Emergency Management of Weird Heart Rhythms

8/7/2019 Emergency Management of Weird Heart Rhythms

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Emergency Treatment of Weird Heart Rhythms

VENTRICULAR TACHYCARDIA

FIRST: look at the patient.Are they…

healthy looking? Comfortable at a hr of 180? Compromised (pale, sweaty, lethargic, dizzy?) Arrested? (unconscious, unresponsive)

Arrested is the group you should REALLY worry about.They are candidates for defibrillation.IF IN DOUBT, ZAP EM. They will die anyway.At least give them the benefit of a medical procedure first.

Hit them with 200 joules (monophasic)

Then, check them again (better? Worse? Different rhythm?) No luck?

Hit them with 300 joules.Check again; still dead-looking?

Hit them with 360 joules.No effect?

Get an ampule of adrenaline (always comes in 1ml )Give it to them as a bolus.

No venous access? Lazy nurses didn’t put in a cannula?You can just squirt it down their endotracheal tube.Adrenaline gets absorbed well enough through the lung.

My patient has had his adrenaline and the ECG still shows broad-complex VT;

Hit them with 360 joules AGAINStill VT?

ITS TIME FOR ANTIARRHYTHMIC DRUGS: amiodarone 300mgNothing happens? How long should this tragic farce be sustained?

FOR ABOUT 20 MINUTES- and then you can give up.UNLESS!! The rhythm changed intermittently during the processOR the patient is hypothermic at 28 degress C; then they might make it.

Monophasicdefibrillators work at ahigher energy of 200joules, and they only pass the

current one way between theelectrodes.

Biphasic defibrillatorswork at a lower energyof 150 joules, and they

switch the direction of thecurrent half-way through the jolt.

Every defibrillator will beautomatically set to its optimumenergy, and

you should always goup in hundreds:Eg. 200

Then 300Then 360 (top setting)



TACHYCARDIA WITHOUT OUTPUT

i.e the heart is beating madly but there is no perfusion

Does the patient look arresty? Glasgow 3?WHAT COULD BE DOING THAT?

Assess in order of curability:FIRST consider things that could be fixed with a huge needle- CHECK THE TRACHEA (midline?)

- If it’s a tension pneumothorax, you’ll need to decompress it with a needle - LISTEN TO THE HEART: diminished sounds? Narrowed pulse?

- Cardiac Tamponade can also be reversed with a huge needle- UNEXPLAINED HYPOXIA, LOUD PULMONARY VALVE SOUND, RV HEAVE?

- Massive Pulmonary Embolism ( give thrombolytic bolus, give CPR)- OBVIOUS HYPOVOLEMIA = dry mouth, sunken eyes = replace fluids, duh

- HYPOKALEMIA? (wide QRS complexes) = replace potassium,- MASSIVE INFARCT = you are probably not going to reverse this -

PROFOUND BRADYCARDIA

Eg. following complete heart block (means that the heart's electrical signal doesn't pass from the

upper to the lower chambers. When this occurs, an independent pacemaker in the lower chambers takes over. Theventricles can contract and pump blood, but at a slower rate than that of the atrial pacemaker.)SEE BELOW:P waves are not conducted to the ventricles because of block at the AV node. The P waves are indicated below andshow no relation to the QRS complexes. They 'probe' every part of the ventricular cycle but are never conducted.

FIRST, GIVE ATROPINE: 500-600 microgramsIt’s a competitive antagonist of muscarinic cholinergic receptors

THEN, give ISOPRENALINE INFUSION (beta-1 blocker, chronotropic but not inotropic) Your patient is still crapping out?PACE EXTERNALLY: defibrillator pads on back and sternum;

Now the patient is twitching crazily every few moments. THIS IS VERY PAINFUL:So you also give a fentanyl patch.



VENTRICULAR FIBRILLATION

A heart like this is pumping nothing.

Treat it like VT: shock, re-assess, give drugs, repeat.THE COARSER THE RHYTHM, THE GREATER YOUR CHANCES OF SUCCESSEg. the rhythm below is salvageable, the rhythm above is … less so

ASYSTOLE

This is a dead heart. Very few people recover from asystole.Still, one must try:THUS give CPR, ventilate, defibrillate, give adrenaline 1ml and then 5ml…

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Emergency Management of Weird Heart Rhythms