1. Arrhythmia recognition and treatment
Cardiology Acute Care Day

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

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

4. 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: 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: msec QRS: msec, narrow unless effected by underlying anomoly

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

6. 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?

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

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

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

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

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

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

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

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

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

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

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

18. Atrial fibrillation
Rate variable
Irregular, narrow QRS
No P waves

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

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

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

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

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

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

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

26. 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

27. 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

28. 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?

29. 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

30. 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

31. Temporary pacing

32. 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

33. 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

34. Following administration of beta-blocker

35. 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

36. 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

37. Termination of SVT with Adenosine
adenosine 6mg IV

38. 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

39. Following bisoprolol

40. 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

41. 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

42. 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

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