1. What to do if called for an arrhythmia
Jordan M. Prutkin, MD, MHS
Assistant Professor
Department of Cardiology/Electrophysiology
University of Washington
7/24/2014

2. What to do… Check the patient’s pulse Get an ECG
Unless there’s no pulse.
Then call a code and do ACLS

3. Approaching an EKG Eyeball Rate Rhythm Axis Intervals P waves QRS
ST-T waves
Overall appearance

4. Approach to Arrhythmias
Do you have calipers?
Are there P waves?
Are the P waves and QRS’s regular?
Are there more P waves than QRS complexes?
Are there more QRS complexes than P waves?
Is there a constant relationship between the P waves and QRS complexes (constant PR)?
Do the QRS complexes look like the baseline QRS (if known)? Are they wider? Narrower?

5. Tachycardia

6. Regular
Irregular
Narrow
Sinus Tach
AVNRT
AVRT
Atrial Tach
Junctional Tach
Atrial Flutter
Afib
MAT
Frequent PACs
Rarely
SVT
Wenckebach
Wide
Monomorphic VT
SVT with:
BBB
Bypass pathway
Ventricular pacing
Polymorphic VT
VFib
Afib, MAT, PACs
with:

7. Narrow Complex Tachycardia

8. Case 1
73 year old female admitted with pneumonia, reports acute onset of shortness of breath

9. Case 1

10. What does this EKG show? Sinus rhythm Atrial fibrillation
Atrial flutter
Atrial tachycardia

11. What does this EKG show? Sinus rhythm Atrial fibrillation
Atrial flutter
Atrial tachycardia

12. Case 2 61 year old male presents to the ED with palpitations
HR 155bpm, BP 122/76

13. Case 2

14. What does this EKG show? Sinus tachycardia Atrial fibrillation
Atrial flutter
Atrial tachycardia
Artifact

15. What does this EKG show? Sinus tachycardia Atrial fibrillation
Atrial flutter
Atrial tachycardia
Artifact

16. Slower heart rate

17. Management of Afib/flutter
Is the patient hemodynamically stable?
If there’s hypotension, acute heart failure, mental status change, ischemia, or angina, then cardiovert

18. If stable, then what?
About 1/2 to 2/3 will terminate spontaneously within 24 hours
Do you need to do anything then?
If rapid or mildly/moderately symptomatic, yes.
Asymptomatic, HR <110bpm
Otherwise, maybe not.

19. Rate control IV PO Diltiazem 5-20mg IV, then 5-20mg/hr
Metoprolol 5mg IV Q5min x 3
Esmolol gtt, if in ICU PO
Diltiazem 30-60mg Q6H
Diltiazem CD mg Q24H
Verapamil mg Q24H
Metoprolol 25mg Q6-8H
Metoprolol XL 25-50mg Q12-24H
Atenolol mg Q24H
Digoxin?

20. Rhythm Control Amiodarone 150mg IV, then 0.5-1 mg/min gtt Flecainide
Should really have a central line
Don’t use if afib >48 hours and no anticoagulation
Flecainide
Propafenone Call cardiology
Ibutilide

21. Anticoagulation/DCCV for AF
Increased risk of stroke after DCCV
If >48 hours, need three weeks of weekly therapeutic coumadin levels, or TEE first
If >48 hours and acute DCCV, give heparin bolus, then infusion and anticoagulate for 4 weeks
If <48 hours, don’t need anticoagulation necessarily
LMWH, dabigatran, rivaroxaban, apixiban okay

22. Sinus tachycardia 78 year old admitted with pyelonephritis HR 120bpm
ECG shows sinus tachycardia

23. Causes of sinus tach Fever Infection/Sepsis Volume depletion
Hypotension/shock
Anemia
Anxiety
Pulmonary embolism MI
Heart failure
COPD
Hypoxia
Hyperthyroid
Pheochromocytoma
Stimulants/Illicit substances

