Lecture 2 : Peri Arrythmia | Cardiac Arrhythmia | Artificial Cardiac Pacemaker

U.M.F. “Gr. T.

Popa” Iaşi
Emergency Medicine

Peri-arrest arrhythmias
Prof.Diana Cimpoeşu MD,PhD


Reversible Causes
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Hypoxia Hypovolemia Hypo/hyperkale mia Hypothermia

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Tension Pneumotorax Tamponade cardiac Toxics Thrombosis (coronary or pulmonary)

Peri-arrest arrhythmias Principles of treatment

In all cases : -give oxygen -i.v acces -monitor - 12-lead ECG -electrolyte abnormalities - correct any abnormalities K, Mg, Ca

Treat the patient not the ECG monitor!

Cardiac arythmia
Principles of treatment

How the pacient is feel? Stable or unstable haemodinamic? We see adverse manifestation ? Witch type of arythmia is present ?

Adverse signs (1)

Clinical signs of low cardiac output : -pallor, sweating , cold extremities , altered menthal status , hypotension (BP<90mmHg ) Excessve tachycardia >150/min.

Adverse signs (2)

Excessive Bradychardia -absolute< 40/min and relative< 60/min on pacients with low cardiac reserve

Signs of Heart Failure. -acute pulmonary oedema, raised jugulars venous pressure, hepatic engorgement

Chest pain

Treatment options

Pacing Cardioversion


All arrhythmias  Anti-arrhythmic medication and other drugs

Cardiac Pacing
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Safe method for treatment of bradychardia Required a skillfull person for transvenous pacing Required is there is a risk of asystola ; instable pacient ; not responding to atropine Transcutaneous pacing – initiate immediately , use analgesia and sedation Fist pacing- serial rhythmic blows 50- 70 / min


Is used to convert atrial or ventricular tachyarrythmias Is used when patient is unstable or deteriorating
– Medication is ineffective

Risk of inducting Ventricular Fibrillation !
– Shock must be syncronised with R wave – Require analgesia and sedation


First shock energies : - Start with 200 J monophasic (120-150 J biphasic ) – for broad complex tachycardia and AF -Start with 100 J monophasic (70-120 J biphasic ) – paroxysmal SVT and atrial flutter

Antiarrhythmic drugs
Could convert tachyarrhytmia – Less secure then cardioversion – Used on patients without severity signs  Used in first episode of bradychardia – Less eficients in case of low cardiac output All antiarrhytmic drugs can cause arrhytmia !

Adverse signs ? – Systolic BP < 90 mmHg – Heart rate < 40 b/min – Ventricular arrhytmias compromising BP – Heart failure If Yes – atropine 500 µ g i.v. and evaluate response  DO NOT GIVE atropine to patients with cardiac transplants , it can cause a high degree AV block or even sinus arrest

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Satisfactory response NO adverse signs Evaluate risk of asystole: Recent asystole? Mobitz II AV block? Complete heart block with broad QRS ? Ventricular pause >3s ?

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IF :
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Risk of asystole or DOES NOT respond to atropine Repeat atropine 500 mcg to maximum 3 mg Transcutaneous pacing Adrenaline 2-10 µ g /min Arange transvenous pacing Seek expert help !

1. 2. 3. 4.


Alternate drugs for pentru bradycardia : - dopamine - isoprenaline - aminophylline - glucagon iv – if beta-blocker or calcium channel blocker overdose


IF does not responde to atropine and: NO risk of asystole ! Observe pacient


Pacient unstable and deteriorating: - syncronised cardioversion, amiodarone 300 mg in 10-20min, repeta cardioversia, reattempt cardioversion, amiodarone 900 mg over 24 h Patient stable – antiarrythmics drugs


Broad complex tachycardia QRS >0,12s: -Usually ventricular in origin but may be caused by supraventricular rhythms with aberrant conduction - regular rhythm – VT or SVT with bundle branch block -Irregular rhythm –VT polymorphic , AF with bundle branch block, Af with WPW

Broad complex tachycardia QRS >0,12s

Pulse? No! – VF/Vtah Yes! – stable/unstable?

Broad complex tachycardia QRS >0,12s

Is patient stable?
– – – – –

Sistolic BP< 90 mmHg Chest Pain Heart Failure Heart Rate > 150 /min Reduced Conscious level Yes •Seek expert help • cardioversion 200J(120-150) synchronised DC Shock up to 3 attempts •Amiodarone 900 mg over 24 h

No •Amiodarone 300mg iv over 10-20 min •Expert cardiology •Cardioversion • Amiodarone 900 mg
over 24 h

correct HipoK, give magnesium 2g over 10 min


Narow complex tachycardia : - regular rhythm : - sinus ,AV nodal re-entry tachycardia , AV re-entry tachycardia (AVRT), atrial flutter with regular AV conduction - Irregular rhythm – AF , atrial flutter with variable AV conduction

Narrow complex tachycardia (PSVT)-Regular

Use vagal manoeuvres
– – Valsalva manoeuvre (forced expiration against a closed glottis) Carotid sinus massage


Adenosine i.v.
– – 6 mg bolus 12 mg bolus, (repeat 12 mg)

Failure to terminate a regular narrow-tach: Seek expert help!

Narrow complex tachycardia (PSVT)Regular
Is patient stable? Sistolic BP< 90 mmHg Chest Pain Heart Failure Heart Rate > 200 /min Reduced Conscious level

No Antiarrythmics

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Yes Cardioversion 100J (70-120J) Amiodarone 300 mg iv 20-60 min

Narrow complex tachycardia (PSVT)-Regular
Seek help N o

Is patient stable? Sistolic BP< 90 mmHg Chest Pain Heart Failure Heart Rate > 200 /min Reduced Conscious level

ye s

•Esmolol: 40 mg 1 min + piv 4 mg /min
o r

Cardioversion 100 J, biphasic(70-120J)

•Verapamil 5-10 mg i.v. or •Amiodarone: 300 mg 20-60 min or •Digoxin: iv maximum 500 µg in 30 min x2

Amiodarone 300 mg in 20 min 900 mg in 24h •Repeat cardioversion

Post-resuscitation care
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Return of spontaneos circulation ROSC Hypoxia and hypercarbia –contribute to secondary brain injury Tracheal intubation, sedation and controlled ventilation Normocarbia Pa CO2 Normal PaO2

1. Australia Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-ofhospital cardiac arrest with induced hypothermia. N Engl J Med 2002;346:557-63. 2. Europa The Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002;346:549-56. Mild therapeutic hypothermia (33°C in the first study and 32°C to 34°C in the second) in survivors of out-of-hospital cardiac arrest.


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