emergency medicine peri-arrest arrhythmias assoc.prof.diana cimpoeşu md,phd assoc.prof.diana...

Emergency MedicineEmergency Medicine

Peri-arrest arrhythmiasPeri-arrest arrhythmias

Assoc.Prof.Diana CimpoeAssoc.Prof.Diana Cimpoeşşu u

MD,PhDMD,PhD 20201313

U.M.F. “Gr. T. Popa” U.M.F. “Gr. T. Popa” IaIaşşii

Monitoring, Rhythm Monitoring, Rhythm Recognition and 12-lead Recognition and 12-lead ECGECG Tachycardia, Tachycardia, Cardioversion and DrugsCardioversion and Drugs

Bradycardia, Bradycardia, Cardiac Pacing and DrugsCardiac Pacing and Drugs

Conducting systemConducting system

QRS ComplexQRS Complex

How to read a rhythm How to read a rhythm stripstrip

1.1. Is there any electrical activity?Is there any electrical activity?

2.2. What is the ventricular (QRS) rate?What is the ventricular (QRS) rate?

3.3. Is the QRS rhythm regular or irregular?Is the QRS rhythm regular or irregular?

4.4. Is the QRS width normal (narrow) or broad?Is the QRS width normal (narrow) or broad?

5.5. Is atrial activity present? Is atrial activity present? (If so, what is it: P waves? Other atrial activity?)(If so, what is it: P waves? Other atrial activity?)

6.6. How is atrial activity related to ventricular How is atrial activity related to ventricular activity?activity?

How to monitor the How to monitor the ECGECG

Self-adhesive padsSelf-adhesive pads

3-lead monitoring3-lead monitoring


Self-adhesive padsSelf-adhesive pads

ECG recognition ECG recognition

Principles of treatment Principles of treatment in peri-arrest arthymiain peri-arrest arthymia

In all cases :In all cases :

-give oxygen-give oxygen

-i.v acces-i.v acces

-monitor-monitor

-12-lead ECG -12-lead ECG

-electrolyte abnormalities - -electrolyte abnormalities - correct any abnormalities K, Mg, Cacorrect any abnormalities K, Mg, Ca

Tachycardia algorithm (with pulse)Tachycardia algorithm (with pulse)

ADVERSE SIGNS?ADVERSE SIGNS?STABLE OR UNSTABLE?STABLE OR UNSTABLE?ShockShock

SyncopeSyncope

Myocardial ischaemiaMyocardial ischaemia

Heart failureHeart failure

Tachycardia algorithmTachycardia algorithm

Case study 1Case study 1 Clinical setting and historyClinical setting and history

– 65-year-old woman65-year-old woman– In monitored bed 3 days after anterior In monitored bed 3 days after anterior

myocardial infarction myocardial infarction – Complains to nurse of feeling unwellComplains to nurse of feeling unwell

Clinical courseClinical course– ABCDE ABCDE

• A : ClearA : Clear• B : Spontaneous breathing, rate 26 minB : Spontaneous breathing, rate 26 min-1-1

• C : Looks pale, HR 200 minC : Looks pale, HR 200 min-1-1, BP 70/42 mmHg, CRT 3 s, BP 70/42 mmHg, CRT 3 s

Initial rhythm?Initial rhythm?• D : Alert, glucose 5.6 mmol lD : Alert, glucose 5.6 mmol l-1-1

• E : Nil of noteE : Nil of note

What action will you take?What action will you take?

Stable broad-complex Stable broad-complex tachycardiatachycardia

Stable narrowStable narrow-complex -complex tachycardiatachycardia

Case study 2Case study 2

Clinical setting and historyClinical setting and history– 48-year-old woman admitted to ED48-year-old woman admitted to ED– History of palpitation over past 12 hHistory of palpitation over past 12 h


• A : ClearA : Clear• B : Spontaneous breathing, rate 16 min B : Spontaneous breathing, rate 16 min -1-1

• C : P 180 min C : P 180 min -1-1, BP 110/90 mmHg, CRT < 2 s , BP 110/90 mmHg, CRT < 2 s

Initial rhythm?Initial rhythm?• D : Alert, glucose 5.5 mmol l D : Alert, glucose 5.5 mmol l -1-1



Case study 2 Case study 2 (continued)(continued)

Clinical courseClinical course– No response to vagal manoeuvresNo response to vagal manoeuvres– Vital signs unchangedVital signs unchanged

What action will you take now?What action will you take now?


