INDIANAENA SYMPOSIUM
2011
Andrew J. Bowman
Acute Care Nurse Practitioner
Fellow – American College CV Nurses
Registered Nurse
Paramedic
Co-Founder
Yahoo Groups
TACHYARRHYTHMIAS
What works…
What doesn’t…
What KILLS!!!
OVERVIEW
• Wide Complex Tachycardia (WCT)
• Ventricular Tachycardia (VT)
• Adenosine in WCT
• Wolff-Parkinson-White Syndrome
• The “walking-talking” VF patient
ACLS Algorithm
• 2010 AHA Guidelines for WCT
– Determine Stability
– Obtain 12 Lead EKG (if Stable)
– Regular or Irregular
ACLS Algorithm
• Regular WCT
– If confirm VT or SVT with Aberrancy
• Treat accordingly
– If not able to determine
• Adenosine likely safe to treat and/or diagnose
ACLS Algorithm
• Irregular WCT
– Atrial Fibrillation or Flutter
• Rate Control
• Rhythm Control
– Polymorphic VT
• Defibrillation Likely Needed
• Treat baseline long QTc if present
Wide Complex Tachycardia
• Definition
– ANY heart rhythm with…
– QRS duration >= 120ms (3 little boxes)
– Ventricular rate > 100bpm
– VERY BROAD & INCLUSIVE!!!
WCT• Differential Dx
– VT
– VT!!
–VT!!!– SVT with BBB
– SVT with Aberrant Conduction
– Paced Rhythms
– AV Re-Entrant Tachycardia with Antidromic Conduction
– Electrolyte Abnormalities
– Drug Toxicity (Na+ Channel Blockers)
Yes or No?
• EKG can reliably distinguish VT from SVT with BBB /aberrant conduction ?
Yes or No?
• EKG can reliably distinguish VT from SVT with BBB /aberrant conduction?
•NO!!!!!
Yes or No?
• EKG can reliably distinguish VT from SVT with BBB /aberrant conduction?
•NO!!!!!
• EKG rules IN VT
• Nothing reliably rules OUT VT
“BEST” Teaching
• Assume wide complex tachycardia (WCT) is VT until proven otherwise
• When in doubt, assume and treat WCT as VT
EKG Favors VT
• AV Dissociation
• Fusion Beats
• Left Axis or Right Axis
• Extreme Right Axis
• QRS > 140ms duration
• RS > 100ms
• Precordial Concordance
– (All UP or All DOWN)
Fusion
QRS > 140msRS > 100ms
Concordance
Brugada Criteria
• 4 step process
– No RS complex all precordial leads?
– RS interval > 100ms in 1 precordial lead?
– AV dissociation?
– Morphology criteria for VT present in precordial leads V1-2 and V6?
Brugada Criteria
• 27 EKG’s with WCT
• 3 ED Physicians
• Applied Brugada Criteria
• 22% Intra-operator variability with OPEN BOOK TEST!!!
Wellens Criteria
• QRS width > 0.14 secs
• Left axis deviation > -30
• AV Dissociation
• Certain QRS configurations– RBBB type QRS
• Monophasic R, qR, QR, RS in V1
• R/S < 1, monophasic R, QR, QS in V6
– LBBB type QRS• qR or Qs in V6
Akhtar Criteria• AV Dissociation
• Positive QRS concordance
• QRS axis between –90 and +180
• LBBB and rightward axis >90
• RBBB and QRS > 0.14 secs
• LBBB and QRS > 0.16 secs
• QRS morphology during tachycardia different from baseline preexisting BBB
Griffith Criteria
• SVT diagnosed only if QRS morphology is typical of a BBB
– RBBB
• rSR’ in V1 and RS in V6 with R/S > 1
– LBBB
• rS or QS in V1 and V2 and delay to S nadir < 70 msecs
• R wave and no Q wave in V6
But What Did We Say???
• EKG can ONLY…
• Rule IN VT
• NOT…
• Rule OUT VT
VT or SVT with BBB
• Can only say SVT with BBB…IF…
• Tachycardia EKG QRS configuration
EXACTLY same as baseline EKG
QRS configuration
43 Male with Palpitations
43 Male, Asymptomatic
11th Commandment
• Thou shalt not give verapamil to WCT tachycardia!
•IT KILLS!!!!!!!
Clinical Information?
• Hemodynamic Status?
• Younger Age?
• No History Cardiac Disease?
•NO!!!!!
Adenosine (Adenocard)
• Can convert SOME VT
• Adenosine will NOT convert all SVT
• Adenosine responsive VT• Usually younger
• No prior known history cardiac disease
• SOUND FAMILIAR?????
Tx of VT
• Pulseless
• Unstable VT with Pulse
• Stable VT
Pulseless
• Treat as VF
• Defibrillate
Unstable VT with Pulse
• Synchronized Cardioversion
Stable VT
• Lidocaine?
• Amiodarone??
• Procainamide???
Lidocaine
• Poor success rate for converting VT to NSR
• 20-30%
Amiodarone
• “GOOD FOR EVERYTHING”
• Except…
Except Cardiac Arrest
• “There is no evidence that ANYantiarrhythmic drug given routinely during cardiac arrest increases survival to hospital discharge.” (Hazinski, Circulation, 2005)
Except Pregnancy
• Avoid amiodarone in pregnancy– The ONLY class D antiarrhythmic
– Fetal hypothyroidism, IUGR, fetal bradycardia, prematurity
– Only if other drugs fail
• Procainamide or Lidocaine preferred in pregnant patients with ventricular arrhythmias
Except A-Fib with WPW
Except Torsades de Pointes
• TDP from prolonged QTc
– Further prolongs QTc and worsens TDP
– If baseline EKG has NORMAL QTc then it is not TDP, it is polymorphic VT
Young Woman - Syncope
Torsades de Pointes
Except “SLOW VT”
• WCT < 120-130bpm
– Think…
• AIVR
• Na channel blocker OD
• Hyperkalemia
“Slow VT”
Post - Tx
“Slow VT”
• Inappropriate Tx of “Slow VT” may cause ASYSTOLE
– WCT from hyperkalemia may be mis-Dx as VT
– AIVR may be mis-Dx as VT
– Tx with Lidocaine = ASYSTOLE!!
