1 / 109

Bhubaneswar / 15.10.06

Bhubaneswar / 15.10.06. Cardiac Arrhythmias in ICU. Dr. P.K.Sahoo Cardiologist Kalinga Hospital Bhubaneswar. Cardiac arrhythmias do not necessarily mean structural heart disease. CARDIAC Myocardial Ischaemia Valvular problems CHF. NON CARDIAC Hypoxemia Hypercapnia Hypotension

kelii
Télécharger la présentation

Bhubaneswar / 15.10.06

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Bhubaneswar / 15.10.06

  2. Cardiac Arrhythmias in ICU Dr. P.K.Sahoo Cardiologist Kalinga Hospital Bhubaneswar

  3. Cardiac arrhythmias do not necessarily mean structural heart disease

  4. CARDIAC Myocardial Ischaemia Valvular problems CHF NON CARDIAC Hypoxemia Hypercapnia Hypotension Electrolyte imbalance (K;Ca;Mg) Drug toxicity Conditions provoking arrhythmias

  5. When you suspect arrhythmia in ICU • 12 lead ECG • Long rhythm strip II;aVf or V1 • Double ECG voltage • ↑ paper speed to 50mm/s

  6. Arrhythmias in ICU • Tachyarrhythmias (>100/min) # Narrow QRS complex # Wide QRS complex • Bradyarrhythmias ( <60/min)

  7. Clinical classification of arrhythmias • Heart rate (increased/decreased) • Heart rhythm (regular/irregular) • Site of origin (supraventricular / ventricular) • Complexes on ECG (narrow/broad)

  8. Narrow QRS complex tachycardias • Atrial premature beats • Sinus Tachycardia (100-150) • PSVT (150-250) • Atrial tachycardia with blocks (150-250) • Atrial flutter (250-350) • Atrial fibrillation (>350) • Multifocal atrial tachycardia

  9. 36 year old woman with asthma has ‘thumping in chest’

  10. 48yr.M; febrile • Sinus tachycardia • Remove precipitating cause • BB if symptomatic

  11. 60yr. F. COPD; Resp. failure • More than 3 different P wave shapes with varying PR interval

  12. 60yr. F. COPD; Resp. failure Multifocal Atrial Tachycardia (Chaotic Atrial Tachycardia) • Treat underlying lung disease • Verapamil

  13. ECG in Supraventricular Tachycardia Atrial Flutter Atrial Fibrillation

  14. Relationship between P & QRS in supraventricular Tachycardia (PR & RP interval) AVNRT AVRT Typical (Slow-Fast) Re-entry : PR > RP, Atypical reentry (Fast-Slow), Sinus & Atrial tachycardias : PR < RP

  15. ECG in AV Nodal Reentrant Tachycardia (AVNRT) • QRS is • Regular (180-200/min) • Narrow (<120ms), • No distinct P wave or retrograde P just after QRS

  16. WPW Syndrome Sinus Rhthm Short PR, Delta wave. Wide QRS, Normal terminal QRS, Secondary ST/T changes AVRT QRS is Regular (180-200/min) Narrow (<120ms), Distinct retrograde P wave after QRS (RP<PR) AF with Accessory pathway

  17. Non- Paroxismal Junctional Tachycardia Increased automaticity of a focus in AV junction (70 – 130 /min) Retrograde P may precede QRS (High Junctional/Coronary sinus rhythm) may coincide or may folow QRS (low junctional rhythm)

  18. Wide QRS Tachycardia

  19. Underlying Arrhythmia of Sudden Cardiac Death Primary VF 8% Torsades de Pointes 13% VT 62% Bradycardia 17% Bayés de Luna A. Am Heart J. 1989;117:151-159.

  20. Underlying Causes of Fatal Arrhythmias Other* Cardiomyopathy 80% Coronary Artery Disease *ion-channel abnormalities, valvular or congenital heart disease, other causes

  21. Rhythm Strip During Episodeof Sudden Death • VT degenerates into VF in 30 sec to 3 minutes • 4 minutes into collapse,VF is identified in 90%, asystole identified in 10% • As more time elapses,asystole and EMD areidentified in 60% of victims 6:02 AM 6:05 AM 6:07 AM 6:11 AM

  22. The ‘Dying Heart’ !!

  23. Wide QRS Tachycardia • Ventricular Premature beats • Ventricular Tachycardia • Ventricular Fibrillation • Torsades de pointes • SVT with aberrancy

  24. Cardiac ArrhythmiaPremature Ventricular Contraction

  25. 50 yr. M. post CABG presents with palpitations ; (haemodynamically stable)

  26. Misconceptions about VT • MISDIAGNOSIS Haemodynamic stable wide QRS tachycardia cannot be VT • UNDERDIAGNOSIS Unexplained syncope : ? Bradyarrhthmia / ??VT

  27. 80% of wide QRS tachycardias are VT

  28. VT : manifestations • Syncope / Near syncope • Wide QRS tachycardia • Sudden Cardiac Death ( VF)

  29. ECG diagnosis of VT

  30. VT : Morphological types • UNCHANGING : Monomorphic • CHANGING : Polymorphic # Repetitive – Torsades de Pointes # Alternate complexes – Bidirectional VT # Stable but changing : RBB  LBB

  31. Monomorphic VT:uniform QRS for all complexes

  32. Polymorphic VT:beat to beat variation in QRS morphology

  33. MONOMORPHIC CAD DCM RV dysplasia No structural disease # RBB pattern # LBB pattern POLYMORPHIC Prolonged QT( Torsades de pointes) # Congenital # Acquired Normal QT # Ischaemic (Acute) # Others VT : common causes

  34. VT : How long does it last ? • SUSTAINED : # >30sec. # Requiring termination due to haemodynamic instability • NON SUSTAINED : # <30 secs # Stops spontaneously

  35. ECG in Ventricular Tachycardia (VT) Non-sustained VT (< 30 sec) Sustained VT (≥ 30 sec)

  36. Non sustained polymorphic VT

  37. Polymorphic VT degenerating to VF

  38. Polymorphic VT in ICU :search for a cause of prolonged QT interval

  39. Polymorphic VT : prolonged QT PHARMACOLOGICAL AGENTS Quinidine, Erythromycin,Chloroquine, Amantadine,TCA,phenothiazines, Organophosporous insecticides, Antihistaminics ( astemizole, terfenadine) ELECTROLYTE ABNORMALITIES Hypo Mg;K;Ca

  40. Is it Ventricular Tachycardia (VT) or Supraventricular tachycardia with abberrancy (SVTab) ?

  41. Wide QRS Tachycardia Supraventricular Tachycardia withAberration,BBB, Accessory pathway Ventricular tachycardia Capture & Fusion beats, AV Dissociation / VA association QRS > 140 msec, Superior QRS axis, Concordant pattern of QRS Capture & Fusion beats AV Dissociation 2:1 VA block

  42. Bed side approach : VT vs SVTab

  43. In an ICU setting assume it to be VT rather than SVTab

  44. Specific Types of VT Verapamil sensitive VT RBBB,LAD, Normal Heart Arrhythmogenic RV Dysplasia VT with LBBB morphology

  45. Specific Types of VT Long QT Syndromes Drugs, Electrolyte, Genetic (Jarvell & Lange-Nielsen syndrome, Romano-Ward Syndrome) Torsades de pointes Brugada Syndrome Risk of MalignantVentricular Arrhythmia & Sudden death

  46. 60 year old man with recurrent blackouts

  47. Malignant Ventricular Arrhythmia Ventricular Flutter Ventricular Fibrillation

  48. Finally : a bad one !!!

  49. Rhythm Management .

More Related