24. Treatment for Sinus Tach
In general, don’t treat heart rate
Treat underlying cause
Exception for acute MI, use beta-blockers

25. Case 3 63 year old male is admitted with chest pain to 5NE
While waiting for a stress test, he reports abrupt onset of palpitations and mild chest discomfort to his nurse.
Pulse 150, blood pressure 132/88

26. Case 3-Presenting EKG

27. What do you do? Cry? Call your senior resident/fellow?
Give metoprolol?
Give adenosine?
All of the above?

28. What do you do? Cry? Call your senior resident/fellow?
Give metoprolol?
Give adenosine?
All of the above?

29. Case 4-Adenosine

30. SVT

31. SVT treatment Vagal maneuvers (with ECG) Adenosine (with ECG)
6mg, 12mg, central line if possible
Beta-blockers/Ca channel blockers (on telemetry)
Can use even if WPW known on baseline ECG
Amiodarone (on telemetry)
Procainamide (on telemetry)
DCCV

32. Case 4-Two patients, same diagnosis

33. What is the diagnosis? Artifact Atrial flutter Atrial tachycardia
Ventricular tachycardia

34. What is the diagnosis? Artifact Atrial flutter Atrial tachycardia
Ventricular tachycardia

35. Wide Complex Tachycardia

36. Case 5 35 year old male with a history of nonischemic cardiomyopathy
Presents with palpitations

37. Case 5

38. What is the diagnosis? Atrial fibrillation Atrial flutter
Sinus Tachycardia
Ventricular Tachycardia

39. What is the diagnosis? Atrial fibrillation Atrial flutter
Sinus Tachycardia
Ventricular Tachycardia

40. Case 5

41. Fusion beat

42. VT-Concordance

43. Paroxysmal RVOT VT

44. What to do? If hemodynamically unstable, ACLS/shock
If hemodynamically stable, don’t shock
Call cardiology
Amiodarone 150mg IV, then mg/min gtt
Lidocaine 100mg IV, 1-4mg/min gtt
Beta-blocker
IABP
Intubate/paralyze

45. PVCs

46. What to do? Most times, nothing if asymptomatic
Beta-blocker first line if symptomatic
Check labs?
Usually normal
Turn off telemetry?
Reasonable

47. Polymorphic VT

48. Polymorphic VT Shock/ACLS Magnesium Get an ECG when not in VT
Call cardiology
Beta-blocker
Isoproterenol
Pacing
Ischemia evaluation
Avoid QT prolonging drugs (

49. VF

50. VF
Shock
Do chest compressions
ACLS drugs
Don’t bother with an ECG

51. Bradycardia

52. Sinus bradycardia

53. Type I, 2nd degree AV block (Wenckebach)

54. Type 2, 2nd degree AV block

55. 2:1 AV block

56. Complete heart block

57. Slow escape rhythm

58. Regularized atrial fibrillation

59. Bradycardia Management
Usually, HR <40bpm
Is the patient symptomatic?
Mental status changes, hypotension, angina, shock, heart failure
Acute or chronic
Are they sleeping? Do they have sleep apnea?
Not everyone with bradycardia, even complete heart block, needs acute treatment if stable

60. Management Trancutaneous pacing (sedate)
Atropine 0.5mg Q3-5min, max 3mg
Avoid if cardiac transplant (may worsen block)
Dopamine infusion
Epinephrine infusion
Isoproterenol infusion
Glucagon if beta-blocker overdose
Transvenous pacing (call cardiology)

61. Conclusions

62. Conclusions You will be called (frequently) about arrhythmia issues
Get an ECG
If tachycardia, don’t use hemodynamics to diagnose
Wide or narrow, regular or irregular
Beta-blockers, calcium channel blockers
Amiodarone
Cardioversion
If bradycardia, where is the level of block?
Are they symptomatic?
Call cardiology for transvenous pacing

63. EKG's or other questions: jprutkin@cardiology.washington.edu
Thanks!
EKG's or other questions: