1. Cardiology II Arrhythmias

2. Objectives O Describe the normal conduction in the heart O Describe pathophysiology of bradycardias O Describe pathophysiology of tachycardias O Describe treatment of the above

3. Case O A 55 year old male calls 911 because his “heart is racing.” He initially is alert, oriented, and has mild shortness of breath. On physical exam, he has a regular tachycardia at 180, and monitor shows a regular, narrow-complex tachycardia. He denies chest pain. Midway through transport, he becomes less responsive, and his blood pressure drops as he starts sweating profusely.

4. Normal Conduction

6. ECG waveform

8. Normal ECG

9. Sinus Arrhythmia

10. Bradycardias O Caused by damage to the conduction system resulting in a “broken road” or by drugs (beta blocker, calcium channel blockers) O If due to drugs, reversible. If not, many require a permanent pacemaker O Our goal is to temporarily support the heart rate until one of those two happen. O Atropine or External Pacing are options.

11. Sinus Bradycardia

12. First Degree AV Block

13. Second Degree (Type I)

14. Second Degree (Type II)

15. Third Degree Block

16. Junctional Rhythm

17. Accelerated Idioventricular

18. Ventricular Escape

19. Ventricular fibrillation

20. What is this?

21. Asystole

22. Branch Blocks O “Hiccups” on the conduction highway past the AV node O Can involve the right bundle, the left bundle, or divisions of the left bundle

23. Right Bundle Branch Block

24. Left Bundle Branch Block

25. Bifasicular Block RB/LA

26. Bifasicular Block – RB/LP

27. Trifasicular Block

28. Tachycardias O Any heart rate greater than 100. O The key is using the pattern to determine what is causing the tachycardia O The treatment is even more diverse, thus, knowing the pattern is critical to choosing the correct therapy. O The three main branches of tachycardia are atrial, nodal, and ventricular

29. Sinus Tachycardia

30. Atrial Fibrillation

31. Atrial Fib with Abberancy

32. Multifocal Atrial Tachycardia

33. Atrial Flutter

35. AV Nodal Reentrant Tachycardia

36. Wolfe Parkinson White

37. Lown-Ganong-Lavine

38. AV Reciprocating Tachycardia

39. Ventricular Tachycardia

40. Torsades de Pointe

41. Miscellaneous

42. LVH

43. RVH

44. Hyperkalemia

45. Digoxin Toxicity

46. Brugada Syndrome

47. Wellen’s Syndrome

48. Treatment Summary O EMT O ABCs O Call for ALS O Rapid Transport O AEMT O IV O Cardioversion of V-tach, V-fib O Paramedic O Atropine, pacing for bradycardias O Vagal Maneuvers, Adenosine for narrow complex tachyarrhythmias O Amio, cardioversion for wide complex tachyarrhythmia