dr ghassem soltani mums department of anesthesiology imam reza hospita l n.
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Dr. Ghassem Soltani MUMS Department of Anesthesiology Imam Reza Hospita l

Dr. Ghassem Soltani MUMS Department of Anesthesiology Imam Reza Hospita l

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Dr. Ghassem Soltani MUMS Department of Anesthesiology Imam Reza Hospita l

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  1. Dr. Ghassem Soltani MUMS Department of Anesthesiology Imam Reza Hospital

  2. Rhythms for unstable tachycardia Sinus tachycardia Atrial fibrillation Atrial flutter Reentry supraventricular tachycardia (SVT) Monomorphic VT Polymorphic VT Wide-complex tachycardia of uncertain type

  3. Drugs for Unstable Tachycardia Drugs are generally not used to manage patients with unstable tachycardia. Immediate cardioversion (sedation drugs in the conscious patient )

  4. Tachycardia Intruduction key to management of a patient with any tachycardia: presence or absence of pulses expert consultation available

  5. Serious or Significant Symptoms Unstable Condition: Hypotension Acutely altered mental status Signs of shock Ischemic chest discomfort AHF “Ventricular rates less than 150/min usually do not cause serious signs or symptoms”

  6. types of shocks Unsynchronized shocks shock may fall randomly anywhere within the cardiaccycle (higher energy level ) Synchronized shocks synchronized with a peak of the QRS complex lower energy level

  7. Potential Problems with synch R-wavepeaks are undifferentiated or of low amplitude not synchronize through the handheld quick-look paddles Synchronization can take extra time

  8. Synchronized Shocks Unstable SVT Unstable atrial fibrillation Unstable atrial flutter Unstable regular monomorphic tachycardia with pulses

  9. Unsynchronized Shocks patient who is pulseless clinical deterioration (severe shock or monomorphic or polymorphic VT is present in the unstable patient) Should the shock cause VF

  10. Energy Dose Unstable atrial fibrillation: Monophasic cardioversion:200-J synchronized shock Biphasic cardioversion: 120- to 200-J synchronized shock atrial flutter and SVT : 50 to 100 J with a monophasic or biphasic Monomorphic VT : synchronized shocks ,100 J

  11. Synchronized Cardioversion Technique Treatment of choice in symptomatic (unstable) reentry SVT or VT with pulses,unstable atrial fibrillation and unstable atrial flutter. Cardioversion is unlikely to be effective for treatment of junctional tachycardia or ectopic or multifocal atrial tachycardia - adhesive electrodes or handheld paddles -synchronized (sync) mode

  12. Stable Tachycardia stable patient with a rapid heart rate > 100/min sinus tachycardia is excluded from the treatment algorithm. type of tachycardia initial assessment and management Treat regular narrow-complex rhythms with vagal maneuvers and adenosine

  13. stable Tachycardia Narrow—QRS complex (SVT) tachycardias Sinus tachycardia Atrial fibrillation Atrial flutter AV nodal reentry Wide—QRS complex tachycardias Monomorphic VT Polymorphic VT SVT with aberrancy Regular or irregular tachycardias Irregular narrow-complex tachycardias are probably atrial fibrillation

  14. Classification of the tachycardia Are symptoms present or absent? Are symptoms due to the tachycardia? Is the patient stable or unstable? Is the QRS complex narrow or wide? Is the rhythm regular or irregular? Is the QRS monomorphic or polymorphic? Is the rhythm sinus tachycardia? The answers guide subsequent diagnosis and treatment.

  15. Sinus Tachycardia Sinus tachycardia : HR > 100/min And does not exceed 220/min and is age- related. gradual onset and gradual termination. external influences :fever, anemia, hypotension, blood loss, or exercise (not cardiac conditions) , regular rhythm, (vagal maneuvers). Cardioversion is contraindicated. ß-Blockers In sinus tachycardia, the goal is to identify and treat the underlying systemic cause

  16. Managing Stable Tachycardia 1) pulses are present? 2) In pulses patient whether stable or unstable ? Pulseless → Cardiac Arrest Algorithm (VF/Pulseless VT) has pulses → Tachycardia Algorithm

  17. Treating Tachycardia Distinguish between supraventricular and ventricular wide-complex rhythms pulseless : Cardiac Arrest Algorithm unstable : do not delay treatment stable patients with wide-complex tachycardia

  18. Wide-complex tachycardia QRS > 0.12 : Consider expert consultation The most common forms of life-threatening wide-complex tachycardia: Monomorphic VT - Polymorphic VT Regular or Irregular A regular: VT or SVT with aberrancy An irregular: atrial fibrillation with aberrancy, pre- excited atrial fibrillation , or polymorphic VT/torsades de pointes

  19. Monomorphic VT

  20. Polymorphic VT

  21. Regular Ventricular Tachycardia A regular SVT with aberrancy

  22. Drugs to Avoid in Patients With Irregular Wide-Complex Tachycardia adenosine, calcium channel blockers, digoxin, and possibly β-blockers in patients with pre-excitation atrial fibrillation

  23. Narrow QRS with regular rhythm Attempt vagal maneuvers Adenosine Attention in: pregnancy , drug interactions (theophylline, caffeine, theobromine , dipyridamoleor carbamazepine), transplanted hearts or after central venous administration and bronchospasm Observe for recurrence

  24. Tachycardia Algorithm Advanced Management Steps