indiana ena 2011 tachyarrhythmias

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INDIANA ENA SYMPOSIUM 2011

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Page 1: Indiana ENA 2011 Tachyarrhythmias

INDIANAENA SYMPOSIUM

2011

Page 2: Indiana ENA 2011 Tachyarrhythmias

Andrew J. Bowman

Acute Care Nurse Practitioner

Fellow – American College CV Nurses

Registered Nurse

Paramedic

Page 3: Indiana ENA 2011 Tachyarrhythmias

Co-Founder

Yahoo Groups

Facebook

Page 4: Indiana ENA 2011 Tachyarrhythmias

TACHYARRHYTHMIAS

What works…

What doesn’t…

What KILLS!!!

Page 5: Indiana ENA 2011 Tachyarrhythmias

OVERVIEW

• Wide Complex Tachycardia (WCT)

• Ventricular Tachycardia (VT)

• Adenosine in WCT

• Wolff-Parkinson-White Syndrome

• The “walking-talking” VF patient

Page 6: Indiana ENA 2011 Tachyarrhythmias

ACLS Algorithm

• 2010 AHA Guidelines for WCT

– Determine Stability

– Obtain 12 Lead EKG (if Stable)

– Regular or Irregular

Page 7: Indiana ENA 2011 Tachyarrhythmias

ACLS Algorithm

• Regular WCT

– If confirm VT or SVT with Aberrancy

• Treat accordingly

– If not able to determine

• Adenosine likely safe to treat and/or diagnose

Page 8: Indiana ENA 2011 Tachyarrhythmias

ACLS Algorithm

• Irregular WCT

– Atrial Fibrillation or Flutter

• Rate Control

• Rhythm Control

– Polymorphic VT

• Defibrillation Likely Needed

• Treat baseline long QTc if present

Page 9: Indiana ENA 2011 Tachyarrhythmias

Wide Complex Tachycardia

• Definition

– ANY heart rhythm with…

– QRS duration >= 120ms (3 little boxes)

– Ventricular rate > 100bpm

– VERY BROAD & INCLUSIVE!!!

Page 10: Indiana ENA 2011 Tachyarrhythmias

WCT• Differential Dx

– VT

– VT!!

–VT!!!– SVT with BBB

– SVT with Aberrant Conduction

– Paced Rhythms

– AV Re-Entrant Tachycardia with Antidromic Conduction

– Electrolyte Abnormalities

– Drug Toxicity (Na+ Channel Blockers)

Page 11: Indiana ENA 2011 Tachyarrhythmias

Yes or No?

• EKG can reliably distinguish VT from SVT with BBB /aberrant conduction ?

Page 12: Indiana ENA 2011 Tachyarrhythmias

Yes or No?

• EKG can reliably distinguish VT from SVT with BBB /aberrant conduction?

•NO!!!!!

Page 13: Indiana ENA 2011 Tachyarrhythmias

Yes or No?

• EKG can reliably distinguish VT from SVT with BBB /aberrant conduction?

•NO!!!!!

• EKG rules IN VT

• Nothing reliably rules OUT VT

Page 14: Indiana ENA 2011 Tachyarrhythmias

“BEST” Teaching

• Assume wide complex tachycardia (WCT) is VT until proven otherwise

• When in doubt, assume and treat WCT as VT

Page 15: Indiana ENA 2011 Tachyarrhythmias

EKG Favors VT

• AV Dissociation

• Fusion Beats

• Left Axis or Right Axis

• Extreme Right Axis

• QRS > 140ms duration

• RS > 100ms

• Precordial Concordance

– (All UP or All DOWN)

Page 16: Indiana ENA 2011 Tachyarrhythmias

Fusion

Page 17: Indiana ENA 2011 Tachyarrhythmias

QRS > 140msRS > 100ms

Page 18: Indiana ENA 2011 Tachyarrhythmias

Concordance

Page 19: Indiana ENA 2011 Tachyarrhythmias

Brugada Criteria

• 4 step process

– No RS complex all precordial leads?

– RS interval > 100ms in 1 precordial lead?

– AV dissociation?

– Morphology criteria for VT present in precordial leads V1-2 and V6?

Page 20: Indiana ENA 2011 Tachyarrhythmias

Brugada Criteria

• 27 EKG’s with WCT

• 3 ED Physicians

• Applied Brugada Criteria

• 22% Intra-operator variability with OPEN BOOK TEST!!!

