1. Arrhythmias Medical Student Teaching Tuesday 24 th January 2012 Dr Karen Jones, SpR Emergency Medicine

2. Aims:  Recognition of common arrhythmias  Identification of adverse features that indicate the risk of imminent deterioration  Understanding the treatment options

3. What are arrhythmias and why are they important?  Rhythms that are not produced by the SA node and transmitted through the electrical system of the heart in the normal way  Some abnormal rhythms may lead to cardiac arrest or deterioration if untreated  If you can identify an arrhythmia and institute the correct treatment you may be able to prevent deterioration

4. The Cardiac Conduction System

5. I think the patient has an arrhythmia, what should I do?

6.  Start with ABC!  Check for a pulse  Give oxygen!  Get the patient on a cardiac monitor  Insert an iv cannula  Assess for adverse features  Get a 12 lead ECG

7. Adverse features  Shock  Syncope  Heart failure  Chest pain  Extreme heart rate  > 150  < 40

8. What treatment options are there?  Do nothing  Simple clinical interventions  Drugs  Electricity

9. Assessing a rhythm 1.Is there any electrical activity? 2.What is the rate – fast, normal or slow? 3.Is the rhythm regular or irregular? 4.Is the QRS complex narrow or wide? 5.Are there P waves? 6.Are the P waves related to the QRS complexes?

10. What is the rhythm?

11. Asystole

12. What is the rhythm?

13. Ventricular Fibrillation

14. Treatment?

15. What is the rhythm?

16. Ventricular Tachycardia (VT)

18. Treatment?

19. It depends…CHECK THE PATIENT!  No pulse = ELECTRICITY (Defibrillate)  Adverse signs = ELECTRICITY (Cardioversion)  No adverse signs = DRUGS (Amiodarone)

20. What is the rhythm?

21. Torsades de Pointes

22. Treatment?

23. What is the rhythm?

24. Sinus Tachycardia

25. Treatment?

26. CHECK THE PATIENT!  Check for a pulse and ABC  Treat the underlying cause  Pyrexia  Hypoxia  Hypovolaemia  Pain  Agitation  Toxins

27. What is the rhythm?

28. AV nodal re-entry tachycardia (Supraventricular tachycardia SVT)

30. Treatment?

31. It depends…CHECK THE PATIENT!  No pulse = CPR  Adverse signs = Electricity (Cardioversion)  No adverse signs = Vagal Manoeuvres Drugs (Adenosine)

32. What is the rhythm?

33. Atrial Fibrillation

35. Treatment?

36. It depends…CHECK THE PATIENT!  No pulse = CPR  Adverse signs =ELECTRICITY (Cardioversion)  No adverse signs = DRUGS

37. What is the rhythm?

38. Atrial Flutter

39. Treatment?

41. What is the rhythm?

42. Sinus Bradycardia

43. What is the rhythm?

44. First Degree AV Block

45. What is the rhythm?

46. Second Degree AV Block Mobitz Type I (Wenckebach)

47. What is the rhythm?

48. Second Degree AV Block Mobitz Type II

49. What is the rhythm?

50. Third Degree AV Block (Complete Heart Block)

51. Treatment?

52. It depends…CHECK THE PATIENT!  Adverse signs = DRUGS (Atropine) Temporary pacing Permanent pacing  No adverse signs =MONITOR

54. TAKE HOME MESSAGES!  Always start with ABC  Check for adverse signs  Get a 12 lead ECG and use the 6 step approach  Treatment depends on the clinical state of the patient CHECK THE PATIENT!