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Arrhythmias FM Lecture Series

This lecture by Alex Dworak provides an in-depth exploration of common and critical arrhythmias, emphasizing their recognition, etiology, and management strategies. The presentation outlines vital objectives, including stabilizing the patient, utilizing ACLS protocols, and effectively interpreting EKG results. Key topics cover Ventricular Tachycardia, Atrial Flutter, Ventricular Fibrillation, and Torsades de Pointes, elaborating on immediate actions and definitive treatments. This resource is invaluable for healthcare professionals seeking to enhance their skills in arrhythmia management and patient care.

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Arrhythmias FM Lecture Series

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  1. ArrhythmiasFM Lecture Series Alex Dworak July 2008

  2. Needless photo of the author with his no-ponytails-until-you’re-in-college son The obligatory objectives slide • Review common and significant arrhythmias and EKG findings • Focus on recognition, etiology, immediate and definitive management • References: Uptodate, ECGlibrary.com

  3. Basic principles of any arrhythmia • Is the patient stable or unstable? If unstable, call Code Blue and follow ACLS. If unsure, call a code—you’ll get help fast, & the ICU team would rather have a “fake code” than a too-late code • No palpable central pulse in the unstable patient means start CPR; a dopplerable pulse won’t perfuse the brain • If stable, stop and think. Call for help from your supervisor or staff. Check code labs (CBC, CMP, Mg/Phos, cardiac enzymes, blood cx) and get a 12 lead EKG. Consider calling Cards if appropriate. • Make sure the wires are hooked up/it’s not artifact. • The telemetry nurses usually recognize what’s worth freaking out about—don’t tune them out.

  4. VT (Ventricular Tachycardia) • “A PVC is just a PVC, but 3 in a row is Vtach!” • Cause: MI, other structural disease, severe electrolyte change • Immediate: If unstable, SHOCK! If stable (talking, maintaining BP), calmly call Cards while the pads are being attached; consider Amiodarone or Lidocaine bolus, head for the ICU or cardiac floor • Definitive: May need AICD, especially if EF<35% to lower chance of sudden death

  5. Normal/ “Confidence Builder” • Examine rate, rhythm (sinus or not—P before every QRS?), axis (left thumb is I, right is AVF—if both “thumbs up,” axis is normal, whereas a down thumb is deviated in the direction of that hand). • Look at ST segments, width of QRS, check for Q waves, PR depression, weird P waves, flipped/peaked T waves or U waves, excess QT interval length • Machine is good at rates and intervals; don’t always trust its interpretation, though! “We read the bottom of the EKG, not the top.” • Take advantage of Dr. O’Dell’s EKG sessions and practice on every EKG you get! (Same goes for Xrays!)

  6. Too much digitalis…

  7. Atrial flutter • Cause: Non-conducted atrial beats, usually in structurally abnormal heart • Characteristically 300 bpm • Not always obvious; 2:1 aflutter (unlike the 16:1 previously) can be both occult and dangerous—consider it with any narrow complex tachyarrhythmia with rate ~150 bpm • Immediate: If unstable, shock. Otherwise, IV metoprolol 5 mg q5min x3 or IV diltiazem drip with bolus; esmololgtt in ICU or verapamil are also considerations. Watch for hypotension. • Definitive: Electric vs. drug cardioversion in consultation with Cards; may need clot prophylaxis

  8. Ventricular Fibrillation • SHOCK! This and unstable VT should always be shocked. • Make sure the leads are hooked up and the patient is actually unstable and pulseless before you hit the button • Definitive: Let Cards and EP sort out the best management; stabilize and then get the patient to the ICU.

  9. Torsades des pointes • Cause: MI, hypoK+, hypoMg++, long QT, drugs (antiarrhythmics, TCAs…) • Immediate: If unstable, shock! Empirically give 1-2 g IV Mg++ (careful if they have renal failure—but intubation is easier than reanimation…) • Definitive: Correct underlying cause, maybe ICD. Consult Cards.

  10. Complete heart blockwith idioventricular escape rhythm • Cause: MI or other disruption of conducting system • No relation of P to QRS • Immediate: tele monitoring • Definitive: Cards consult for EP workup and pacing

  11. Acute anterior MI • Causes: thrombosis, drugs (cocaine, meth) • Immediate: ACLS • Definitive: Percutaneous stent vs. CABG depending on anatomy at cath and risk factors (i.e. DM) • No beta blockers for coke abusers

  12. Look for the P waves

  13. 2:1 AV block • Could be either Mobitz I (“Wenke walks away”) or Mobitz II (“Moby falls down like he got kicked in the head”?) • Mobitz I has repetitively lengthening PR until the dropped beat, then resets • Mobitz II just drops a beat suddenly; unstable and needs pacing • Can’t tell if it’s 2:1; assume it’s Mobitz II, put on telemetry and get Cards eval

  14. Chest pain, got hypotensive with NTG in the ambulance.

  15. Posterior MI • Usually not isolated; lateral involvement common • ST depression in V1, V2 is actually inverted STEMI on the back of the heart in the RV • Immediate: PRELOAD dependent, give lots of fluids (may need to intubate if they’ve got LV involvement too) and the usual ACLS • Definitive: same as any MI

  16. Afib with RVR • Usually in the context of known afib • Treatment is same as for aflutter: • Immediate: If unstable, shock. Otherwise, IV metoprolol 5 mg q5min x3 or IV diltiazem drip with bolus; esmololgtt in ICU or verapamil are also considerations. Watch for hypotension. • Definitive: Electric vs. drug cardioversion in consultation with Cards; definitely needs clot prophylaxis unless a good reason not to

  17. Credits, Suggested Reading • www.ecglibrary.com • www.uptodate.com • Pocket ACLS survival guide (must have, <$10 at bookstore) • Pocket EKG survival guide • Hurst’s The Heart or Braunwald if you’re really gung-ho Cake is the best!

  18. Torsades des feet. • Completely unrelated video of (Christian) Taekwondo practitioners doing 540 tornado kicks—yes, it’s totally useless in a real fight, but I’d like to see any haters try one and not land on their faces.  • Separate (techno!) video of two credible Darth Maul impersonators

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