Tachyarrthymias Sinus Tachycardia Sinus Tachycardia Atrial

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Tachyarrhythmias(also known as things that go
crump in the night!)

• Subha Varahan, M.D.

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Are you the intern on.?

• This pt.s HR is 140 and he doesnt look so
  good..
• Hypotensive?
• Hypoxic?
• New for the patient?
• STAT ECG!!!
• GO EXAMINE THE PATIENT!!!!
• Call your senior resident, get a crash cart
  ready, establish access, and IVF if needed!

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Tachyarrthymias

• Narrow Complex (Supraventricular Tachycardias)
• Regular rhythm
• Sinus tachycardia (ST)
• Ectopic atrial tachycardia
• AVNRT/AVRT
• Atrial flutter with fixed block (AFL)
• - Irregular rhythm
• Atrial fibrillation (AF)
• Multifocal atrial tachycardia (MAT)
• Atrial flutter with variable block

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Sinus Tachycardia
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Sinus Tachycardia

• Rate lt150
• Determine the underlying cause!!!
• Pain
• Fever (Infection)
• Hypovolemia
• Hypoxemia
• Anemia
• Hypothyroidism
• Anxiety
• Beta-agonists

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Atrial Fibrillation with RVR
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Atrial Flutter
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Atrial Fibrillation/Flutter

• Rate
• A-fib gt100 bpm
• A-flutter conducts with 21 block to give a
  ventricular rate of 150 (saw-tooth pattern)
• Normotensive
• New or old?
• Etiologies Ischemia, CHF, myocarditis/pericarditi
  s, hypertensive crisis, infection,
  thyrotoxicosis, drugs
• Old Off medications, dehydration
• New check cardiac biomarkers, TSH, CBC, CXR and
  ECHO in AM

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Atrial Fibrillation/Flutter

• Therapy ? Aimed at rate control!!!
• Metoprolol 5 mg IV x 3 doses and then start PO
  metoprolol
• Diltiazem Bolus with 10-20 mg IV and rebolus as
  needed start gtt at 5 mg and titrate to keep HR
  lt100
• Digoxin 0.5 mg IV, then 0.25 mg IV q6h x 2
  doses, and then PO digoxin
• Amiodarone 150 mg load, then 1 mg/min gtt x 6
  hours, followed by 0.5 mg/min gtt x 18 hours

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Atrial Fibrillation/Flutter

• Hypotensive
• Cardioversion!
• Get your senior resident
• Start at 100 J and work your way up
• Transfer to CICU/MICU for closer monitoring
• Anti-coagulation
• Start heparin gtt/low-molecular weight heparin
• No need to start warfarin at night

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AVNRT/AVRT
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AVNRT/AVRT

• Rate 150-250 bpm
• P wave morphology retrograde P waves distorting
  the end of the QRS complex (AVNRT) or distinctly
  after (AVRT)
• Therapy
• Vagal maneuvers Carotid massage, Valsalva
• Adenosine 6 mg IV push with ECG recording if no
  response, try 12 mg IV push x 2 doses
• Rate control Metoprolol 5 mg IV push or
  Ca-channel blockers
• Hypotensive Cardioversion!
• AM Radiofrequency ablation

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Tachyarrthymias

• Wide-complex tachycardias
• Regular
• Ventricular tachycardia (VT)
• SVT with aberrancy
• Wolff-Parkinson White syndrome (WPW)
• Irregular
• Ventricular fibrillation (VF)
• Artifact

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Ventricular Tachycardia
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Ventricular Tachycardia

• Monomorphic Previous MI, cardiomyopathy, RV
  dysplasia
• Polymorphic Ischemia, torsades de pointes,
  cardiomyopathy
• Brugada Criteria
• Absence of RS complex in all precordial leads
  (V1-V6)
• RS interval gt 100msec (onset of R to nadir of S)
• A-V dissociation
• Morphology criteria for VT in V1-2 and V6
• RBBB-like QRS (predominantly positive in V1)
• Morphology criteria for VT in V1-2 and V6
• RBBB-like QRS (predominantly positive in V1)
• If all criteria are absent, 99 likelihood that
  diagnosis is SVT!

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Ventricular Tachycardia

• Non-sustained VT
• Defined as ?3 consecutive beats at a rate gt 120
  bpm lasting lt 30 seconds
• Stable
• Review rhythm strip, check if pt. symptomatic,
  replete electrolytes (K gt4, Mg gt2)
• Sustained VT
• GO SEE THE PATIENT STAT!!!!
• Stable
• Amiodarone load (Pregnancy Use lidocaine)
• Unstable
• Cardioversion (follow ACLS protocol)!

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WPW
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WPW

• Electrically active muscle fibers bridge the
  atria and ventricles and cause pre-excitation of
  the ventricles
• WPW is a reentry mechanism with an accessory
  pathway
• Accessory pathway is able to conduct faster than
  the AV node

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WPW

• PR interval is shorter
• Upstroke of the QRS wave is slurred this is
  known as a delta wave
• Therapy
• A-fib with WPW
• Procanimide
• Cardioversion

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Ventricular Fibrillation
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Ventricular Fibrillation

• Call a CODE BLUE!
• Follow ACLS protocol!
• GOOD LUCK!