1. ADVANCED CONCEPTS IN EMERGENCY CARE (EMS 483)
Bradycardia & Tachycardia
ADVANCED CONCEPTS IN EMERGENCY CARE (EMS 483)
Lalith Sivanathan
2015

2. Content Rhythms for bradycardia Symptomatic bradycardia
Signs and symptoms of symptomatic bradycardia
Management of symptomatic bradycardia
Transcutaneous pacing
Unstable Tachycardia
Rhythms
Signs and symptoms
Management
Synchronized cardioversion
Stable Tachycardia

3. Rhythm for bradycardia
Sinus bradycardia
First degree AV block
Second degree AV block
Type I (Wenckeback / mobitz I)
Type II ( Mobitz II)
Third degree AV block

4. Symptomatic bradycardia
Patient have heart rates in the normal sinus range but these rates are inappropriate or insufficient for them. This is called functional or relative bradycardia (for eg. A heart rate of 70/min is too slow for a patient in cardiogenic shock.

5. A symptomatic bradycardia exists clinically when 3 criteria are present
The heart rate is slow
The patient has symptoms
The symptoms are due to the slow heart rate.

6. Signs and symptoms Symptoms Signs
Chest discomfort or pain, shortness of breath
Decreased level of consciousness
weakness, fatigue, light – headedness, dizziness or syncope
Signs
Hypotension, drop in BP on standing (orthostatic hypotension)
Diaphoresis, pulmonary congestion, frank congestive heart failure or pulmonary edema
Bradycardia related frequent premature ventricular complexes or VT

7. Management A Maintain patent airway B
Assist breathing as needed; give oxygen in case of hypoxemia; monitor oxygen saturation C
Monitor blood pressure and heart rate; obtain and review 12-lead ECG; establish IV access D
Conduct a problem focused history and physical examination; search for and treat possible contributing factors

8. If patient has poor perfusion secondary to bradycardia
Give atropine as first line treatment
Atropine 0.5mg IV – may repeat to a total dose of 3 mg
If atropine is ineffective
Transcutaneous pacing Or
Dopamine 2 to 10 mcg/kg per minute (chronotropic or heart rate dose)
Epinephrine 2 to 10 mcg/min

9. TRANSCUTANEOUS PACING
Indications
Hemodynamically unstable bradycardia
Symptomatic Sinus bradycardia
Mobitz type II Second degree AV block
Third degree AV block
Precautions
TCP is contraindicated in severe hypothermia and not recommended for asystole
Conscious patients require analgesia for discomfort
Do not assess the carotid pulse to confirm mechanical capture; electrical stimulation causes muscular jerking that may mimic the carotid pulse.

10. Steps to perform TCP Step Action 1
Place pacing electrodes on the chest according to package instructions 2
Turn the pacer ON 3
Set the demand rate to approximately 60/min. This rate can be adjusted up or down (based on patient clinical response) once pacing is established 4
Set the current milliampered output 2 mA above the dose at which consistent capture is observed (safety margin)

11. Unstable Tachycardia
Unstable tachycardia exists when the heart rate is too fast for the patient’s clinical condition and the excessive heart rate causes symptoms or an unstable condition because the heart is
Beating so fast that cardiac output is reduced. This can cause pulmonary edema, coronary ischemia and reduced blood flow to vital organs
Beating ineffectively so that coordination between atrium and ventricles or the ventricles themselves reduces cardiac output

12. Rhythms for unstable tachycardia
Atrial fibrillation
Atrial flutter
Reentry supraventricular tachycardia (SVT)
Monomorphic VT
Polymorphic VT
Wide complex tachycardia or uncertain type

13. Symptoms and signs Hypotension Altered mental status Signs of shock
Ischemic chest discomfort
Acute heart failure

14. Management
Look for signs of increased work of breathing (tachypnea or intercostal, suprasternal retractions)
Give oxygen, if indicated and monitor oxygen saturation
Obtain an ECG to identify the rhythm
Evaluate the blood pressure
Establish IV access
Identify and treat reversible causes.

15. If the patient is unstable but has a pulse with regular uniform wide complex VT (monomorphic VT)
Treat with synchronized cardioversion and an initial shock of 100 J monophasic waveform)
If there is no response to the first shock increasing the dosage in a step wise pattern is reasonable

16. Arrhythmic with a polymorphic QRS appearance (polymorphic VT) such as torsades de pointes will usually not permit synchronization. If patient has polymorphic VT
Treat as VF with high energy unsynchronized shocks ( defibrillation doses)

17. When to use synchronized shocks
Unstable SVT
Unstable atrial fibrillation
Unstable atrial flutter
Unstable regular monomorphic tachycardia with pulses

18. When to use unsynchronized shocks
For a patient who is pulseless
For a patient demonstrating clinical deterioration (in prearrest) such as those with severe shock or polymorphic VT, when you think a delay in converting the rhythm will result in cardiac arrest
When you are unsure whether monomorphic or polymorphic VT is present in the unstable patient

19. Should the unsynchronized shock cause VF (occurring in only a very small minority of patients despite the theoretical risk), immediately attempt defibrillation

20. Synchronized cardioversion
Sedate all conscious patients unless unstable or deteriorating rapidly
Turn on the defibrillator (monophasic or biphasic)
Attach monitor leads to the patient and ensure proper display of the patient’s rhythm. Position adhesive electrode (conductor) pads on the patient
Press the SYNC control button to engage the synchronization mode.
Look for markers on the R wave indicating sync mode.

21. 6. Adjust monitor gain if necessary until sync markers occur with each R wave 7. Select the appropriate energy level 8. Announce to team members: “charging defibrillator – stand clear” 9. Press the CHARGE button 10. Clear patient when the defibrillator is charged

22. 11. Press the SHOCK button
12. Check the monitor. If tachycardia persists, increase the energy level (joules)
Activate the sync mode after delivery of each synchronized mode after delivery of synchronized shock.

23. STABLE TACHYCARDIA Rhythms for stable tachycardia
Narrow QRS complex (SVT tachycardias)
Sinus tachycardia
Atrial fibrillation
Atrial flutter
AV nodal reentry
Wide QRS comples tachycardias
Monomorphic VT
Polymorphic VT
Regular or irregular tachycardia

24. Narrow QRS with regular rhythm
Attempt vagal maneuvers
Valsalva maneuver or carotid sinus massage will terminate about 25% of SVTs
Give adenosine
If SVT does not respond to vagal maneuvers:
Give adenosine 6 mg as a rapid IV push in a large (eg anticubital) vein over 1 sec. follow with a 20 ml saline flush and elevate the arm immediately
If SVT does not convert within 1 to 2 mins, give a seond dose of adenosine 12 mg rapid IV push following the same procedure above

25. Summary Rhythms for bradycardia Symptomatic bradycardia
Signs and symptoms of symptomatic bradycardia
Management of symptomatic bradycardia
Transcutaneous pacing
Unstable Tachycardia
Rhythms
Signs and symptoms
Management
Synchronized cardioversion
Stable Tachycardia

26. Questions?
Thank you….