2. 2

3.  Unstable :  Altered mental status  Ischemic chest discomfort  Acute heart failure  Hypotension  Other signs of shock  Symptomatic:  Palpitations  Lightheadedness  Dyspnea 07/07/1392Bradycardia & Tachycardia 3

4.  A heart rate of <60 beats per minute.  When bradycardia is the cause of symptoms, the rate is generally <50 beats per minute, which is the working definition of bradycardia used here. 07/07/1392Bradycardia & Tachycardia 4

5. Management of clinically significant bradycardia. 07/07/1392Bradycardia & Tachycardia 5

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7. Should focus on :  signs of increased work of breathing  Tachypnea  Intercostal retractions  Suprasternal retractions  Paradoxical abdominal breathing  oxyhemoglobin saturation as determined by pulse oximetry. 07/07/1392Bradycardia & Tachycardia 7

8.  Provide supplementary oxygen  Attach a monitor to the patient  Evaluate blood pressure  Establish IV access.  If possible, obtain a 12-lead ECG to better define the rhythm. 07/07/1392Bradycardia & Tachycardia 8

9. 07/07/1392Bradycardia & Tachycardia 9

10.  Do not necessarily require treatment  Unless:  There is suspicion that the rhythm is likely to progress to symptoms  Or become life-threatening (eg, Mobitz type II second-degree AV block in the setting of acute myocardial infarction [AMI]) 07/07/1392Bradycardia & Tachycardia 10

11.  Is suspected to be the cause of:  Acute altered mental status  Ischemic chest discomfort  Acute heart failure  Hypotension  Or other signs of shock  The patient should receive immediate treatment 07/07/1392Bradycardia & Tachycardia 11

12. 07/07/1392Bradycardia & Tachycardia 12 Immediate treatment

13. 07/07/1392Bradycardia & Tachycardia 13

14.  Are classified as:  First  Second  Third-degree  Blocks may be caused by :  Medications  Electrolyte disturbances  Structural problems resulting from AMI or other myocardial diseases 07/07/1392Bradycardia & Tachycardia 14

15. 07/07/1392Bradycardia & Tachycardia 15

16.  Is divided into Mobitz types I and II  Mobitz types I: 07/07/1392Bradycardia & Tachycardia 16

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18. 07/07/1392Bradycardia & Tachycardia 18

19.  Atropine remains the first-line drug for acute symptomatic bradycardia  Atropine :  Should be considered a temporizing measure while awaiting a transcutaneous or transvenous pacemaker  For patients with  Symptomatic sinus bradycardia  Conduction block at the level of the AV node  Sinus arrest. 07/07/1392Bradycardia & Tachycardia 19

20.  The recommended dose is:  0.5 mg IV every 3 to 5 minutes to a maximum total dose of 3 mg.  Doses of ‹ 0.5 mg may paradoxically result in further slowing of the heart rate 07/07/1392Bradycardia & Tachycardia 20

21.  Use atropine cautiously in the presence of acute coronary ischemia or MI  Increased heart rate may worsen ischemia or increase infarction size. 07/07/1392Bradycardia & Tachycardia 21

22.  Atropine will likely be :  Ineffective in patients who have undergone cardiac transplantation  Because the transplanted heart lacks vagal innervation 07/07/1392Bradycardia & Tachycardia 22

23.  Avoid relying on atropine in :  Type II second-degree or third degree AV block  These bradyarrhythmias are not likely to be responsive to reversal of cholinergic effects by atropine  These are preferably treated with TCP or adrenergic support as temporizing measures while the patient is prepared for transvenous pacing 07/07/1392Bradycardia & Tachycardia 23

24.  TCP may be useful for the treatment of symptomatic bradycardias  TCP is, at best, a temporizing measure  TCP is painful in conscious patients  whether effective or not :  The patient should be prepared for transvenous pacing  And expert consultation should be obtained. 07/07/1392Bradycardia & Tachycardia 24

25.  It is reasonable to initiate TCP in unstable patients who do not respond to atropine  Immediate pacing might be considered in unstable patients with high-degree AV block when IV access is not available  If the patient does not respond to drugs or TCP, transvenous pacing is probably indicated 07/07/1392Bradycardia & Tachycardia 25

26.  Although not first-line agents for treatment of symptomatic bradycardia:  Dopamine  Epinephrine  Isoproterenol  Use alternatives when a bradyarrhythmia is :  Unresponsive to or inappropriate for treatment with atropine,  Or as a temporizing measure while awaiting the availability of a pacemaker. 07/07/1392Bradycardia & Tachycardia 26

27.  Dopamine infusion may be used for :  Patients with symptomatic bradycardia  Particularly if associated with:  Hypotension,  In whom atropine may be inappropriate  Or after atropine fails  Begin dopamine infusion at 2 to 10 mcg/kg per minute and titrate to patient response. 07/07/1392Bradycardia & Tachycardia 27

