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ARRHYTHMIAS

AND THEIR MANAGEMENT


Dr (Mrs) D.S.Gunawardena
Consultant Cardiac ElectroPhysiologist
&
Cardiologist

Arrhythmias are
commonly encountered
in clinical practice

Presentation
Episodic palpitation
Giddiness/presyncope/syncope
Features of unstable angina
Generalized Fits
Heart failure
Thrombo embolism

CLASSIFICATION
R h y t h m D is o r d e r s
T a c h y a r r h y t h m ia s
>100 bpm
N a r r o w C o m p le x T . C .
Q R S < 0 .1 2 s
R e g u la r

I r e g u la r

B r a d y a r r h y t h m ia s
<60 bpm

B r o a d C o m p le x T . C .
Q R S > 0 .1 2 s
R e g u la r

I r e g u la r

Regular Narrow Complex


Tachycardia
Examples:
Sinus Tachycardia
Supra ventricular Tachycardia
Atrial Flutter with 2:1 AV block

Irregular Narrow Complex


Tachycardia
Examples:
Atrial fibrillation
Atrial flutter with variable AV
block

Broad Complex
Tachycardia
In SR
Sinus tachycardia with BBB
Not in SR
Ventricular tachycardia
SVT with BBB

SUPRAVENTRICULAR
TACHYCARDIA ( SVT)
Commonest arrhythmia encountered

Haemodynamically stable
patient with SVT

Try Vagal manoevours

Vogel maneuvers
Carotid Sinus massage
Valsalva manoevour,
Diving reflex,
DO NOT use eye ball pressure.

Pharmacological
management
IV Adenosine
IV Digoxin
IV Verapamil
Beta Blockers
IV Amiodarone

Block the AV node

Intravenous Adenosine
Indication : SVT
Contraindications : Bronchial

Asthma

T1/2: short acting

IV Adenosine

18 G Cannula

IV Push of Adenosine

IV Flush of N. Saline 20 ml

IV Adenosine
3mg (first bolus dose)
6mg
9mg

12mg

18 mg
24 mg
Maximum dose

IV Verapamil
Start with 2.5 mg

IV Digoxin
0.25 mg over an hour
0.25 mg over an hour
0.25 mg over an hour
0.25 mg over an hour
Maximum up to 1 mg

Beta blockers
IV Beta blockers

BROAD COMPLEX
TACHYCARDIAS - VT

VT OR SVT

Majority of broad complex


tacchycardias are ventricular
in origin

Minority of broad complex


tachycardias are supra
ventricular in origin

VENTRICULAR
TACHYCARDIA
DIAGNOSTIC
CRITERIA

AV dissociation
Capture beat
Fusion beat
Negative concordance
Retrograde P ( 2:1 VA
block)

SUGGESTIVE
FEATURES

Broad QRS
complex
Axis deviation
Positive
concordance

VT showing AV
disassociation

VT showing capture beat

VT showing fusion beat

VT showing positive
concordance

VT showing negative
concordance

VENTRICULAR
FIBRILLATION

POLYMORPHIC VT

MANAGEMENT

Initial assessment

A, B, C

CPR

Identify individual arrhythmia

Management of VT/VF

DC cardioversion during CPR


If arrhythmia recurs or continues,
IV antiarryhthmics
boluses & infusion
-Lidocaine
-Amiodarone

Resistant VT/VF

Consider cardioversion while on


antiarrhythmics
Correction of precipitating factors
Hypoxaemia
Acidosis
Ischaemia
Electrolyte imbalances- correction
of K+, Mg2+ and Ca2+

Management of VT
Polymorphic VT/Torsades
OR

Rapid monomorphic VT/V Flutter


>260/min

ATRIAL
FIBRILLATION

AF WITH NARROW
COMPLEXES

AF WITH BROAD COMPLEXES

AF with broad QRS


complexes
Differential Diagnosis

AF with Pre existing BBB


AF with rate dependent BBB
AF with antegrade conduction of
accessory pathways

1.AF with Pre existing BBB


+

2.AF with Rate dependent


BBB

3.AF with WPW


+

ATRIAL FLUTTER

Atrial Fibrillation/Flutter
Complications:

Thrombo-embolism
Precipitate heart failure

Management of
Atrial Fibrillation/Flutter

Haemodynamically unstable

Synchronized DC shock

Anticoagulation in emergency
DC shock

Duration of AF is more than 48 hours

With iv Heparin before DC shock


followed by Warfarin for 4 weeks

Anti coagulation in AF
Other indications

1.Risk factors for cerebro vascular


accidents

2.Before and after elective cardio


version

Anti coagulation in AF
Warfarin
INR

therapy

around 2.5 to 3

Haemodynamically stable

1. Reduce ventricular rate by


using rate control drugs
2. Amiodarone

AF with broad QRS


complexes
If accessory pathway is
suspected
Avoid
Adenosine, Digoxin, Ca channel
blockers

BRADYARRHYTHMIAS

Classification of
Bradyarrhythmias
SA node
Sinus bradycardia
Sinus block/arrest
AV node
AV block
Nodal bradycardia

Classification of
Bradyarrhythmias
Global dysfunction of the conduction

system
Asystole
Electrolyte imbalance
Hyperkalaemia or Hypokalaemia

HYPERKALAEMIA

HYPOKALAEMIA

2ND DEGREE HEART BLOCK


(2:1)

2ND DEGREE HEART BLOCK


(WENKEBACH )

Complete Heart Block

IDIOVENTRICULAR
RHYTHM - IVR

ASYSTOLE

Management of
Bradyarrhythmias
&
Asystolic Arrest

If unstable
Consider CPR
Reconfirm rhythm
Correct reversible factors
e.g. Hypoxia, Electrolytes, Ischemia,
With hold rate controlling drugs

Pharmacotherapy

IV Atropine

IV Isoprenaline

IV Epinephrine

Intra cardiac Adrenaline

Indications for Temporary


Pacing

Refractory bradyarrhythmias

Prophylactic cardiac pacing in


refractory tachyarrhythmias

MANAGEMENT OF
IDIOVENTRICULAR
RHYTHM

Accelerate the SA node function

Correction of reversible factors

Once arrhythmia is
terminated an
ECG is mandatory

Acute Myocardial Infarction


Long QT syndrome
WPW Syndrome
Brugada syndrome

MI with LBBB

WPW Syndrome

Brugada Syndrome

DEFIBRILLATION
Indications
Haemodynamically unstable
patient with Tachyarrhythmias

* Except sinus tachycardia

DEFIBRILLATION
Haemodynamically unstable patient

Hypotension

Pulmonary oedema

Ongoing ischemia

TYPES OF
DEFIBRILLATORS

MONOPHASIC DEFIBRILLATOR

BIPHASIC DEFIBRILLATOR

WAVEFORM IN
MONOPHASIC
DEFIBRILLATION

WAVEFORM IN BIPHASIC
DEFIBRILLATION

MODE OF
DEFIBRILLATION

INDICATION FOR
SYNCHRONIZED DC
SHOCK
Tachyarrhythmias with well
recognised QRS complexes

REASONS TO GIVE
SYNCHRONIZED DC SHOCK
To avoid falling of shock wave on
vulnerable period of the T wave

To prevent occurrence of
ventricular arrhythmias

HOW TO SELECT THE


AMOUNT OF JOULES
According to the latest
guidelines
In cardiac arrest
consider highest amount of
joules

HOW TO SELECT THE


AMOUNT OF JOULES

Atrial flutter 25- 50 J


Atrial fibrillation 200J
Slow VT 200J onwards

THANK YOU