Tachy arrhythmia
-12 lead ECG + Rhythm strip (and onset)
- stable v. unstable (AMS, hypotensive, angina chest pain (ischemia), SOB (HF?, esp restrictive);
unstsable->electricity; stable->ECG-> narrow (His purkinje) v wide (focal point spread via cell 2 cell/gap
junctions; or bundle, or SVT w/ aberrancy (bundle with high heart rate; aberrancy means conducted
other than His purkinje)-> regular v irregular -> identify rhythm
Treat: underlying cause to correct? Rate v rhythm control (depends on etiology); anticoagulation
Wide complex tachycardia
Ddx-
- Monomorphic VT
- Polymorphic VT (ischemic v torsatdes)
- SVT with aberrancy
Tx- Amiodarone bolus 150mg over 10min, followed by gtt (careful of cardioversion)
Unstable gets electricity (200J): synchronize CDV for SVT or monomorphic VT (organized rhythms), defib
for VF
Torsades: beta-agonist (isoproterenol, pacing) + Mg
The wonkier it looks, the more likely its ischemic; the worse it looks, the worse it is
Amiodarone is the DOC for almost all tachyarrythmia
VT vs. SVT with aberrancy: Brugada criteria
1. Is there an absence of RS complex in all precordial leads (V1-V6)? (ex. neg deflection
everywhere, or pos deflection everywhere) DIRECTION
a. Yes: VT (SN 21%; Sp 100%); all neg or all pos- start from apex going up is VT
b. NO
2. Is the R to S interval> 100msec (2.5 boxes/ wide) in one precordial lead? HOW DOES IT
SPREAD THROUGH MYOCARDIUM (fast via His or slow via gap junction)
a. Yes: VT (Sn66%, Sp: 98%)
b. NO
3. Is there AV dissociation?
a. Yes: VT (Sn 82%, Sp 98%)
b. No (saying ventricle listens to atria)
Polymorphic VT->torsade->Mg then isoprel
Unstable narrow complex tachycardia
Tx: peristable: try amiodarone; unstable: synchronized cardioversion
Irregular (afib) v regular -> P waves (no- AVNRT, same- flutter, 3 different- MAT, Wonky (not
positive in V2)- atrial tachy)
Stable narrow complex tachycardia
Dx: vagal (carotid massage, orbital pressure), adenosine
Tx: depends on rhythm; usually BB or CCB
Afib/Aflutter; sinus tach (treat underlying), AVnRT (BB/CCB, ablation), Atach (BB/CCB,
ablation), MAT (CCB, ablation), WPW (procainamide/electricity->ablation; amio in real life)
Adenosine: blocks AV node; purpose: reveal underlying atrial activity (because shh ventricle); dosing:
6mg->12 if no response
Warning: 12 ECG (need to see the atrial activity-> the purpose); zoll pads, feels like Death, avoid
in wpw
Afib or aflutter
- onset <48hr (clots unlikely exist; cardiovert w amio) v >48hr (clots likely exist; dont cardiovert):
-rate control (<110bpm; dont need to get to perfect rate)
- IV: Meoprolol, diltiazem (avoid esmolol b/c halflife too short, verapamil b/c halflife too long)
- PO: all of the above
- digoxin (careful in renal failure, Rx interactions): HF in afib; cardiomyopathy; good because
doesnt cardiovert
- rhythm control (cardioversion)
- amiodarone (IV, gtt, PO)
- DC synchron
Amiodarone: mechanism: does everything; use: all tachy arrhythmias; pharmo: lipophilic- large Vd, long
life
- bolus: 150mg over 10 min (no limit on number of boluses because quickly goes into adipose; most
beta-blockade so highest risk for hypotension)
- 24hr gtt
- load- amount to appropriately treat the arrhythmia, NOT to reach steady state in circulation
o Atrial 6-8g, ventricular 10-12g
- Maintenance: lowest effective (atrial 200, ventricle 400)
- Rare acute lung injury