Page 21: Indiana ENA 2011 Tachyarrhythmias

Wellens Criteria

• QRS width > 0.14 secs

• Left axis deviation > -30

• AV Dissociation

• Certain QRS configurations– RBBB type QRS

• Monophasic R, qR, QR, RS in V1

• R/S < 1, monophasic R, QR, QS in V6

– LBBB type QRS• qR or Qs in V6

Page 22: Indiana ENA 2011 Tachyarrhythmias

Akhtar Criteria• AV Dissociation

• Positive QRS concordance

• QRS axis between –90 and +180

• LBBB and rightward axis >90

• RBBB and QRS > 0.14 secs

• LBBB and QRS > 0.16 secs

• QRS morphology during tachycardia different from baseline preexisting BBB

Page 23: Indiana ENA 2011 Tachyarrhythmias

Griffith Criteria

• SVT diagnosed only if QRS morphology is typical of a BBB

– RBBB

• rSR’ in V1 and RS in V6 with R/S > 1

– LBBB

• rS or QS in V1 and V2 and delay to S nadir < 70 msecs

• R wave and no Q wave in V6

Page 24: Indiana ENA 2011 Tachyarrhythmias

But What Did We Say???

• EKG can ONLY…

• Rule IN VT

• NOT…

• Rule OUT VT

Page 25: Indiana ENA 2011 Tachyarrhythmias

VT or SVT with BBB

• Can only say SVT with BBB…IF…

• Tachycardia EKG QRS configuration

EXACTLY same as baseline EKG

QRS configuration

Page 26: Indiana ENA 2011 Tachyarrhythmias

43 Male with Palpitations

Page 27: Indiana ENA 2011 Tachyarrhythmias

43 Male, Asymptomatic

Page 28: Indiana ENA 2011 Tachyarrhythmias

11th Commandment

• Thou shalt not give verapamil to WCT tachycardia!

•IT KILLS!!!!!!!

Page 29: Indiana ENA 2011 Tachyarrhythmias

Clinical Information?

• Hemodynamic Status?

• Younger Age?

• No History Cardiac Disease?

•NO!!!!!

Page 30: Indiana ENA 2011 Tachyarrhythmias

Adenosine (Adenocard)

• Can convert SOME VT

• Adenosine will NOT convert all SVT

• Adenosine responsive VT• Usually younger

• No prior known history cardiac disease

• SOUND FAMILIAR?????

Page 31: Indiana ENA 2011 Tachyarrhythmias

Tx of VT

• Pulseless

• Unstable VT with Pulse

• Stable VT

Page 32: Indiana ENA 2011 Tachyarrhythmias

Pulseless

• Treat as VF

• Defibrillate

Page 33: Indiana ENA 2011 Tachyarrhythmias

Unstable VT with Pulse

• Synchronized Cardioversion

Page 34: Indiana ENA 2011 Tachyarrhythmias

Stable VT

• Lidocaine?

• Amiodarone??

• Procainamide???

Page 35: Indiana ENA 2011 Tachyarrhythmias

Lidocaine

• Poor success rate for converting VT to NSR

• 20-30%

Page 36: Indiana ENA 2011 Tachyarrhythmias

Amiodarone

• “GOOD FOR EVERYTHING”

• Except…

Page 37: Indiana ENA 2011 Tachyarrhythmias

Except Cardiac Arrest

• “There is no evidence that ANYantiarrhythmic drug given routinely during cardiac arrest increases survival to hospital discharge.” (Hazinski, Circulation, 2005)

Page 38: Indiana ENA 2011 Tachyarrhythmias

Except Pregnancy

• Avoid amiodarone in pregnancy– The ONLY class D antiarrhythmic

– Fetal hypothyroidism, IUGR, fetal bradycardia, prematurity

– Only if other drugs fail

• Procainamide or Lidocaine preferred in pregnant patients with ventricular arrhythmias

Page 39: Indiana ENA 2011 Tachyarrhythmias

Except A-Fib with WPW

• More on this later!

