Arrhythmia recognition and treatment Cardiology Acute Care Day

Outline Objectives Normal sinus rhythm How to recognise an arrhythmia Bradyarrhythmias Tachyarrhythmias Treatment strategy for arrhythmias

Outline Objectives Normal sinus rhythm How to recognise an arrhythmia Bradyarrhythmias Tachyarrhythmias Treatment strategy for arrhythmias

ECG of sinus rhythm ECG of sinus rhythm QRS P Normal rate Regular, narrow QRS P waves present P:QRS is 1:1 Normal sinus rhythm ECG Criteria Rate: 60-100 bpm. Rhythm: Regular. A normal variant called Sinus Arrythmia changes rhythm in response to respiration. This is seen most often in young healthy people. Pacemaker: Each beat originates in the SA node. P wave: look the same, all originate from the same locus (SA node) PRI: 120-200 msec QRS: 80-120 msec, narrow unless effected by underlying anomoly

Outline Objectives Normal sinus rhythm How to recognise an arrhythmia Bradyarrhythmias Tachyarrhythmias Treatment strategy for arrhythmias

How to recognise an arrhythmia What is the QRS rate? Are the QRS complexes regular? Is the QRS broad or narrow? Are there P waves? What is the P:QRS relation?

Outline Objectives Normal sinus rhythm How to recognise an arrhythmia Bradyarrhythmias Tachyarrhythmias Treatment strategy for arrhythmias

Bradyarrhythmias Bradyarrhythmias Sinus bradycardia Sinus arrest (“Sick Sinus Syndrome”) Junctional bradycardia Atrioventricular block (First degree) Second degree - type I (Wenckebach) / type II Third degree

* Sinus bradycardia Rate < 60bpm Regular, narrow QRS P waves present P:QRS is 1:1

* Sinus arrest Rate < 60bpm Irregular, narrow QRS P waves present P:QRS is 1:1 Pause with absence of P wave

* Junctional bradycardia Rate < 60bpm Regular, narrow QRS No P waves

* First degree AV block Rate variable Regular, narrow QRS P waves present P:QRS is 1:1 with PR interval >200ms

Second degree AV block (type I) * * Rate < 60bpm Irregular narrow QRS P:QRS not 1:1 increasing PR interval then dropped beat

Second degree AV block (type II) * * * Rate < 60bpm Irregular narrow QRS P:QRS not 1:1 normal PR interval with intermittent dropped beats

Third degree (complete) AV block * Rate < 60bpm Regular broad QRS No relation between P and QRS

Outline Objectives Normal sinus rhythm How to recognise an arrhythmia Bradyarrhythmias Tachyarrhythmias Treatment strategy for arrhythmias

Tachyarrhythmias Irregular Atrial fibrillation Regular Narrow QRS Sinus tachycardia Supraventricular tachycardia (SVT) Atrial flutter Broad QRS Ventricular tachycardia SVT with Bundle Branch Block

Atrial fibrillation Rate variable Irregular, narrow QRS No P waves

* Sinus tachycardia Rate > 100bpm Regular, narrow QRS P waves present P:QRS is 1:1

Supraventricular tachycardias Atrial tachycardia Junctional tachycardia AV re-entrant tachycardia AV node re-entrant tachycardia * *

Supraventricular tachycardia * Rate > 100bpm Regular, narrow QRS P waves variable - not apparent, or after QRS

Atrial flutter Rate variable Regular, narrow QRS Sawtooth atrial activity 300bpm - variable AV block

Ventricular tachycardia * Rate > 100bpm Regular, broad QRS P waves variable - may be dissociated

* SVT with Bundle Branch Block Rate > 100bpm Regular, broad QRS X Rate > 100bpm Regular, broad QRS P waves variable - usually not visible

Outline Outline Normal sinus rhythm How to diagnose an arrhythmia Bradyarrhythmias Tachyarrhythmias Treatment strategy for arrhythmias

Treatment strategy First assess the patient and CHECK THEIR PULSE Are they compromised? low BP, impaired consciousness, heart failure, chest pain Then assess the ECG Is there a high risk of cardiac arrest? VT, complete heart block If compromise or high risk Treat with electricity DC cardioversion / temporary pacing If not Look for reversible causes / treat with drugs

89 year old female Syncope BP 75/40 What is the QRS rate? Is the QRS regular? Is the QRS broad or narrow? Are there p-waves? What is the p – QRS relation? 89 year old female Syncope BP 75/40

Third degree (complete) AV block Assess the patient If compromised: Immediate temporary pacing (initially transcutaneous, refer to expert to consider placing a temporary pacing wire) If not compromised: What is the risk of asystole?

Third degree (complete) AV block What factors predict a high risk of asystole? Recent asystole Mobitz type II AV block Third degree heart block with broad QRS Ventricular pause >3seconds

Third degree (complete) AV block What is this patients risk of asystole? High Consider temporary pacing Address reversible causes: Drugs affecting the conducting system Acute MI

Temporary pacing

75 yr old male Mild breathlessness BP 135/85 What is the QRS rate? Is the QRS regular? Is the QRS broad or narrow? Are there p-waves? What is the p – QRS relation? 75 yr old male Mild breathlessness BP 135/85

Atrial fibrillation Assess the patient If they are compromised DC cardioversion If not, decide treatment strategy Rate control vs rhythm control Rate control AV nodal blockers CCB, β-blocker, digoxin Rhythm control Anti-arrhythmics Amiodarone, flecainide Anticoagulation

Following administration of beta-blocker

47 year old female Palpitations BP 120/70 What is the QRS rate? Is the QRS regular? Is the QRS broad or narrow? Are there p-waves? What is the p – QRS relation? 47 year old female Palpitations BP 120/70

Supraventricular tachycardia Assess the patient If they are compromised DCCV If not compromised: Vagal manoeuvres IV Adenosine (extremely short half-life, need to give rapidly) Terminates re-entry circuits using AVN Will slow atrial tachycardia and atrial flutter IV verapamil Consider: AVN slowing (digoxin) Antiarrhythmic (amiodarone) DCCV/ A pacing

Termination of SVT with Adenosine adenosine 6mg IV

62 year old male IV adenosine Palpitations BP 120/70 What is the QRS rate? Is the QRS regular? Is the QRS broad or narrow? Are there p-waves? What is the p – QRS relation? 62 year old male IV adenosine Palpitations BP 120/70

Following bisoprolol

82 year old male Chest pain BP 80/50 What is the QRS rate? Is the QRS regular? Is the QRS broad or narrow? Are there p-waves? What is the p – QRS relation? 82 year old male Chest pain BP 80/50

Ventricular tachycardia Assess the patient DO THEY HAVE A PULSE? No? Use BLS/ALS ALGORITHM If any compromise: Immediate DCCV Call anaesthetist Secure airway Conscious sedation Synchronised DC shock Manage on CCU If no compromise: (GET 12 LEAD ECG) Consider IV amiodarone/other antiarrhythmics Consider reversible causes

Treatment strategy First assess the patient and CHECK THEIR PULSE Are they compromised? low BP, impaired consciousness, heart failure, chest pain Then assess the ECG Is there a high risk of cardiac arrest? VT, complete heart block If compromise or high risk Treat with electricity DC cardioversion / temporary pacing If not Look for reversible causes / treat with drugs

Any questions Any questions? Normal sinus rhythm How to recognise an arrhythmia Bradyarrhythmias Tachyarrhythmias Treatment strategy for arrhythmias