Ass. Prof. Tomon Thongsri, MD Buddhachinaraj Phitsanuloke Hospital
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1 Treatment Bradyarrhythmia Ass. Prof. Tomon Thongsri, MD Buddhachinaraj Phitsanuloke Hospital 1
2 What is the rhythm?
3 Sinus Bradycardia
4 What s rhythm
5 Sinus Bradycardia Treatment Asymptomatic No treatment required Except in chronotropic incompetence Permanent pacing is indicate.
6 Sinus Bradycardia Treatment Symptomatic : immediate treatment long-term treatment Treatment aimed at restoring normal sinus rate Specific to etiology of bradycardia If patient is on rate controlling medications-stop them. If patient is hypokalemic-replace it. If the patient is hypothyroid-replace it Permanent pacemaker if the patient has continued symptoms with no improvement from intervention or with no identifiable cause.
7 Bradycardia Algorithm (1 of 2) Bradycardia Heart Rate less than 60 bpm and inadequate for clinical condition Maintain patent airway; assist breathing as needed Give oxygen Monitor ECG (identify rhythm), blood pressure, oximetry Establish IV access Serious signs or symptoms of poor perfusion caused by the bradycardia? (eg. acute altered mental status, ongoing chest pain, hypotension or other signs of shock) 7
8 Bradycardia Algorithm (2 of 2) Observe/Monitor Reminders If pulseless arrest develops go to Pulseless Arrest Algorithm Search for and treat possible contributing factors: Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo/Hyper-kalemia Hypoglycemia Hypothermia Toxins Tamponade, cardiac Tension pneumothorax Thrombosis (coronary or pulmonary) Trauma (hypovolemia, inc ICP) Adequate Perfusion Poor Perfusion Prepare for transcutaneous pacing; use without delay for high degree block (type II second -degree block or thirddegree AV block) Consider Atropine 0.5 mg/iv while awaiting pacer. May repeat to a total dose of 3 mg. If ineffective, begin pacing. Consider Epinephrine (2 to 10 µg/min) or dopamine (2 to 10 µg/kg/min infusion while awaiting pacer or if pacing ineffective. Prepare for transvenous pacing Treat contributing causes Consider expert consultation 8
9 Sinus Bradycardia Treatment Symptomatic : immediate treatment long-term treatment Treatment aimed at restoring normal sinus rate Specific to etiology of bradycardia If patient is on rate controlling medications-stop them. If patient is hypokalemic-replace it. If the patient is hypothyroid-replace it Permanent pacemaker if the patient has continued symptoms with no improvement from intervention or with no identifiable cause.
10 What Is This Rhythm? 10
11 First degree AV Block Definition: Prolongation of the PR interval > 200 msec Pathophysiology: Every atrial impulse is transmitted to the ventricles, resulting in a regular ventricular rate. Can arise from delays in the conduction system in the AV node itself (most common), the His-Purkinje system, or a combination of both. Mortality/Morbidity: In and of itself, first-degree AV block is a benign condition, with no associated increase in morbidity or mortality. Treatment Define cause :drug overdose, acute MI, myocarditis No treatment indicated if asymptomatic.