Page 40: Indiana ENA 2011 Tachyarrhythmias

Except Torsades de Pointes

• TDP from prolonged QTc

– Further prolongs QTc and worsens TDP

– If baseline EKG has NORMAL QTc then it is not TDP, it is polymorphic VT

Page 41: Indiana ENA 2011 Tachyarrhythmias

Young Woman - Syncope

Page 42: Indiana ENA 2011 Tachyarrhythmias

Torsades de Pointes

Page 43: Indiana ENA 2011 Tachyarrhythmias

Except “SLOW VT”

• WCT < 120-130bpm

– Think…

• AIVR

• Na channel blocker OD

• Hyperkalemia

Page 44: Indiana ENA 2011 Tachyarrhythmias

“Slow VT”

Page 45: Indiana ENA 2011 Tachyarrhythmias

Post - Tx

Page 46: Indiana ENA 2011 Tachyarrhythmias

“Slow VT”

• Inappropriate Tx of “Slow VT” may cause ASYSTOLE

– WCT from hyperkalemia may be mis-Dx as VT

– AIVR may be mis-Dx as VT

– Tx with Lidocaine = ASYSTOLE!!

– Tx with Amiodarone = ASYSTOLE!!

Page 47: Indiana ENA 2011 Tachyarrhythmias

Tx Slow VT

• Hyperkalemia

– NaHCO3

• TCA OD (Na+ Channel Blocker)

– NaHCO3

• AIVR

– Benign Neglect

Page 48: Indiana ENA 2011 Tachyarrhythmias

So What to Use???

Page 49: Indiana ENA 2011 Tachyarrhythmias

•Procainamide is

BACK!!!!!

Page 50: Indiana ENA 2011 Tachyarrhythmias

Procainamide

• Excellent success ALL types of WCT’s

– VT

– SVT or Afib with BBB

– SVT or Afib with WPW

• When in doubt….…reach for procainamide

Page 51: Indiana ENA 2011 Tachyarrhythmias

Procainamide Dosing

• 20 – 50 mg/min “bolus” until…

– Arrhythmia suppression

– Hypotension

– QRS widens > 50% baseline

– 17mg/kg total dose

• Then 1-4mg/min infusion

Page 52: Indiana ENA 2011 Tachyarrhythmias

Wolff-Parkinson-White

• Pre-excitation of ventricles because of abnormal pathway of conduction that bypasses the AV node.

Page 53: Indiana ENA 2011 Tachyarrhythmias

WPW

Page 54: Indiana ENA 2011 Tachyarrhythmias

WPW

• EKG Findings

– Short PR interval

– Widened QRS

– Delta wave

– Repolarization changes

Page 55: Indiana ENA 2011 Tachyarrhythmias
Page 56: Indiana ENA 2011 Tachyarrhythmias

WPW

Page 57: Indiana ENA 2011 Tachyarrhythmias

WPW Tachyarrhythmias

• Orthodromic Conduction

• Antidromic Conduction

• Atrial Fibrillation

Page 58: Indiana ENA 2011 Tachyarrhythmias

Orthodromic

• Conduction down AVN then back through accessory pathway

• Narrow complex QRS (unless BBB)

Page 59: Indiana ENA 2011 Tachyarrhythmias

Orthodromic Tx

• Adenosine

• Other AVN blockers

– Calcium blockers

– Beta blockers

Page 60: Indiana ENA 2011 Tachyarrhythmias

Antidromic

• Conduction down accessory pathway then back through AVN

• Wide complex QRS

Page 61: Indiana ENA 2011 Tachyarrhythmias

Antidromic Tx

• Adenosine

• Procainamide

Page 62: Indiana ENA 2011 Tachyarrhythmias

A-Fib with WPW

• Atria 400-600 bpm

• AVN blocks many

• Accessory pathway still available

Page 63: Indiana ENA 2011 Tachyarrhythmias

A-Fib with WPW

Page 64: Indiana ENA 2011 Tachyarrhythmias

A-Fib with WPW

• Classic EKG Findings

– Irregularly-irregular (may be difficult to “eyeball”)

– Narrow and wide QRS morphology

– Portions “very fast” (>200-250bpm, may approach 300bpm)

Page 65: Indiana ENA 2011 Tachyarrhythmias

A-Fib with WPW

Page 66: Indiana ENA 2011 Tachyarrhythmias

WPW w A-Fib

Page 67: Indiana ENA 2011 Tachyarrhythmias

WPW with A-Fib

Page 68: Indiana ENA 2011 Tachyarrhythmias

WPW with A-Fib

Page 69: Indiana ENA 2011 Tachyarrhythmias

WPW with A-Fib

Page 70: Indiana ENA 2011 Tachyarrhythmias

A-Fib with WPW

• Atria at 400-600bpm

• If unopposed to ventricles

• Ventricles at 400-600bpm

–VF!!!

Page 71: Indiana ENA 2011 Tachyarrhythmias

Tx A-Fib with WPW

• AVOID AV NODE BLOCKERS!!!!!

