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Cardiac Arrhythmias

JSDJ

The Interventricular Conduction
System
 SA Node
 Internodal Tracts
 AV Node
 Bundle of His
 RBB
 LBB

Classification of Cardiac
Arrhythmias

 Disturbance of Impulse formation
 A. Disturbance of SA Dysfunction
1. Sinus Tachycardia
2. Sinus Bradycardia
3.Sinus Arrhythmia
4. Sinus Arrest

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Bradyarrhythmias The slow pokes (HR<60)… .

First Degree AV Block  Delay at the AV node results in prolonged PR interval  PR interval>0.  Leave it alone .2 sec.

Second Degree AV Block Type 1 (Wenckebach)  Increasing delay at AV node until a p wave is not conducted.  Often comes post inferior MI with AV node ischemia  Gradual prolongation of the PR interval before a skipped QRS. QRS are normal!  No pacing as long as no bradycardia. .

Second Degree AV Block Type 2   Diseased bundle of HIS with BBB. . Sudden loss of a QRS wave because p wave was not transmitted beyond AV node. QRS are abnormal!  May be precursor to complete heart block and needs pacing.

 Must treat with pacemaker. .Third Degree AV Block  Complete heart block where atria and ventricles beat independently AND atria beat faster than ventricles.

Left Bundle Branch Block Left ventricle gets a delayed impulse  QRS is widened (at least 3 boxes)  V5 and V6 have RR’ (rabbit ears)   Be careful not to miss any hiding q waves!  Pacemaker if syncope occurs .

.Right Bundle Branch Block Right ventricle gets a delayed impulse  QRS is widened (at least 3 boxes)    V1 and V2 have rSR’ Pacemaker if syncope occurs.

Bifascicular Block  RBBB plus LABB OR RBBB plus LPBB QRS is widened (at least 3 boxes)  V5 and V6 have RR’ (rabbit ears)    V1 and V2 have rSR’ Pacemaker if syncope occurs .

Tachyarrhythmias The speed demons…(HR >100) .

Tachyarrhythmias  Supraventricular tachycardia  Atrial fibrillation  Atrial flutter  Ventricular tachycardia   Monomorphic  Polymorphic (Torsades de pointe) Ventricular fibrillation .

Supraventricular Tachycardia .

but we usually do this only in young patients .SVT  Reentrant arrhythmia at AV node that is spontaneous in onset  May have neck fullness. class 1A or 1C or amiodarone or sotalol work well  Ablation will cure it too. hypotension and/or polyuria due to ANP  Narrow QRS with tachycardia  First line is vagal maneuvers  Second line is adenosine or verapamil  For chronic SVT.

Multifocal Atrial Tachycardia .

 Three or more types of p waves and a rate > 100  Digoxin worsens it. . atrial stretch and local metabolic imbalance. COPD. so treat with oxygen and slow channel blocker like verapamil or diltiazem.MAT  Automatic atrial rhythm from various different foci  Seen in hypoxia.

Wolf Parkinson White .

short PR interval (<0.WPW  Ventricles receive partial signal normally and partially through accessory pathway  Symptomatic tachycardia.12)  Electrophysiologic testing helps to identify the reentry pathway and location of the accessory pathway . a delta wave and prolonged QRS (>0.12).

a-fib can happen via the accessory pathway  Inhibition of the AV node will end up in worsening the a-fib because none of the signals are slowed down by the AV node before hitting the ventricle. * Do not use any meds that will slow AV node conduction. adenosine or calcium channel blockers. * The best choice is procainamide as it slows the accessory pathway. ie digoxin. *If patient becomes hypotensive. cardiovert immediately! . beta-blockers.WPW  Because WPW has both normal conduction through the AV node and accessory pathway conduction that bypasses the AV node.

Atrial Flutter .

there is AV node damage  Treatment is to slow AV node conduction with amiodarone. if it is 3:1 or higher. Usually a 2:1 conduction pattern. . propafenone or sotalol  DC cardiovert if <48 hours or unstable  You can also ablate the reentry pathway within the atrium between the tricuspid and the IVC.Atrial Flutter  Atrial activity of 240-320 with sawtooth pattern.

Atrial Fibrillation .

thyrotoxicosis or ETOH  Therapy is either rate control via slowing AV node conduction with stroke prophylaxis or rhythm control . valvular heart desease.A-Fib  Can be due to HTN. WPW. cardiomyopathy. sick sinus.

Ventricular Tachycardia .

Ventricular Tachycardia  Impulse is initiated from the ventricle itself  Wide QRS. IV Amiodarone and/or DCCV  Consider procainamide  Nonsustained ventricular tachycardia needs no treatment . Rate is 140-250  If unstable DC cardiovert  If not.

Torsades de Pointes  “Twisting of the points” is usually caused by medication (quinidine. amiodarone. disopyramide. lidocaine. or temporary overdrive pacing  Chronic: may need pacemaker/ICD. sotalol. hypokalemia or bradycardia especially after MI  Has prolonged QT interval  Acute: Remove offending medication. Shorten the QT interval with magnesium. beta-blockers . isoproterenol. TCA).

hypothermia & electric shock can precipitate  Absence of ventricular complexes  Usually terminal event  Use Amiodarone if refractory to DCCV.Ventricular Fibrillation  Most common in acute MI. anesthesia. also drug overdose. .

Sudden Cardiac Death .