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Emergency Medicine Peri -arrest arrhythmias Assoc.Prof.Diana Cimpoe ş u MD,PhD 20 13

U.M.F. “Gr. T. Popa” Ia ş i. Emergency Medicine Peri -arrest arrhythmias Assoc.Prof.Diana Cimpoe ş u MD,PhD 20 13. Monitoring, Rhythm Recognition and 12-lead ECG Tachycardia, Cardioversion and Drugs Bradycardia , Cardiac Pacing and Drugs. Conducting system. QRS Complex.

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Emergency Medicine Peri -arrest arrhythmias Assoc.Prof.Diana Cimpoe ş u MD,PhD 20 13

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  1. U.M.F. “Gr. T. Popa” Iaşi Emergency Medicine Peri-arrest arrhythmias Assoc.Prof.DianaCimpoeşu MD,PhD 2013

  2. Monitoring, Rhythm Recognition and 12-lead ECGTachycardia, Cardioversion and DrugsBradycardia, Cardiac Pacing and Drugs

  3. Conducting system

  4. QRS Complex

  5. How to read a rhythm strip • Is there any electrical activity? • What is the ventricular (QRS) rate? • Is the QRS rhythm regular or irregular? • Is the QRS width normal (narrow) or broad? • Is atrial activity present? (If so, what is it: P waves? Other atrial activity?) • How is atrial activity related to ventricular activity?

  6. How to monitor the ECG • Self-adhesive pads • 3-lead monitoring • 12-lead monitoring

  7. Self-adhesive pads

  8. 3-lead monitoring

  9. ECG recognition

  10. Principles of treatment in peri-arrest arthymia • In all cases : -give oxygen -i.vacces -monitor -12-lead ECG -electrolyte abnormalities - correct any abnormalities K, Mg, Ca

  11. Tachycardia algorithm (with pulse)

  12. Shock Syncope Myocardial ischaemia Heart failure Adverse signs?Stable or Unstable?

  13. Tachycardia algorithm

  14. Case study 1 • Clinical setting and history • 65-year-old woman • In monitored bed 3 days after anterior myocardial infarction • Complains to nurse of feeling unwell • Clinical course • ABCDE • A : Clear • B : Spontaneous breathing, rate 26 min-1 • C : Looks pale, HR 200 min-1, BP 70/42 mmHg, CRT 3 s Initial rhythm? • D : Alert, glucose 5.6 mmol l-1 • E : Nil of note What action will you take?

  15. Stable broad-complex tachycardia

  16. Stable narrow-complex tachycardia

  17. Case study 2 • Clinical setting and history • 48-year-old woman admitted to ED • History of palpitation over past 12 h • Clinical course • ABCDE • A : Clear • B : Spontaneous breathing, rate 16 min -1 • C : P 180 min -1, BP 110/90 mmHg, CRT < 2 s Initial rhythm? • D : Alert, glucose 5.5 mmol l -1 • E : Nil of note What action will you take?

  18. Case study 2 (continued) • Clinical course • No response to vagal manoeuvres • Vital signs unchanged What action will you take now?

  19. Case study 2 (continued) Adenosine Indications • Narrow-complex tachycardia • Regular broad-complex tachycardia of uncertain nature • Broad-complex tachycardia only if previously confirmed SVT with bundle branch block Contraindications • Asthma Dose • 6 mg bolus by rapid IV injection • Up to 2 doses of 12 mg if needed Actions • Blocks conduction through AV node

  20. Case study 2 (continued) Amiodarone Indications • Broad-complex and narrow-complex tachycardia Dose • 300 mg over 20-60 min IV • 900 mg infusion over 24 h • Preferably via central venous catheter Actions • Lengthens duration of action potential • Prolongs QT interval • May cause hypotension

  21. Case study 3 • Clinical setting and history • 76-year-old man • History of hypertension treated with a diuretic • In the recovery area after an uncomplicated hernia repair • Nurses report the sudden onset of tachycardia • Clinical course • ABCDE • A : Clear • B : Spontaneous breathing, rate 18 min -1 • C : P 170 min -1, BP 100/60 mmHg, CRT < 2 s Initial rhythm? • D : Alert, glucose 4.0 mmol l -1 • E : Nil of note What action will you take?

  22. Case study 3 (continued) • Clinical course • Patient is given IV metoprolol • 30 min later, he complains of chest discomfort • ABCDE • A : Clear • B : Spontaneous breathing, rate 24 min -1 • C : HR 170 min -1, BP 85/50 mmHg, CRT 4 s What is the rhythm? What action will you take?

  23. Case study 3 (continued) • Clinical course • Cardioversion restores sinus rhythm • Patient is transferred back to the day-case unit What actions may be required as part of discharge planning?