AdenosineAdenosineIndicationsIndications

– NNarrow-complex tachycardia arrow-complex tachycardia – Regular broad-complex Regular broad-complex tachycardia of uncertain tachycardia of uncertain

naturenature– Broad-complex tachycardia only if previously Broad-complex tachycardia only if previously

confirmed SVT with bundle branch blockconfirmed SVT with bundle branch blockContraindicationsContraindications

– AsthmaAsthmaDoseDose

– 6 mg bolus by rapid IV injection6 mg bolus by rapid IV injection– Up to 2 doses of 12 mg if neededUp to 2 doses of 12 mg if needed

ActionsActions– Blocks conduction through AV nodeBlocks conduction through AV node


AmiodaroneAmiodaroneIndicationsIndications

– Broad-Broad-complex and narrow-complex complex and narrow-complex tachycardia tachycardia

DoseDose– 300 mg over 20-60 min IV300 mg over 20-60 min IV– 900 mg infusion over 24 h 900 mg infusion over 24 h – Preferably via central venous catheterPreferably via central venous catheter

ActionsActions– Lengthens duration of action potentialLengthens duration of action potential– Prolongs QT intervalProlongs QT interval– May cause hypotensionMay cause hypotension


– 76-year-old man 76-year-old man – History of hypertension treated with a diureticHistory of hypertension treated with a diuretic– In the recovery area after an uncomplicated hernia repair In the recovery area after an uncomplicated hernia repair – Nurses report the sudden onset of tachycardiaNurses report the sudden onset of tachycardia



• C : P 170 min C : P 170 min -1-1, BP 100/60 mmHg, CRT < 2 s, BP 100/60 mmHg, CRT < 2 s

Initial rhythm?Initial rhythm?• D : Alert, glucose 4.0 mmol l D : Alert, glucose 4.0 mmol l -1-1

• E : Nil of noteE : Nil of noteWhat action will you take?What action will you take?


Clinical courseClinical course– Patient is given IV metoprololPatient is given IV metoprolol– 30 min later, he complains of chest discomfort30 min later, he complains of chest discomfort– ABCDE ABCDE


• C : HR 170 min C : HR 170 min -1-1, BP 85/50 mmHg, CRT 4 s, BP 85/50 mmHg, CRT 4 sWhat is the rhythm?What is the rhythm?

What action will you takeWhat action will you take??


Clinical courseClinical course– Cardioversion restores sinus rhythmCardioversion restores sinus rhythm– Patient is transferred back to the day-Patient is transferred back to the day-

case unitcase unit

What actions may be required What actions may be required as part of discharge planning?as part of discharge planning?

Peri-Arrest Peri-Arrest BradycardiaBradycardia

Bradycardia, Bradycardia, Cardiac Pacing Cardiac Pacing

and Drugsand Drugs

BradycardiaBradycardiaalgorithmalgorithm

Includes rates Includes rates inappropriately inappropriately slow for slow for haemodynamic haemodynamic statestate


– 60-year-old man referred to admissions unit by GP60-year-old man referred to admissions unit by GP– Long-term history of heart diseaseLong-term history of heart disease– Feeling light-headed and breathlessFeeling light-headed and breathless

Clinical courseClinical course– ABCDEABCDE

• A : ClearA : Clear• B : Spontaneous breathing, rate 18 minB : Spontaneous breathing, rate 18 min-1 -1

• C : Looks pale, P 40 minC : Looks pale, P 40 min-1-1, BP 90/50 mmHg, CRT 3 s, BP 90/50 mmHg, CRT 3 s

Initial rhythm?Initial rhythm?• D : Alert, glucose 4.5 mmol lD : Alert, glucose 4.5 mmol l-1-1



Case study Case study (continued)(continued)

Clinical courseClinical course– No response to atropineNo response to atropine– Patient becomes more breathless, cold, Patient becomes more breathless, cold,

clammy and mildly confusedclammy and mildly confused– Change in rhythmChange in rhythm– ABCDEABCDE

• A : ClearA : Clear• B : Spontaneous breathing, rate 24 minB : Spontaneous breathing, rate 24 min-1 -1

widespread crackles on auscultationwidespread crackles on auscultation• C : Looks pale, HR 35 minC : Looks pale, HR 35 min-1-1, BP 80/50 mmHg, CRT 4 s, BP 80/50 mmHg, CRT 4 s• D : Responding to verbal stimulationD : Responding to verbal stimulation• E : Nil of noteE : Nil of note

What will you do now?What will you do now?

