Approach to tachyarrhythmia

This presentation describes the emergency department management of sinus tachycardia, supraventricular tachycardia, atrial flutter, atrial fibrillation, ventricular tachycardia and ventricular ectopic

1. Approach to tachy -arrhythmia DR KTD PRIYADARSHANI REGISTRAR IN EMERGENCY MEDICINE PRIMARY CARE UNIT TEACHING HOSPITAL- PERADENIYA

2. What is normal rhythm? HR 60-100 bpm Origin from SA node Propagate through normal conduction pathway With normal velocities

3. Causes of arrhythmias Abnormal rhythmicity of pacemaker Shift of the pacemaker from the sinus node to another place in the heart Blocks at different points in the impulse through the heart Abnormal pathways of impulse transmission through the heart Spontaneous generation of spurious impulses in almost any part of the heart

4. L ets’ workout.. 7 step approach to ECG rhythm analysis Rate Pattern of QRS complexes QRS morphology P waves Relationship between P waves and QRS complexes Onset and termination Response to vagal maneuvers

5. Resuscitation A, B- Start Oxygen C- IV access, hemodynamic stability D E If time allows- 12 lead ECG VBG- correct electrolyte imbalance 2 main priorities Is the patient stable? What is nature of the arrhythmia?

6. Adverse features of arrhythmia Shock- SBP < 90mmHg, pallor, sweating, cold extremities, clammy, confusion or impaired level of consciousness Syncope- transient loss of consciousness due to cerebral perfusion Myocardial ischemia- ischemic chest pain, evidence of ischemia on the ECG Heart failure- pulmonary edema and or raised JVP (+/- peripheral edema and liver enlargement)

7. SINUS TACHYCARDIA

8. Sinus tachycardia Sinus rhythm with resting heart rate (HR) > 100 bpm in adults, or above the normal range for age in children Normal heart rates Newborn : 110 – 150 bpm 2 years : 85 – 125 bpm 4 years : 75 – 115 bpm 6 years+ : 60 – 100 bpm

9. Management Correct Causes Hypoxia Hypovolemia Fever Thyrotoxicosis Anemia Pain Pharmacological Beta-agonists: adrenaline, isoprenaline , salbutamol, dobutamine Sympathomimetics : amphetamines, cocaine, methylphenidate Antimuscarinics :  antihistamines, TCAs, carbamazepine, atropine Others: caffeine, theophylline, marijuana

10. Supraventricular Tachycardia (SVT)

11. SVT Regular tachycardia ~140-280 bpm Narrow QRS complexes (< 120ms ) P waves if visible exhibit retrograde conduction with P-wave inversion in leads II, III, aVF .

12. Management Unstable patient Unstable + adverse features = synchronized electrical cardio version. Sedate patient 120-150J biphasic Repeat 3 times with stepwise increase in joules

13. Stable BP>100 mmHg Vagal maneuvers— Valsalva and/or carotid sinus massage. Adenosine = large vein + flush 6 mg as a rapid IV bolus. 12 mg and again and 18 mg if no response . transient sense of impending doom, chest discomfort and shortness of breth Consider verapamil 2.5–5 mg IV over 2 min (if adenosine is contraindicated) or verapamil ( continuous slow infusion of 1 mg/min to a maximum of 20 mg or 5 mg IV slowly, which may be repeated). Diltiazem infusion (2 mg/min to a maximum of 50 mg) is an alternativ Flecainide (2 mg/kg over 30–45 minutes) would be considered third-line therapy Catheter ablation may be considered in recurrent episodes not amenable to medical treatment.

14. Atrial flutter

15. Atrial flutter Narrow complex tachycardia Regular atrial activity at ~300 bpm “Saw-tooth” pattern of inverted flutter waves in leads II, III, aVF Upright flutter waves in V1 that may resemble P waves Loss of the isoelectric baseline Ventricular rate depends on AV conduction ratio

16. Handy Tips For Spotting Flutter Rapid Recognition Narrow complex tachycardia at 150 bpm (range 130-170)? Yes -> Suspect flutter! Vagal Manoeuvres +/- Adenosine Atrial flutter will not usually cardiovert with these techniques (unlike  AVNRT ) RR intervals In atrial flutter with variable block the R-R intervals will be multiples of the P-P interval

17. Management administer an antiarrhythmic drug; initiate DC cardioversion low energy 50J; or initiate rapid atrial pacing to terminate the atrial flutter

18. Atrial fibrillation

19. Atrial fibrillation Irregularly irregular rhythm No P waves Absence of an isoelectric baseline Variable ventricular rate QRS complexes usually < 120ms, unless pre-existing bundle branch block, accessory pathway, or rate-related aberrant conduction Fibrillatory waves may be present and can be either fine (amplitude < 0.5mm) or coarse (amplitude > 0.5mm) Fibrillatory waves may mimic P waves leading to misdiagnosis

20. Causes of Atrial Fibrillation Cardiac causes Non-cardiac causes Common: • Ischaemic heart disease • Rheumatic heart disease • Hypertension  • Sick sinus syndrome • Pre-excited syndromes (e.g. WPW) Less common:  • Cardiomyopathy • Pericardial disease • Atrial septal defect • Atrial myxoma • Acute infections, especially pneumonia  • Electrolyte abnormalities  • Lung carcinoma • Other intrathoracic pathology (e.g. pleural effusion)  • Pulmonary embolism  • Thyrotoxicosis Post-surgery (especially cardiac)  • Excessive alcohol or caffeine

