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Terrifying Tachycardias

Terrifying Tachycardias. Susan P. Torrey, MD, FACEP, FAAEM Associate Professor of Emergency Medicine UMass Medical School – Baystate Medical Center Springfield, Mass. I have no disclosures TorreyEKG.com. Objectives. Consider the diagnostic grid Answer several interesting questions

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Terrifying Tachycardias

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  1. Terrifying Tachycardias Susan P. Torrey, MD, FACEP, FAAEM Associate Professor of Emergency Medicine UMass Medical School – Baystate Medical Center Springfield, Mass

  2. I have no disclosures TorreyEKG.com

  3. Objectives • Consider the diagnostic grid • Answer several interesting questions • What’s the scariest atrial fib you’ll ever see? • How DO you know it is ventricular tach?

  4. Rate Rate = 300 ÷ # “big boxes” between R-R 300 – 150 – 100 – 75 – 60 – 50

  5. Rate?

  6. Diagnostic grid - tachycardias Cherchez le P

  7. Diagnostic grid - tachycardias

  8. Sinus tachycardia • normal P before every QRS • upright P in lead II

  9. Sinus tachycardia • Emergency Department differential: • compensation for shock - dehydration, hemorrhage, sepsis • fever • drugs (cocaine, anticholinergic) • acute pulmonary embolism • thyrotoxicosis • anxiety - only as a dx of exclusion

  10. Atrial flutter • atrial activity – regular deflections (F waves) - F waves usually 300/minute • rate and regularity of QRS variable - in purest form, multiple of 300

  11. Atrial flutter • untreated, flutter usually has 2:1 AV block  regular rhythm at 150/minute

  12. Rate of 150… • when the rate is 140 – 150/minute  always consider 2:1 atrial flutter

  13. Supraventricular tachycardia • Regular, narrow tachycardia due to re-entry • AV nodal re-entry vs. AV re-entry (WPW) • Onset and termination is abrupt • Heart rate 140-220/minute • Differential: sinus tach, 2:1 flutter, ? a fib

  14. SVT

  15. Diagnostic grid - tachycardias

  16. Atrial fibrillation • no discernible P waves - atrial activity is fibrillatory waves (f) - fibrillatory waves – II and V1 • ventricular rhythm is irregularly irregular - untreated ventricular rate 100 – 180/min

  17. Multifocal atrial tachycardia • P waves of varying morphology (≥ 3 foci) - absence of single dominant P wave • Variable PP, RR, PR intervals - theother irregularly irregular rhythm • Seen with COPD, elderly, seriously ill

  18. Diagnostic grid - tachycardias • aberrancy • pre-existing BBB • bypass tract

  19. Ventricular tachycardia • Abnormal wide QRS • Regular rhythm – “dead regular” • Rate usually 140-200/minute

  20. Diagnostic grid - tachycardias • aberrancy • pre-existing BBB • bypass tract

  21. What is the scariest tachycardiayou will ever see? 38-year-old man with history of palpitations

  22. Or this…

  23. Scary atrial fib • Atrial fib with… - aberrancy - pre-existing bundle, or… - bypass tract with Wolff-Parkinson-White! - changing QRS shape and rapid conduction

  24. Atrial fib with WPW • most AV node blockers ↑ bypass conduction • must avoid A – B – C – D • A – adenosine • B – beta-blockers • C – calcium-channel blockers • D – digoxin • treat with electricity or procainamide

  25. What about amiodarone? • 2005 ACLS – rec: amiodarone • 2010 ACLS – returns to procainamide Simonian S Inter Emerg Med 2010 • Literature review challenges superiority and safety of amiodarone for atrial fib with WPW • Complex drug with effects on Na+, K+, and Ca++ channels, as well as α- and β-blocking effects

  26. rapid atrial fib with wide complex after cardioversion after ablation of bypass tract

  27. How do you know if it’s V. tach?

  28. How do you know if it’s V. tach? • EKG criteria favoring V. Tach • AV dissociation

  29. AV dissociation

  30. How do you know if it’s V. tach? • EKG criteria favoring V. Tach • AV dissociation • QRS concordance • all chest leads (V1-6) predominantly negative

  31. QRS concordance

  32. How do you know if it’s V. tach? • algorithms • Brugada’s four-step algorithm  98% sens / 96% spec • Circ 1991 • Vereckei’s new “simplified” algorithm • Euro Heart J 2007

  33. How do you know if it’s V. tach? • clinical predictors • association with heart disease or MI  98% positive predictive value • Aktar Ann Intern Med 1988

  34. It’s v. tach!

  35. In conclusion… • Remember, tachycardias are easy… • Narrow or wide complex? • Regular or irregular?

  36. Diagnostic grid - tachycardias

  37. In conclusion… • Remember, tachycardias are easy… • Narrow or wide complex? • Regular or irregular? • If the rate is around 150 think 2:1 flutter.

  38. In conclusion… • Remember, tachycardias are easy… • Narrow or wide complex? • Regular or irregular? • If the rate is around 150  think 2:1 flutter. • Rapid wide-complex atrial fib  think WPW… • Avoid A – B – C – D

  39. In conclusion… • Remember, tachycardias are easy… • Narrow or wide complex? • Regular or irregular? • If the rate is around 150  think 2:1 flutter. • Rapid wide-complex atrial fib  think WPW… • Treat wide-complex tachycardia per ACLS

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