Jordan M. Prutkin, MD, MHSAssistant Professor

Department of Cardiology/Electrophysiology

University of Washington7/24/2014

What to do…Check the patient’s pulseGet an ECG

Unless there’s no pulse. Then call a code and do ACLS

Approaching an EKGEyeballRateRhythmAxisIntervalsP wavesQRS ST-T wavesOverall appearance

Approach to ArrhythmiasDo you have calipers?Are there P waves? Are the P waves and QRS’s regular? Are there more P waves than QRS complexes?Are there more QRS complexes than P waves?Is there a constant relationship between the P

waves and QRS complexes (constant PR)?Do the QRS complexes look like the baseline

QRS (if known)? Are they wider? Narrower?

Regular Irregular

Narrow Sinus TachAVNRTAVRTAtrial TachJunctional TachAtrial Flutter

AfibMATFrequent PACsRarely SVT Atrial Flutter Wenckebach

Wide Monomorphic VTAVRTSVT with: BBB Bypass pathway Ventricular pacing

Polymorphic VTVFibAfib, MAT, PACs with: BBB Bypass pathway Ventricular pacing

Case 173 year old female admitted with pneumonia,

reports acute onset of shortness of breath

Case 1

What does this EKG show?1. Sinus rhythm2. Atrial fibrillation3. Atrial flutter4. Atrial tachycardia

What does this EKG show?1. Sinus rhythm2. Atrial fibrillation3. Atrial flutter4. Atrial tachycardia

Case 261 year old male presents to the ED with

palpitationsHR 155bpm, BP 122/76

What does this EKG show?1. Sinus tachycardia2. Atrial fibrillation3. Atrial flutter4. Atrial tachycardia5. Artifact

What does this EKG show?1. Sinus tachycardia2. Atrial fibrillation3. Atrial flutter4. Atrial tachycardia5. Artifact

Management of Afib/flutterIs the patient hemodynamically stable?

If there’s hypotension, acute heart failure, mental status change, ischemia, or angina, then cardiovert

If stable, then what?About 1/2 to 2/3 will terminate spontaneously

within 24 hoursDo you need to do anything then?

If rapid or mildly/moderately symptomatic, yes. Asymptomatic, HR <110bpm

Otherwise, maybe not.

Rate controlIV

Diltiazem 5-20mg IV, then 5-20mg/hrMetoprolol 5mg IV Q5min x 3Esmolol gtt, if in ICU

PODiltiazem 30-60mg Q6HDiltiazem CD 120-240mg Q24HVerapamil 120-240mg Q24HMetoprolol 25mg Q6-8HMetoprolol XL 25-50mg Q12-24HAtenolol 12.5-50mg Q24HDigoxin?

Rhythm ControlAmiodarone 150mg IV, then 0.5-1 mg/min gtt

Should really have a central lineDon’t use if afib >48 hours and no

anticoagulation

FlecainidePropafenone Call cardiologyIbutilide

Anticoagulation/DCCV for AFIncreased risk of stroke after DCCVIf >48 hours, need three weeks of weekly

therapeutic coumadin levels, or TEE firstIf >48 hours and acute DCCV, give heparin

bolus, then infusion and anticoagulate for 4 weeks

If <48 hours, don’t need anticoagulation necessarily

LMWH, dabigatran, rivaroxaban, apixiban okay

Sinus tachycardia78 year old admitted with pyelonephritisHR 120bpmECG shows sinus tachycardia

Causes of sinus tachFeverInfection/SepsisVolume depletionHypotension/shockAnemiaAnxietyPulmonary

embolism

MIHeart failureCOPDHypoxiaHyperthyroidPheochromocytom

aStimulants/Illicit

substances

Treatment for Sinus TachIn general, don’t treat heart rateTreat underlying causeException for acute MI, use beta-blockers

Case 363 year old male is admitted with chest pain

to 5NEWhile waiting for a stress test, he reports

abrupt onset of palpitations and mild chest discomfort to his nurse.

Pulse 150, blood pressure 132/88

Case 3-Presenting EKG

What do you do?1. Cry?2. Call your senior resident/fellow?3. Give metoprolol?4. Give adenosine?5. All of the above?

What do you do?1. Cry?2. Call your senior resident/fellow?3. Give metoprolol?4. Give adenosine?5. All of the above?

Case 4-Adenosine

SVT

SVT treatmentVagal maneuvers (with ECG)Adenosine (with ECG)

6mg, 12mg, central line if possibleBeta-blockers/Ca channel blockers (on

telemetry)Can use even if WPW known on baseline ECG

Amiodarone (on telemetry)Procainamide (on telemetry)DCCV

What is the diagnosis?1. Artifact2. Atrial flutter3. Atrial tachycardia4. Ventricular tachycardia

What is the diagnosis?1. Artifact2. Atrial flutter3. Atrial tachycardia4. Ventricular tachycardia

Case 535 year old male with a history of

nonischemic cardiomyopathyPresents with palpitations

What is the diagnosis?1. Atrial fibrillation2. Atrial flutter3. Sinus Tachycardia4. Ventricular Tachycardia

What is the diagnosis?1. Atrial fibrillation2. Atrial flutter3. Sinus Tachycardia4. Ventricular Tachycardia

Fusion beat

VT-Concordance

What to do?If hemodynamically unstable, ACLS/shockIf hemodynamically stable, don’t shockCall cardiologyAmiodarone 150mg IV, then 0.5-1.0mg/min

gttLidocaine 100mg IV, 1-4mg/min gttBeta-blockerIABPIntubate/paralyze

PVCs

What to do?Most times, nothing if asymptomaticBeta-blocker first line if symptomaticCheck labs?

Usually normalTurn off telemetry?

Reasonable

Polymorphic VTShock/ACLSMagnesiumGet an ECG when not in VTCall cardiologyBeta-blockerIsoproterenolPacingIschemia evaluationAvoid QT prolonging drugs (www.torsades.org)

VFShockDo chest compressionsACLS drugsDon’t bother with an ECG

Sinus bradycardia

Type 2, 2nd degree AV block

Regularized atrial fibrillation

Bradycardia ManagementUsually, HR <40bpmIs the patient symptomatic?

Mental status changes, hypotension, angina, shock, heart failure

Acute or chronicAre they sleeping? Do they have sleep apnea?Not everyone with bradycardia, even

complete heart block, needs acute treatment if stable

ManagementTrancutaneous pacing (sedate)Atropine 0.5mg Q3-5min, max 3mg

Avoid if cardiac transplant (may worsen block)Dopamine infusionEpinephrine infusionIsoproterenol infusionGlucagon if beta-blocker overdoseTransvenous pacing (call cardiology)

ConclusionsYou will be called (frequently) about arrhythmia

issuesGet an ECGIf tachycardia, don’t use hemodynamics to diagnose

Wide or narrow, regular or irregularBeta-blockers, calcium channel blockersAmiodaroneCardioversion

If bradycardia, where is the level of block?Are they symptomatic?Call cardiology for transvenous pacing

EKG's or other questions:jprutkin@cardiology.washington.

edu