28.  Epinephrine infusion may be used for:  Patients with symptomatic bradycardia  Particularly if associated with:  Hypotension  Whom atropine may be inappropriate  After atropine fails  Begin the infusion at 2 to 10 mcg/min and titrate to patient response 07/07/1392Bradycardia & Tachycardia 28

29.  The recommended adult dose is 2 to 10 mcg/ min by IV infusion, titrated according to heart rate and rhythm response 07/07/1392Bradycardia & Tachycardia 29

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33.  An arrhythmia with a rate of 100 beats per minute  As with defining bradycardia:  Rate of 150 beats per minute is more likely attributable to an arrhythmia 07/07/1392Bradycardia & Tachycardia 33

34.  Fever  Dehydration  Other underlying conditions  When a heart rate is <150 beats per minute:  It is unlikely that symptoms of instability are caused primarily by the tachycardia 07/07/1392Bradycardia & Tachycardia 34

35. Should focus on :  signs of increased work of breathing  Tachypnea  Intercostal retractions  Suprasternal retractions  Paradoxical abdominal breathing  oxyhemoglobin saturation as determined by pulse oximetry. 07/07/1392Bradycardia & Tachycardia 35

36.  Provide supplementary oxygen  Attach a monitor to the patient  Evaluate blood pressure  Establish IV access.  If possible, obtain a 12-lead ECG to better define the rhythm. 07/07/1392Bradycardia & Tachycardia 36

37. 07/07/1392Bradycardia & Tachycardia 37

38.  The provider should assess the patient’s degree of instability and determine if the instability is related to the tachycardia 07/07/1392Bradycardia & Tachycardia 38

39.  Is suspected to be the cause of:  Acute altered mental status  Ischemic chest discomfort  Acute heart failure  Hypotension  Or other signs of shock  The patient should receive immediate syn- chronized cardioversion 07/07/1392Bradycardia & Tachycardia 39

40.  The patient with a regular narrow-complex :  May be treated with adenosine while preparations are made for synchronized cardioversion 07/07/1392Bradycardia & Tachycardia 40

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43.  If possible:  Establish IV access before cardioversion  Administer sedation if the patient is conscious  Do not delay cardioversion if the patient is extremely unstable 07/07/1392Bradycardia & Tachycardia 43

44.  Synchronized Cardioversion Vs Unsynchronized Shocks(defibrillation) 07/07/1392Bradycardia & Tachycardia 44

45.  Synchronized cardioversion is recommended to treat :  Unstable SVT  Unstable atrial fibrillation  Unstable atrial flutter  Unstable monomorphic (regular) VT 07/07/1392Bradycardia & Tachycardia 45

46.  Biphasic energy dose for cardioversion of :  Atrial fibrillation is 120 to 200 J  Atrial flutter and other SVTs 50 J to 100 J  Monomorphic VT (regular form and rate) with a pulse 100 J If there is 07/07/1392Bradycardia & Tachycardia 46

47.  Polymorphic VT :  Treat as VF deliver high-energy unsynchronized shocks (defibrillation doses)  Any doubt whether monomorphic or polymorphic VT in the unstable patient :  Defibrillation doses 07/07/1392Bradycardia & Tachycardia 47

48.  The provider has time to :  Obtain a 12-lead ECG  Evaluate the rhythm  Determine the width of the QRS complex  Determine treatment options.  Stable patients may await expert consultation 07/07/1392Bradycardia & Tachycardia 48

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50.  Appearance of the QRS complex  Heart rate  Regularity 07/07/1392Bradycardia & Tachycardia 50

51.  Vagal maneuvers:  Valsalva maneuver or carotid sinus massage  Adenosine:  If PSVT does not respond to vagal maneuvers  Give 6 mg of IV adenosine as a rapid IV push through a large vein followed by a 20 mL saline flush  Calcium Channel Blockers and B-Blockers:  Verapamil, Diltiazem, Metoprolol,Atenolol, Propranolol, 07/07/1392Bradycardia & Tachycardia 51

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57.  Ventricular tachycardia (VT)  Ventricular fibrillation(VF)  SVT with aberrancy  Pre-excited tachycardias (Wolff-Parkinson-White syndrome)  Ventricular paced rhythms 07/07/1392Bradycardia & Tachycardia 57

58.  Determine if the rhythm is regular or irregular  A regular wide-complex tachycardia:  Adenosine  Procainamide  Amiodarone  Sotalol  Cardioversion  An irregular wide-complex tachycardia:  Procainamide  Amiodarone  Magnesium  Isoproterenol  Cardioversion 07/07/1392Bradycardia & Tachycardia 58

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