acute management of stable narrow complex tachycardia

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Acute Management of Stable Narrow Complex Tachycardia. Mini Lecture 2013. Objectives. Review the initial approach to diagnose and treat narrow complex tachycardia Review examples of AVNRT, AVRT, Atrial Tachycardia This is not a comprehensive review of all the narrow complex tachycardias - PowerPoint PPT Presentation

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  • Acute Management of Stable Narrow Complex Tachycardia

    Mini Lecture2013

  • ObjectivesReview the initial approach to diagnose and treat narrow complex tachycardia Review examples of AVNRT, AVRT, Atrial Tachycardia This is not a comprehensive review of all the narrow complex tachycardiasYou are not expected to manage these patients on your own, always ask for back up

  • CaseNurse calls to inform you that bed 10s heart rate just went up to 200s on telemetry. Which of the following information should you obtain asap?A. Blood pressureB. Mental statusC. EKGD. Focused Physical ExamE. All of the above

  • CaseNurse calls to inform you that bed 10s heart rate just went up to 200s on telemetry. Which of the following information should you obtain asap?A. Blood pressureB. Mental statusC. EKGD. Focused Physical ExamE. All of the above

  • Narrow Complex Tachycardia Rate >100 (often 150-250)QRS
  • Initial Assessment for TachycardiaQuestionsSymptomatic?Hypotensive?12 lead EKGIV access

    Stable or Unstable? Altered Mental Status Hypotension Chest Pain Acute SOB Hypoxia

  • Unstable?

    Crash CartACLSCall for backup Senior residentCardiology fellowNocturnistCode blue

  • Stable?Initial AssessmentFocused H&PTalk to the patient to assess mental statusReason for admission (sepsis, ACS)Cardiac Hx (CAD, HF, Afib, SVT)Recent electrolytesMedications (AV nodal agents, digoxin)Listen to heart and lungsVolume statusJVD

  • EKG shows..

  • Too fast to interpret rhythm?Vagal Maneuvers and Adenosine Slow down the rhythm Terminate certain SVTs which conduct through the AV node If possible obtain 12 lead EKG recording during intervention

  • Vagal maneuversBearing downFace in ice cold waterCarotid MassageBlowing into a folded strawCough

    AdenosineMay avoid if bronchospasm/asthma/COPD?Caution if history of pre-exitation/ WPW?*Warn them about the symptoms6mg IV push followed by NS flush followed by12mg IV push followed by NS flush

  • AVNRTCauseDual AV nodal pathways with differing refractory periodsOften initiated by a PAC60% SVTDXRate 150-250Inverted p or psuedo S

    TxVagal AdenosineBB: Metoprolol 5mg q5min x3 CCB: Diltiazem 10mg IV, repeat 10-30mg IV in 5-10 min

  • AVNRTPSUEDO S WAVES

  • AVRTCauseRe-entrant tachycardic circuit with conduction down AV node and back up a bypass tract (i.e. WPW)30% SVTDx:Rate 150-250 Retrograde P inferior leads

    Tx:Vagal AdenosineBB: Metoprolol 5mg min q5 x 3CCB: Diltiazem 10mg IV, repeat 10-30mg IV in 5-10 min

  • AVRT

  • Atrial TachycardiaCauseEnhanced Automaticity of atrial tissue or ectopic atrial pacemaker10% SVTDxP wave precedes each QRSUnusual p wave axisAdenosine may show continued atrial beats, without AV conductionTx:BB: metoprolol 5mg q5 x 3CCB: Diltiazem 10mg IV, repeat 10-30mg IV in 5-10 min

  • ADENOSINEAtrial TachycardiaUnusual p wave axisContinued atrial automaticity

  • General PrinciplesNote the common theme: Vagal Maneuvers, Adenosine, Beta Blockers, Calcium Channel Blockers, caution in WPWCheck vitals (BP) frequently during acute setting to make sure a stable situation does not become unstableAgain, this is meant to be a review of the initial management of SVT you are not expected to independently manage these patients- Call for backup!

  • Case Follow UpNurse calls: Bed 10s heart rate just went up to 200s You reply:What is his blood pressure?Is his arousable and oriented?Please get a 12 lead EKG nowDoes he have IV access?Ill be right there..

  • References

    UpToDateMed Res UCLA http://medres.med.ucla.edu/FP Notebook http://www.fpnotebook.com/Images sited previously

    Answer E intern should ask the nurse these questions on the phone so the nurse can start getting the information that you need if he or she doesnt have it already. Then go see the patient asap.

    Answer E, Be aware of they types of narrow complex tachycardia or SVTWe will only talk more about AVNRT, AVRT, ATRIAL TACHYCARDIA in more detailBack to the initial assessment when you are called by the nurse- it is Important to first decide if this is an unstable or stable situationACLS review: DC cardioversion Narrow regular 50-100J, Narrow Irregular 120-200J, AdenosineRun through the following in your evaluation4Hs: Hypovolemia, Hypoxia, Hyperthermia, Hyper/Hypokalemia, 4Ts: Tamponade, Tension PTX, Thromboembolism, Toxins,Sensation that the heart has stopped, chest pain, shortness of breath

    Crash Cart Should Be available in the event that the patient becomes unstable i.e. you may need atropine for a long pause or urgent cardioversionDont forget to obtain frequent vital signs while you are at the bedsideTachyarrythmias and WPW- AV nodal blocking agents are contraindicated

    Since it is a nodal rhythm, adenosine/vagal/BB.CCB can terminate the rhythmV4 p wave at the end QRS, and characteristic pseudo S wave

    WPW is an example of AVRT, use caution with AV nodal agents which can stimulate the bypass tract causing degeneration to vfib because AV nodal blocking agents can speed up the bypass tract (you can try to look at an ekg taken prior to event to look for pre-exitation, you should discuss with cardioology fellow)Narrow complex rate ~ 150Retrograde p waves seen in ST segment (unlike AVNRT where p is usually burried)

    http://www.heartpearls.com/tag/avrtAdenosine will not terminate this rhythm, but it can help with the dxInitally you can see tachycardia with unusual p wave axisThis is a rhythm strip with adenosine administration showing continued atrial beats when AV node is blocked indicating atrial tachycardia rather than AVNRT, AVRT This is a MKSAP question

    http://www.google.com/imgres?q=atrial+tachycardia+with+adenosine&um=1&hl=en&client=safari&sa=N&tbo=d&rls=en&biw=1207&bih=745&tbm=isch&tbnid=8JCTGAwaG_B1YM:&imgrefurl=http://www.sciencedirect.com/science/article/pii/S0022347694702705&docid=_4YbF3CNS4velM&imgurl=http://ars.els-cdn.com/content/image/1-s2.0-S0022347694702705-gr3.jpg&w=580&h=212&ei=coj4UPWcNMXZ2QXbh4G4Cw&zoom=1&iact=hc&vpx=511&vpy=304&dur=2926&hovh=136&hovw=372&tx=225&ty=90&sig=106833721564813075518&page=1&tbnh=97&tbnw=266&start=0&ndsp=20&ved=1t:429,r:7,s:0,i:105

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