21. Management Diagnosis of atrial fibrillation Assessment of duration Assessment for anticoagulation Rate or rhythm control Treatment of underlying / associated diseases

22. non-life-threatening hemodynamic instability, caused by AF, as: Ventricular rate >150 bpm Ongoing chest pain Critical perfusion AF not permanent—electrical cardioversion should be performed. Where there is a delay in organizing electrical cardioversion , intravenous amiodarone should be used. AF permanent—pharmacological rate control strategy should be used. Treatment should be with intravenous β-blockers or rate-limiting calcium antagonists. If these are contraindicated, amiodarone should be used. AF in WPW— flecainide may be used as an alternative for attempting pharmacological cardioversion . AV node-blocking agents (e.g. diltiazem , verapamil, or digoxin) should not be used.

23. In stable patients there are several treatment options: • Rate control by drug therapy (e.g. beta-blocker or rate-limiting calcium antagonist) • Rhythm control by drug therapy (e.g. amiodarone or flecanide ) • Rhythm control by electrical cardioversion • Anticoagulation to prevent thromboembolism (should be considered in all patients)  NICE recommend that all patients should initially be rate controlled unless: AF is thought to be reversible Presence of heart failure thought to be caused by AF New onset AF Atrial flutter thought to benefit from ablation Rhythm strategy thought to be more suitable based on clinical judgement

24. Rate control is used in those with permanent AF and those with persistent AF, where a rate control treatment strategy has been chosen. Rhythm control may be achieved via electrical or pharmacological cardioversion . It should be considered in patients who remain symptomatic despite rate control, or where a rate control strategy has been unsuccessful. In patients without haemodynamic compromise, this can be performed electively. NICE recommends that a transthoracic echocardiogram is performed prior to elective cardioversion .

25. Factors which make a patient unsuitable for cardioversion : Contraindication to anticoagulation Structural heart disease that precludes long-term maintenance of sinus rhythm Long duration of AF (>12 months) History of multiple failed attempts/relapses Ongoing reversible cause (e.g. thyrotoxicosis) THROMBOPROPHYLAXIS In AF CHA2DSVASC score 0,1-M, 2-F

26. VENTRICULAR TACHYCARDIA

27. AV dissociation fusion beats or capture beats wide QRS complexes>140 ms rate>100 bpm: commonly 150–200 bpm rhythm regular c onstant QRS axis, often with marked left axis deviation or northwest axis deep S wave with r/S ratio<1 in right bundle branch block (RBBB) morphology VT Monomorphic most common associated with MI Polymorphic QRS at 200 beats/min or more which change amplitude and axis so they appear to twist around the baseline

28. VT vs SVT Criteria for diagnosis of VT using the 4-step Brugada algorithm:

29. Management PULSELESS ACLS protocol Immediate unsynchronized defibrillation CPR with minimal interruption (30:2, with 2 minute cycles) Intubation O2 IV access Adrenaline 1mg 3 min Amiodarone 300mg (following 3rd shock) Exclude reversible causes (4 H’s and T’s)

30. CLINICALLY COMPROMISED Haemodynamically unstable, chest pain, ischaemia , heart failure, VR > 150/min -> synchronised shock (x 3) O2 IV access Rapid exclusion of reversible factors (wire, PA catheter in RV, hypoK + or Mg2 +) Synchronised DC Shock (50J Bi, 100 Mono ) (150 - >200J-> 360J) Amiodarone 5mg/kg over 20-60 min if patient stable -> infusion Consider: 2 nd line drugs procainamide 50mg/min lignocaine 1mg/kg sotalol 1mg/kg Magnesium Inotrope = Dopamine infusion Overdrive pacing

31. CLINICALLY STABLE- debate between cardioversion and pharmacological treatment O2 Amiodarone IV amiodarone 150 mg as a slow bolus over 10 minutes. This can be repeated a second time if conversion has not been achieved IV procainamide 100 mg (where available) every 5 minutes to a maximum dose of 10–20 mg/kg body weight IV lignocaine 50–100 mg IV push at a rate not more than 50 mg/min. This can be repeated a second time if conversion is not achieved . Sotolol 1 mg/kg is used as second-line agent. Cardioversion if medical therapy fails (quickly) – will need sedation Consider pacing if cardioversion no effective Evaluation and treatment of cause (usually IHD) If associated with long QT -> consider Mg2+

32. Premature ventricular complexes Broad QRS complex (≥ 120 ms ) with abnormal morphology Premature — i.e. occurs earlier than would be expected for the next sinus impulse Discordant ST segment and T wave changes. Usually followed by a full compensatory pause Retrograde capture of the atria may or may not occur

33. Causes Frequent or symptomatic PVCs may be due to: Anxiety Sympathomimetics Beta-agonists Excess caffeine Hypokalaemia Hypomagnesaemia Digoxin toxicity Myocardial ischemia

34. Management

35. References Diagnosis and management in emergency medicine by Brown and Cardagon 7 th edition Text book of Adult emergency medicine 4 th edition by peter cameron Life in the fast lane- ECG library

36. Questions?

37. Thank you!