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Arrhythmias FM Lecture Series. Alex Dworak July 2008. Needless photo of the author with his no-ponytails-until-you’re-in-college son. The obligatory objectives slide. Review common and significant arrhythmias and EKG findings

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Arrhythmias FM Lecture Series

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Arrhythmias fm lecture series l.jpg

ArrhythmiasFM Lecture Series

Alex Dworak July 2008


The obligatory objectives slide l.jpg

Needless photo of the author with his no-ponytails-until-you’re-in-college son

The obligatory objectives slide

  • Review common and significant arrhythmias and EKG findings

  • Focus on recognition, etiology, immediate and definitive management

  • References: Uptodate, ECGlibrary.com


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Basic principles of any arrhythmia

  • Is the patient stable or unstable? If unstable, call Code Blue and follow ACLS. If unsure, call a code—you’ll get help fast, & the ICU team would rather have a “fake code” than a too-late code

  • No palpable central pulse in the unstable patient means start CPR; a dopplerable pulse won’t perfuse the brain

  • If stable, stop and think. Call for help from your supervisor or staff. Check code labs (CBC, CMP, Mg/Phos, cardiac enzymes, blood cx) and get a 12 lead EKG. Consider calling Cards if appropriate.

  • Make sure the wires are hooked up/it’s not artifact.

  • The telemetry nurses usually recognize what’s worth freaking out about—don’t tune them out.


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VT (Ventricular Tachycardia)

  • “A PVC is just a PVC, but 3 in a row is Vtach!”

  • Cause: MI, other structural disease, severe electrolyte change

  • Immediate: If unstable, SHOCK! If stable (talking, maintaining BP), calmly call Cards while the pads are being attached; consider Amiodarone or Lidocaine bolus, head for the ICU or cardiac floor

  • Definitive: May need AICD, especially if EF<35% to lower chance of sudden death


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Normal/ “Confidence Builder”

  • Examine rate, rhythm (sinus or not—P before every QRS?), axis (left thumb is I, right is AVF—if both “thumbs up,” axis is normal, whereas a down thumb is deviated in the direction of that hand).

  • Look at ST segments, width of QRS, check for Q waves, PR depression, weird P waves, flipped/peaked T waves or U waves, excess QT interval length

  • Machine is good at rates and intervals; don’t always trust its interpretation, though! “We read the bottom of the EKG, not the top.”

  • Take advantage of Dr. O’Dell’s EKG sessions and practice on every EKG you get! (Same goes for Xrays!)


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Too much digitalis…


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Atrial flutter

  • Cause: Non-conducted atrial beats, usually in structurally abnormal heart

  • Characteristically 300 bpm

  • Not always obvious; 2:1 aflutter (unlike the 16:1 previously) can be both occult and dangerous—consider it with any narrow complex tachyarrhythmia with rate ~150 bpm

  • Immediate: If unstable, shock. Otherwise, IV metoprolol 5 mg q5min x3 or IV diltiazem drip with bolus; esmololgtt in ICU or verapamil are also considerations. Watch for hypotension.

  • Definitive: Electric vs. drug cardioversion in consultation with Cards; may need clot prophylaxis


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Ventricular Fibrillation

  • SHOCK! This and unstable VT should always be shocked.

  • Make sure the leads are hooked up and the patient is actually unstable and pulseless before you hit the button

  • Definitive: Let Cards and EP sort out the best management; stabilize and then get the patient to the ICU.


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Torsades des pointes

  • Cause: MI, hypoK+, hypoMg++, long QT, drugs (antiarrhythmics, TCAs…)

  • Immediate: If unstable, shock! Empirically give 1-2 g IV Mg++ (careful if they have renal failure—but intubation is easier than reanimation…)

  • Definitive: Correct underlying cause, maybe ICD. Consult Cards.


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Complete heart block with idioventricular escape rhythm

  • Cause: MI or other disruption of conducting system

  • No relation of P to QRS

  • Immediate: tele monitoring

  • Definitive: Cards consult for EP workup and pacing


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Acute anterior MI

  • Causes: thrombosis, drugs (cocaine, meth)

  • Immediate: ACLS

  • Definitive: Percutaneous stent vs. CABG depending on anatomy at cath and risk factors (i.e. DM)

  • No beta blockers for coke abusers


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Look for the P waves


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2:1 AV block

  • Could be either Mobitz I (“Wenke walks away”) or Mobitz II (“Moby falls down like he got kicked in the head”?)

  • Mobitz I has repetitively lengthening PR until the dropped beat, then resets

  • Mobitz II just drops a beat suddenly; unstable and needs pacing

  • Can’t tell if it’s 2:1; assume it’s Mobitz II, put on telemetry and get Cards eval


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Chest pain, got hypotensive with NTG in the ambulance.


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Posterior MI

  • Usually not isolated; lateral involvement common

  • ST depression in V1, V2 is actually inverted STEMI on the back of the heart in the RV

  • Immediate: PRELOAD dependent, give lots of fluids (may need to intubate if they’ve got LV involvement too) and the usual ACLS

  • Definitive: same as any MI


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Afib with RVR

  • Usually in the context of known afib

  • Treatment is same as for aflutter:

  • Immediate: If unstable, shock. Otherwise, IV metoprolol 5 mg q5min x3 or IV diltiazem drip with bolus; esmololgtt in ICU or verapamil are also considerations. Watch for hypotension.

  • Definitive: Electric vs. drug cardioversion in consultation with Cards; definitely needs clot prophylaxis unless a good reason not to


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Credits, Suggested Reading

  • www.ecglibrary.com

  • www.uptodate.com

  • Pocket ACLS survival guide (must have, <$10 at bookstore)

  • Pocket EKG survival guide

  • Hurst’s The Heart or Braunwald if you’re really gung-ho

Cake is the best!


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Torsades des feet.

  • Completely unrelated video of (Christian) Taekwondo practitioners doing 540 tornado kicks—yes, it’s totally useless in a real fight, but I’d like to see any haters try one and not land on their faces. 

  • Separate (techno!) video of two credible Darth Maul impersonators


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