil (risk of AV block in combination) Digoxin (b) Narrow complex regular tachycardia (SVT) Note Sinus tachycardia is usually secondary to a systemic illness and responds to treatment of that condition, rather than requiring specific treatment The aim is firstly to make the diagnosis and then to terminate the tachycardia - making the diagnosis depends on determining the pattern of atrial activation (P waves) and their relation to the QRS - this is often difficult due to the fast QRS rate Slowing AV nodal conduction allows accurate diagnosis: Vagal manoeuvres Carotid sinus massage Contraindicated if carotid bruits Valsalva IV adenosine Contraindicated in asthma ALWAYS record a rhythm strip during administration AV nodal blocker with a short half life Given as a fast IV bolus into an antecubital vein Blocks AVN conduction This can be briefly distressing for patients, who should be warned about chest tightness and breathlessness and reassured that these will pass quickly
16 16 Cardiology Acute Care Day 22 April 2013 Arrhythmia Tutorial Course Material Will terminate tachycardias which are sustained by a re-entrant circuit involving the AVN Will allow diagnosis of other SVTs by revealing the P morphology If adenosine fails give IV verapamil Contraindindicated in heart failure, hypotension and in patients on β-blockers If this fails, take specialist advice on other antiarrhythmics, cardioversion or overdrive pacing (c) Broad complex tachycardias Note Any type of narrow complex tachycardia can be aberrantly conducted (i.e. with bundle branch block) which will produce a broad complex tachycardia. If in doubt, or in an emergency, any broad complex tachycardia should be treated as VT. In the non-compromised patient where SVT with aberrant conduction is suspected (typical BBB pattern, history of SVT) IV adenosine may be appropriate to make an accurate diagnosis. IV adenosine will have no effect on VT, but will affect SVT as described above. First assess the patient VT is a cardiac arrest rhythm and you must always check for a pulse VT with a pulse can deteriorate quickly and so the patient needs to be closely monitored while treatment is instigated If the patient has any signs of compromise: Immediate DCCV Call anaesthetist Secure airway Conscious sedation Synchronised DC shock Manage on CCU If no compromise Make sure that the patient is appropriately monitored Always get a 12-lead ECG of the tachycardia Consider IV amiodarone/other antiarrhythmics
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