Case studyCase study (continued)(continued)

Consider need for expert helpConsider need for expert help Prepare for transcutaneous pacingPrepare for transcutaneous pacing Consider percussion pacing as Consider percussion pacing as

interim measureinterim measure Confirm electrical capture and Confirm electrical capture and

mechanical response once mechanical response once transcutaneous pacing has startedtranscutaneous pacing has started


AtropineAtropineIndicationIndication

– Symptomatic brSymptomatic bradycardia adycardia ContraindicationContraindication

– Do not give to patients who have had a cardiac transplantDo not give to patients who have had a cardiac transplant DoseDose

– 500 mcg IV, repeated every 3 - 5 min to maximum of 3 mg500 mcg IV, repeated every 3 - 5 min to maximum of 3 mgActionsActions

– Blocks vagus nerveBlocks vagus nerve– Increases sinus rateIncreases sinus rate– Increases atrioventricular conductionIncreases atrioventricular conduction

Side effectsSide effects– Blurred vision, dry mouth, urinary retentionBlurred vision, dry mouth, urinary retention– ConfusionConfusion


AdrenalineAdrenaline

Infusion of 2-10 mcg minInfusion of 2-10 mcg min-1-1 titrated to response titrated to response

OR OR IsoprenalineIsoprenaline infusion 5 mcg min infusion 5 mcg min-1-1 as starting as starting dosedose

OR OR DopamineDopamine infusion 2-5 mcg kg infusion 2-5 mcg kg-1-1 min min-1-1

Post-resuscitation carePost-resuscitation care

Return of spontaneos circulation Return of spontaneos circulation ROSCROSC

Hypoxia and hypercarbia –Hypoxia and hypercarbia –contribute to secondary brain contribute to secondary brain injuryinjury

Post resuscitation carePost resuscitation care

The goal is to restore:The goal is to restore:

Normal cerebral functionNormal cerebral function

Stable cardiac rhythmStable cardiac rhythm

Adequate organ perfusionAdequate organ perfusion

Quality of lifeQuality of life

Post cardiac arrest Post cardiac arrest syndromesyndrome Post cardiac arrest brain injury:Post cardiac arrest brain injury:

– Coma, seizures, myoclonusComa, seizures, myoclonus

Post cardiac arrest myocardial Post cardiac arrest myocardial dysfunctiondysfunction

Systemic ischaemia-reperfusion Systemic ischaemia-reperfusion responseresponse– ‘‘Sepsis-like’ syndromeSepsis-like’ syndrome

Persistence of precipitating pathologyPersistence of precipitating pathology

Airway and breathingAirway and breathing

Ensure a clear airway, adequate Ensure a clear airway, adequate oxygenation and ventilationoxygenation and ventilation

Consider tracheal intubation, Consider tracheal intubation, sedation and controlled ventilationsedation and controlled ventilation

Pulse oximetry: Pulse oximetry: – Aim for SpOAim for SpO22 94 – 98% 94 – 98%

Capnography:Capnography:– Aim for normocapniaAim for normocapnia– Avoid hyperventilationAvoid hyperventilation


Look, Look, listen and feellisten and feel

Consider:Consider:– SSimple/tension pneumothoraximple/tension pneumothorax– CCollapse/consolidationollapse/consolidation– Bronchial intubationBronchial intubation– PPulmonary oedemaulmonary oedema– AspirationAspiration– Fractured ribs/flail segmentFractured ribs/flail segment


Insert gastric tube to decompress Insert gastric tube to decompress stomach and improve lung stomach and improve lung compliancecompliance

Secure airway for transferSecure airway for transfer

Consider immediate extubation if Consider immediate extubation if patient breathing and conscious patient breathing and conscious level improves quickly after ROSClevel improves quickly after ROSC

CirculationCirculation

Pulse and Pulse and blood pressureblood pressure Peripheral perfusionPeripheral perfusion e.g. capillary e.g. capillary

refill timerefill time Right ventricular failureRight ventricular failure

– Distended neck veinsDistended neck veins

Left ventricular failureLeft ventricular failure– Pulmonary oedema Pulmonary oedema

ECG monitor and 12-lead ECGECG monitor and 12-lead ECG

DisabilityDisability

Neurological assessment:Neurological assessment:

Glasgow Coma ScaleGlasgow Coma Scale score score

Pupils Pupils

Limb tone and movementLimb tone and movement

Posture Posture

Further assessmentFurther assessment

HistoryHistoryHealth before the cardiac arrestHealth before the cardiac arrest

Time delay before resuscitationTime delay before resuscitation

Duration of resuscitationDuration of resuscitation

Cause of the cardiac arrestCause of the cardiac arrest

Family historyFamily history

Further assessment Further assessment

MonitoringMonitoringVital signsVital signsECGECGPulse oximetryPulse oximetryBlood pressureBlood pressure e.g. arterial line e.g. arterial lineCapnographyCapnographyUrine outputUrine outputTemperatureTemperature