– A

– B

– C

– D

Page 72: Indiana ENA 2011 Tachyarrhythmias

Tx A-Fib with WPW

• AVOID AV NODE BLOCKERS!!!!!

– A – Adenosine AND Amiodarone

– B – Beta Blockers

– C – Calcium Channel Blockers

– D - Digitalis

Page 73: Indiana ENA 2011 Tachyarrhythmias

A-Fib, WPW & AV Nodal Blockers (The Problem)

• Is there evidence of irregularity?

• Is there evidence of changing QRS morphology?

• Are there sections of “very fast” ventricular rates?

Page 74: Indiana ENA 2011 Tachyarrhythmias

A-Fib, WPW & AV Nodal Blockers (The Problem)

Page 75: Indiana ENA 2011 Tachyarrhythmias

Pitfalls

• Patient with A-Fib with WPW

– Mis-Dx as SVT/VT & give adenosine

•VF

– Mis-Dx as A-Fib with BBB & give AVN blockers

•VF

Page 76: Indiana ENA 2011 Tachyarrhythmias

AHA

• Still recommends Amiodarone for A-Fib in the setting of WPW

Page 77: Indiana ENA 2011 Tachyarrhythmias

NO!!!!!• Amiodarone

– Class I (Na+)

– Class II (Beta)

– Class III (K+)

– Class IV (Calcium)

Page 78: Indiana ENA 2011 Tachyarrhythmias

How to Tx?

• P-

• P-

Page 79: Indiana ENA 2011 Tachyarrhythmias

How to Tx?

• Procainamide

• Propofol (or sedation of choice) and DCC.

Page 80: Indiana ENA 2011 Tachyarrhythmias

“Walking-Talking” VF

Page 81: Indiana ENA 2011 Tachyarrhythmias

“Walking-Talking” VF

• Medics sent for “weak & dizzy all over”

• BP cannot be obtained

• Pulse “hard to palpate” – “keep losing it”

• SpO2 80% and poor waveform

Page 82: Indiana ENA 2011 Tachyarrhythmias

Arrival to ED

• Awake and talking

• Hoses entering chest wall

• Battery pack on waist

• Rhythm below

Page 83: Indiana ENA 2011 Tachyarrhythmias

Walking-Talking 12 Lead

Page 84: Indiana ENA 2011 Tachyarrhythmias

VAD

• Ventricular Assist Device

• Provides mechanical support for failing heart

• Support can be… hours…days…months…years

Page 85: Indiana ENA 2011 Tachyarrhythmias

VAD

• Bridge to re-evaluation

• Bridge to recovery

• Bridge to transplant

• Bridge to destination therapy

Page 86: Indiana ENA 2011 Tachyarrhythmias

VAD Patient

• Anti-coagulation

– Triple therapy

• Anti-arrhythmics

• Anti-hypertensives

Page 87: Indiana ENA 2011 Tachyarrhythmias

VAD Types

• Pulsatile Flow

– Heartmate XVE

– Thoratec IVAD

• Non-Pulsatile Flow

– Heartmate II

Page 88: Indiana ENA 2011 Tachyarrhythmias

Calling 911

• Lack of energy or weakness

• Symptoms may be vague

Page 89: Indiana ENA 2011 Tachyarrhythmias

Outpatient Emergencies

• Arrhythmia

• Hemolysis

• Renal Failure

• Infection

• Decreased Preload from Dehydration

• GI Bleeding

Page 90: Indiana ENA 2011 Tachyarrhythmias

Arrhythmia

• VAD’s do not affect EKG tracing

• Effects of Prolonged Arrhythmia

– Poor Perfusion

– Hypoxia

– Brain Damage

– Death

Page 91: Indiana ENA 2011 Tachyarrhythmias

Who Has A VAD???

Page 92: Indiana ENA 2011 Tachyarrhythmias

Arrhythmia

• VT / VF

– DEFIBRILLATE!!!!!

– May require sedation

– Disconnect VAD from wall outlet

Page 93: Indiana ENA 2011 Tachyarrhythmias

No CPR for VAD’s

• Disruption of pump anastamosis site

• Fatal hemorrhage

• Call VAD Center

Page 94: Indiana ENA 2011 Tachyarrhythmias

Summary

• WCT = Tx as VT until proven otherwise

• Adenosine probably safe for everything EXCEPT A-Fib with WPW

•NO AVN Blockers A-Fib with WPW

• VAD’s are more common

Page 95: Indiana ENA 2011 Tachyarrhythmias

Thank You!!!!!