12 What Is This Rhythm? 12
13 What Is This Rhythm? 13
14 What Is This Rhythm? 14
15 Mobitz II & Third degree AV Block Treatment symptomatic high degree heart block ACLS as indicated Identification of etiology based on clinical presentation Transcutaneous pacing for unstable patients Permanent pacemaker Undefined causes irreversible causes
16 Mobitz II & Third degree AV Block Treatment asymptomatic high degree heart block Permanent pacemaker Undefined causes irreversible causes
17 What Is This Rhythm? 17
18 Junctional bradycardia Treatment Asymptomatic No treatment required Except in chronotropic incompetence Permanent pacing is indicate. Symptomatic: permanent pacing Undefined causes or irreversible causes
19 Pacemaker Temporary pacemaker external pacemaker internal pacemaker Permanent pacemaker single chamber : VVI dual chamber : DDDR 19
20 Temporary pacemaker external (transcutaneous) internal (transvenous) 20
21 Transcutaneous Pacing 21
22 22
23 Transcutaneous Pacing pad 23
24 Setting :Transcutaneous Pacing Pacing rate /min Output start 20 ma mode demand vs fix 24
25 Transcutaneous Pacing: Capture vs No Capture Bradycardia: no pacing 25 Feb 88 Lead I Size 1.0 HR=41 Pacing Spike Pacing below threshold: no capture Bradycardia: No Pacing 25 Feb 88 Lead I Size 1.0 HR=43 35 ma Capture: Spike + broad QRS QRS: opposite polarity Pacing above threshold: with capture Pacing Below Threshold (35 ma): No Capture 25 Feb 88 Lead I Size 1.0 HR=71 60 ma Pacing Above Threshold (60 ma): With Capture (Pacing-PulseMarker ) 25
26 Temporary pacemaker external (transcutaneous) internal (transvenous) 26
27 Transvenous pacemaker Pulse generator lead 27
28 Transvenous Pacing Pacing rate /min Output 3-5 ma ( 3-5 เท า threshold) mode demand vs fix 28
29 Permanent pacemaker
30 Cardiac Pacemakers
31 Cardiac device Implantation
32 Permanent pacemaker single chamber VVI VVIR 32
33 Permanent pacemaker dual chamber 33
34
35 Pacemaker Nomenclature 1 st letter chamber paced 2 nd letter chamber sensed 3 rd letter Response to chamber sensed 4 th letter - rate response VVI VVIR DDD DDDR AAI
36 Pacemaker Nomenclature I II III IV V Chamber Paced Chamber Sensed Response to Sensing Rate Modulation, Programmability Antitachycardia Features A=Atrium A=Atrium T=Triggered P=Simple P=Pacing V=Ventricle V=Ventricle I=Inhibited M=Multiprogrammable S=Shock D=Dual D=Dual D=Dual R=Rate Adaptive D=Dual O=None O=None O=None C=Communicating O=None
37 Pacemaker Nomenclature 1 st letter chamber paced 2 nd letter chamber sensed 3 rd letter Response to chamber sensed 4 th letter - rate response VVI VVIR DDD DDDR AAI
38 Examples Cycle length VVI set rate 60 BPM Paces ventricle Senses ventricle Inhibited by a sensed ventricular event
39 Paced Rhythm Recognition DDD set rate BPM Paces ventricle Senses atrium trigger by a sensed at atrium DDD / 60 / 120
40 Paced Rhythm Recognition DDD set rate BPM Paces ventricle Pace atrium Pace at atrium then trigger to pace at ventricle
41 Paced Rhythm Recognition DDD set rate BPM Paces atrium sense ventricle Pace at atrium then inhibit to pace at ventricle
42 Patient with DDD
43 Patient with DDD DDD set rate BPM hysterisis 50 /min sense atrium sense ventricle inhibit at atrium and inhibit to pace at ventricle
44 Patients with VVI came with palpitation 44
45 Patients with VVI came with dental caries 45
46 การด แลท วไป แผลระว ง infection or protusion 46
47 Cardiac device
48 electromagnetic interference (EMI) When patient with pacemaker go to procedure
49 Preparation for procedure in devices and arrhythmia Avoid patients: Bradycardia HR < 50 /min Tachycardia HR > 120 /min - AICD patients should be turn off device before procedure - Keep electrical device as far from generator as possible - avoid electrical cord cross patient s chest wall and keep away from device - Have backup plan for device failure - Have magnet available
50 Electrocautery Use - Place grounding pad as far from generator as possible - Place grounding pad as near to surgical field as possible - Use bipolar electrocautery if possible - Have surgeon use short bursts of electrocautery (<1 sec apart) - Maintain lowest possible current - If cautery causes asystole, place magnet over control unit & change from inhibited to fixed mode - Change back afterwards - be alert for R on T phenomenon 50
51
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