Further assessment Further assessment

InvestigationsInvestigationsArterial blood gases Arterial blood gases Full blood countFull blood countBiochemistry including blood glucoseBiochemistry including blood glucoseTroponinTroponinRepeat 12-lead ECG Repeat 12-lead ECG Chest X-rayChest X-rayEchocardiographyEchocardiography

Chest X-rayChest X-ray

Transfer of the patientTransfer of the patient

Discuss with admitting teamDiscuss with admitting team Cannulae, drains, tubes securedCannulae, drains, tubes secured SuctionSuction Oxygen supplyOxygen supply MonitoringMonitoring DocumentationDocumentation Reassess before leavingReassess before leaving Talk to familyTalk to family

Out-of-hospital VF arrest Out-of-hospital VF arrest associated with AMIassociated with AMI

Pacing

Cooling

IABP

Defibrillator

Inotropes

Ventilation

Enteral nutrition

Insulin

Optimising organ functionOptimising organ function

HeartHeart

Post cardiac arrest syndromePost cardiac arrest syndrome

Ischaemia-reperfusion injury:Ischaemia-reperfusion injury:– Reversible myocardial dysfunction Reversible myocardial dysfunction

for 2-3 daysfor 2-3 days– ArrhythmiasArrhythmias


HeartHeart

Poor myocardial function despite Poor myocardial function despite optimal filling:optimal filling:– EchocardiographyEchocardiography– Cardiac output monitoringCardiac output monitoring– Inotropes and/or balloon pumpInotropes and/or balloon pump

Mean blood pressure to achieve: Mean blood pressure to achieve: – Urine output of 1 ml kgUrine output of 1 ml kg-1-1 hour hour-1-1 – Normalising lactate concentrationNormalising lactate concentration


BrainBrain

Impaired cerebral autoregulation – Impaired cerebral autoregulation – maintain ‘normal’ blood pressuremaintain ‘normal’ blood pressure

SedationSedation Control seizuresControl seizures Glucose (4-10 mmol lGlucose (4-10 mmol l-1-1)) NormocapniaNormocapnia Avoid/treat hyperthermiaAvoid/treat hyperthermia Consider therapeutic hypothermiaConsider therapeutic hypothermia

Therapeutic hypothermiaTherapeutic hypothermiaWho to cool?Who to cool?

Unconscious adults with ROSC after VF Unconscious adults with ROSC after VF arrest should be cooled to 32-34arrest should be cooled to 32-34ooCC

May benefit patients after May benefit patients after non-shockable/in-hospital cardiac arrestnon-shockable/in-hospital cardiac arrest

Exclusions: severe sepsis, pre-existing Exclusions: severe sepsis, pre-existing medical coagulopathymedical coagulopathy

Start as soon as possible and continue for Start as soon as possible and continue for 24 h24 h

Rewarm slowly 0.25Rewarm slowly 0.25ooC hC h-1-1

Therapeutic hypothermiaTherapeutic hypothermiaHow to cool?How to cool?

Induction - 30 ml kgInduction - 30 ml kg-1-1 4 4ooC IV fluid C IV fluid and/or external coolingand/or external cooling

Maintenance - external cooling:Maintenance - external cooling:– Ice packs, wet towelsIce packs, wet towels– Cooling blankets or padsCooling blankets or pads– Water circulating gel-coated padsWater circulating gel-coated pads

Maintenance - internal coolingMaintenance - internal cooling– Intravascular heat exchangerIntravascular heat exchanger– Cardiopulmonary bypassCardiopulmonary bypass

Assessment of Assessment of prognosisprognosis

No clinical neurological signs can No clinical neurological signs can predict outcome < 24 h after ROSCpredict outcome < 24 h after ROSC

Poor outcome predicted at 3 days by:Poor outcome predicted at 3 days by:– Absent pupil light Absent pupil light andand corneal reflexes corneal reflexes– Absent or extensor motor response to Absent or extensor motor response to

painpain

But limited data on reliability of these But limited data on reliability of these criteria after therapeutic hypothermiacriteria after therapeutic hypothermia

Organ donationOrgan donation

Non-surviving post cardiac arrest Non-surviving post cardiac arrest patient may be a suitable donor:patient may be a suitable donor:

– Heart-beating donor (brainstem Heart-beating donor (brainstem death)death)

– Non-heart-beating donorNon-heart-beating donor

Questions?Questions?

emergency medicine peri-arrest arrhythmias assoc.prof.diana cimpoeşu md,phd assoc.prof.diana...

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