Treatment of Arrhythmias in the Emergency Setting Zian H. Tseng, M.D. Assistant Professor of Medicine Cardiac Electrophysiology Section Cardiology Division University of California, San Francisco There are no potential conflicts of interest to disclose My Most Important Slide Take a deep breath Things will go a lot slower if you rush or panic Make use of those around you Pride can be dangerous Keep moving forward 1
Don t Forget the Basics 79 yo man with a history of CHF s/p remote ICD presents with progressive, severe dyspnea at rest Compliant with his medicines; described some diarrhea after a recent trip to Mexico Sitting up, diaphoretic, tachypneic, oxygen saturation ~87%, blood pressure ~88/40 Don t Forget the Basics Don t Forget the Basics When you have a questionable ECG: If you can, always 1. Compare it to a previous ECG 2
Current: 2 months prior: Don t Forget the Basics When you have a questionable ECG: If you can, always 1. Compare it to a previous ECG 2. Think about electrolytes (K, Mg 2, Ca 2 ) SVT Tachyarrhythmias: Unstable Atrial fibrillation Unconscious, altered mental status, ongoing chest pain Hypotension is a clinical judgment AF with WPW VT/ VF 3
Tachyarrhythmias: Quasi-stable SVT Atrial fibrillation AF with WPW VT/ VF Tachyarrhythmias: Quasi-stable SVT Tachyarrhythmias: Quasi-stable SVT Vagal Manuevers WAIT! GET A RUNNING 12 LEAD ECG! 4
Tachyarrhythmias: Quasi-stable SVT Vagal Manuevers Carotid sinus massage Valsava Will terminate ~20% 1 1. Lim SH et al. Ann Emerg Med 1998;31:30-35 Tachyarrhythmias: Quasi-stable SVT Adenosine Metabolized by red blood cells and endothelium Give 6 mg IV with 20 cc flush Repeat with 12 mg IV X 2 How do I know if I ve given enough? Tachyarrhythmias: Quasi-stable Atrial Fibrillation Nondihydropyrdine Calcium channel blockers Diltiazem Verapamil Beta-blockers Metoprolol Atenolol Carvedilol Labetolol Propanolol Blood Pressure 1. Address underlying condition 2. Esmolol 3. Digoxin 4. Amiodarone 5
Tachyarrhythmias: Quasi-stable Tachyarrhythmias: Quasi-stable Tachyarrhythmias: Quasi-stable Atrial Fibrillation with preexcitation AV nodal blockers Give: Procainamide Ibutilide 6
Tachyarrhythmias: Quasi-stable Ventricular Tachycardia Scarcity of data Amiodarone probably the most effective 1,2 -- Can cause bradycardia -- Can exacerbate polymorphic VT scrutinize for pause-dependence and QTc -- Can hinder EP studies/ ablation Extrapolate from cardiac pulseless VT/ VF versus placebo: 1. Kudenchuck PJ et al. N Engl J Med 1999;341:871-878 versus lidocaine: 2. Dorian P et al. N Engl J Med 2002;346:884-890 Tachyarrhythmias: Quasi-stable Ventricular Tachycardia Scarcity of data Consider -- Lidocaine gtt -- Procainamide - watch for hypotension and prolonged QT Tachyarrhythmias: Quasi-stable Ventricular Tachycardia Get EP involved May respond to beta-blockers or calcium channel blockers May be amenable to ablation 7
Tachyarrhythmias Tachyarrhythmias Tachyarrhythmias 8
Tachyarrhythmias 1.Electrolytes Tachyarrhythmias 1.Electrolytes Hypokalemia Hypo-Mg T U Tachyarrhythmias 1.Electrolytes Hypokalemia Hypo-Mg2 Hypo-Ca2 9
Tachyarrhythmias 1.Electrolytes Hypokalemia Hypo-Mg2 Hypo-Ca2 2. DRUGS www.torsades.org 3. Congenital Tachyarrhythmias 1. IV magnesium (effecetive even if normal Mg 2 level) 2. Isoproterenol 3. Transvenous pacing 4. Unstable DC shock PARA- Blood Flow 10
PARA- Blood Flow PARA- Blood Flow PARA- Blood Flow 11
PARA- Blood Flow Vagal tone Inferior wall MI 1. Atropine 12
1. Atropine 2. Dopamine 1. Atropine 2. Dopamine 3. Epinephrine 1. Atropine 1 2. Dopamine 1 3. Epinephrine 1 4. Isoproterenol (vasodilating) 1. AHA Guidelines. Circulation 2005;112:67-77 13
Betablocker Calcium channel blocker Glucagon Calcium Conduction disease Anterior MI 1. Atropine 2. Dopamine 3. Epinephrine 4. Isoproterenol 14
1. Atropine 2. Place external pacing pads 3. Pace if atropine fails 4. Dopamine 5. Epinephrine 6. Isoproterenol 7. Transvenous pacer AHA Guidelines. Circulation 2005;112:67-77 Transcutaneous Pacing Pt. comes in with multiple, recurrent shocks from his ICD 1. Place external pads 2. Place magnet on chest 1. PUTS DEVICE IN MAGNET MODE 2. FOR AN ICD: INHIBITS THERAPY DETECTION 3. FOR A PACEMAKER: INHIBITS SENSING 15
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