  24. Peri-Arrest Bradycardia Bradycardia, Cardiac Pacing and Drugs

  25. Bradycardiaalgorithm Includes rates inappropriately slow for haemodynamic state

  26. Case study 4 • Clinical setting and history • 60-year-old man referred to admissions unit by GP • Long-term history of heart disease • Feeling light-headed and breathless • Clinical course • ABCDE • A : Clear • B : Spontaneous breathing, rate 18 min-1 • C : Looks pale, P 40 min-1, BP 90/50 mmHg, CRT 3 s Initial rhythm? • D : Alert, glucose 4.5 mmol l-1 • E : Nil of note What action will you take?

  27. Case study (continued) • Clinical course • No response to atropine • Patient becomes more breathless, cold, clammy and mildly confused • Change in rhythm • ABCDE • A : Clear • B : Spontaneous breathing, rate 24 min-1 widespread crackles on auscultation • C : Looks pale, HR 35 min-1, BP 80/50 mmHg, CRT 4 s • D : Responding to verbal stimulation • E : Nil of note What will you do now?

  28. Case study(continued) • Consider need for expert help • Prepare for transcutaneous pacing • Consider percussion pacing as interim measure • Confirm electrical capture and mechanical response once transcutaneous pacing has started

  29. Case study (continued) Atropine Indication • Symptomatic bradycardia Contraindication • Do not give to patients who have had a cardiac transplant Dose • 500 mcg IV, repeated every 3 - 5 min to maximum of 3 mg Actions • Blocks vagus nerve • Increases sinus rate • Increases atrioventricular conduction Side effects • Blurred vision, dry mouth, urinary retention • Confusion

  30. Case study (continued) Adrenaline Infusion of 2-10 mcg min-1 titrated to response OR Isoprenaline infusion 5 mcg min-1 as starting dose OR Dopamine infusion 2-5 mcg kg-1 min-1

  31. Post-resuscitation care • Return of spontaneos circulation ROSC • Hypoxia and hypercarbia –contribute to secondary brain injury

  32. Post resuscitation care The goal is to restore: • Normal cerebral function • Stable cardiac rhythm • Adequate organ perfusion • Quality of life

  33. Post cardiac arrest syndrome • Post cardiac arrest brain injury: • Coma, seizures, myoclonus • Post cardiac arrest myocardial dysfunction • Systemic ischaemia-reperfusion response • ‘Sepsis-like’ syndrome • Persistence of precipitating pathology

  34. Airway and breathing • Ensure a clear airway, adequate oxygenation and ventilation • Consider tracheal intubation, sedation and controlled ventilation • Pulse oximetry: • Aim for SpO2 94 – 98% • Capnography: • Aim for normocapnia • Avoid hyperventilation

  35. Airway and breathing • Look, listen and feel • Consider: • Simple/tension pneumothorax • Collapse/consolidation • Bronchial intubation • Pulmonary oedema • Aspiration • Fractured ribs/flail segment

  36. Airway and breathing • Insert gastric tube to decompress stomach and improve lung compliance • Secure airway for transfer • Consider immediate extubation if patient breathing and conscious level improves quickly after ROSC

  37. Circulation • Pulse and blood pressure • Peripheral perfusion e.g. capillary refill time • Right ventricular failure • Distended neck veins • Left ventricular failure • Pulmonary oedema • ECG monitor and 12-lead ECG

  38. Disability Neurological assessment: • Glasgow Coma Scale score • Pupils • Limb tone and movement • Posture

  39. Further assessment History • Health before the cardiac arrest • Time delay before resuscitation • Duration of resuscitation • Cause of the cardiac arrest • Family history

  40. Further assessment Monitoring • Vital signs • ECG • Pulse oximetry • Blood pressure e.g. arterial line • Capnography • Urine output • Temperature

  41. Further assessment Investigations • Arterial blood gases • Full blood count • Biochemistry including blood glucose • Troponin • Repeat 12-lead ECG • Chest X-ray • Echocardiography

  42. Chest X-ray

  43. Transfer of the patient • Discuss with admitting team • Cannulae, drains, tubes secured • Suction • Oxygen supply • Monitoring • Documentation • Reassess before leaving • Talk to family

  44. Out-of-hospital VF arrest associated with AMI Enteral nutrition Insulin Cooling Inotropes Defibrillator Ventilation Pacing IABP

  45. Optimising organ functionHeart • Post cardiac arrest syndrome • Ischaemia-reperfusion injury: • Reversible myocardial dysfunction for 2-3 days • Arrhythmias

  46. Optimising organ functionHeart • Poor myocardial function despite optimal filling: • Echocardiography • Cardiac output monitoring • Inotropes and/or balloon pump • Mean blood pressure to achieve: • Urine output of 1 ml kg-1 hour-1 • Normalising lactate concentration

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