– Tx with Amiodarone = ASYSTOLE!!
Tx Slow VT
• Hyperkalemia
– NaHCO3
• TCA OD (Na+ Channel Blocker)
– NaHCO3
• AIVR
– Benign Neglect
So What to Use???
•Procainamide is
BACK!!!!!
Procainamide
• Excellent success ALL types of WCT’s
– VT
– SVT or Afib with BBB
– SVT or Afib with WPW
• When in doubt….…reach for procainamide
Procainamide Dosing
• 20 – 50 mg/min “bolus” until…
– Arrhythmia suppression
– Hypotension
– QRS widens > 50% baseline
– 17mg/kg total dose
• Then 1-4mg/min infusion
Wolff-Parkinson-White
• Pre-excitation of ventricles because of abnormal pathway of conduction that bypasses the AV node.
WPW
WPW
• EKG Findings
– Short PR interval
– Widened QRS
– Delta wave
– Repolarization changes
WPW
WPW Tachyarrhythmias
• Orthodromic Conduction
• Antidromic Conduction
• Atrial Fibrillation
Orthodromic
• Conduction down AVN then back through accessory pathway
• Narrow complex QRS (unless BBB)
Orthodromic Tx
• Adenosine
• Other AVN blockers
– Calcium blockers
– Beta blockers
Antidromic
• Conduction down accessory pathway then back through AVN
• Wide complex QRS
Antidromic Tx
• Adenosine
• Procainamide
A-Fib with WPW
• Atria 400-600 bpm
• AVN blocks many
• Accessory pathway still available
A-Fib with WPW
A-Fib with WPW
• Classic EKG Findings
– Irregularly-irregular (may be difficult to “eyeball”)
– Narrow and wide QRS morphology
– Portions “very fast” (>200-250bpm, may approach 300bpm)
A-Fib with WPW
WPW w A-Fib
WPW with A-Fib
WPW with A-Fib
WPW with A-Fib
A-Fib with WPW
• Atria at 400-600bpm
• If unopposed to ventricles
• Ventricles at 400-600bpm
–VF!!!
Tx A-Fib with WPW
• AVOID AV NODE BLOCKERS!!!!!
– A
– B
– C
– D
Tx A-Fib with WPW
• AVOID AV NODE BLOCKERS!!!!!
– A – Adenosine AND Amiodarone
– B – Beta Blockers
– C – Calcium Channel Blockers
– D - Digitalis
A-Fib, WPW & AV Nodal Blockers (The Problem)
• Is there evidence of irregularity?
• Is there evidence of changing QRS morphology?
• Are there sections of “very fast” ventricular rates?
A-Fib, WPW & AV Nodal Blockers (The Problem)
Pitfalls
• Patient with A-Fib with WPW
– Mis-Dx as SVT/VT & give adenosine
•VF
– Mis-Dx as A-Fib with BBB & give AVN blockers
•VF
AHA
• Still recommends Amiodarone for A-Fib in the setting of WPW
NO!!!!!• Amiodarone
– Class I (Na+)
– Class II (Beta)
– Class III (K+)
– Class IV (Calcium)
How to Tx?
• P-
• P-
How to Tx?
• Procainamide
• Propofol (or sedation of choice) and DCC.
“Walking-Talking” VF
“Walking-Talking” VF
• Medics sent for “weak & dizzy all over”
• BP cannot be obtained
• Pulse “hard to palpate” – “keep losing it”
• SpO2 80% and poor waveform
Arrival to ED
• Awake and talking
• Hoses entering chest wall
• Battery pack on waist
• Rhythm below
Walking-Talking 12 Lead
VAD
• Ventricular Assist Device
• Provides mechanical support for failing heart
• Support can be… hours…days…months…years
VAD
• Bridge to re-evaluation
• Bridge to recovery
• Bridge to transplant
• Bridge to destination therapy
VAD Patient
• Anti-coagulation
– Triple therapy
• Anti-arrhythmics
• Anti-hypertensives
VAD Types
• Pulsatile Flow
– Heartmate XVE
– Thoratec IVAD
• Non-Pulsatile Flow
– Heartmate II
Calling 911
• Lack of energy or weakness
• Symptoms may be vague
Outpatient Emergencies
• Arrhythmia
• Hemolysis
• Renal Failure
• Infection
• Decreased Preload from Dehydration
• GI Bleeding
Arrhythmia
• VAD’s do not affect EKG tracing
• Effects of Prolonged Arrhythmia
– Poor Perfusion
– Hypoxia
– Brain Damage
– Death
Who Has A VAD???
Arrhythmia
• VT / VF
– DEFIBRILLATE!!!!!
– May require sedation
– Disconnect VAD from wall outlet
No CPR for VAD’s
• Disruption of pump anastamosis site
• Fatal hemorrhage
• Call VAD Center
Summary
• WCT = Tx as VT until proven otherwise
• Adenosine probably safe for everything EXCEPT A-Fib with WPW
•NO AVN Blockers A-Fib with WPW
• VAD’s are more common
Thank You!!!!!