Pitfalls in Arrhythmias Jeffrey Tabas, M.D. Professor of Emergency - - PDF document

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Pitfalls in Arrhythmias

Jeffrey Tabas, M.D.

Professor of Emergency Medicine Office of CME UCSF School of Medicine

Goals

Using a case based approach, we will review pitfalls in management of:

• Tachydysrhythmias

– Narrow – Wide

• Bradydysrhythmias

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Background 2010 ACLS Guidelines Background Narrow Complex Tachycardia

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Regular – SVT

• Adenosine preferred
• Beta blocker, CaCB if needed

Irregular – Atrial Fib

• Beta blocker
• CaCB
• Amiodarone
• Procainamide

Background Narrow Complex Tachycardia Background Regular NCT

Adenosine

• 6 – 12 mg IV
• Maximize delivery
• Beware with dipyridamole (Aggrenox),

carbamezipine

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Background Afib and Aflutter

Metoprolol

• 5 mg IV Q5 mins x 3 then oral dose
• Causes hypotension, bronchospasm

Diltiazem

• 20 mg IV over 2 min, repeat Q10-15 min
• 10 mg IV if at all tenous!!!!
• 60 mg po or IV drip
• Causes hypotension

Amiodarone (o.k. if wide)

• 150 mg over 10 mins
• 1 mg/min infusion
• Causes hypotension (less than others)

Procainamide for conversion (best for wide)

• 1 gm over 1 hour
• Causes hypotension and prolongs QT

Background Afib and Aflutter

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Background Wide Complex Tachycardia Background Regular WCT

• Adenosine
• Amiodarone
• Procainamide

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Bradycardia with Pulse

Case #1

A 70 y.o. male is brought in by ambulance from nursing facility with supraventricular tachycardia. Drinks a lot of coffee. Field vitals are HR =150, BP = 88/30. Paramedics tried 6 mg and 12 mg of adenosine unsuccessfully.

• 26b. 50 y.o BIBA w/ near syncope.

Case #2 Case #2

A 50 A 50 y.o y.o. male is BIBA with palpitations. He was noted to have intermitt . male is BIBA with palpitations. He was noted to have intermittent ent VTach VTach. . Because he was Because he was “ “semi semi-

• stable

stable” ” in the field, no intervention was given. in the field, no intervention was given. ED vital signs were: HR = 200, SBP = 90, RR = 18, ED vital signs were: HR = 200, SBP = 90, RR = 18, Afebrile Afebrile His exam was significant for difficult access due to extensive His exam was significant for difficult access due to extensive hx hx of IDU

• f IDU

Case # 3 Case # 3

A 25 A 25 y.o y.o. male presents with palpitations / pain radiating to left neck. . male presents with palpitations / pain radiating to left neck. One similar One similar episode in Mexico. Told that if recurrent, he should cough or mi episode in Mexico. Told that if recurrent, he should cough or mimic having a BM. mic having a BM.

Case #4 Case #4

A 50 A 50 y.o y.o. male presents to the ED feeling weak. . male presents to the ED feeling weak. Initial vitals show: HR = 50, BP = 80/50 Initial vitals show: HR = 50, BP = 80/50

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Bibliography

• Anderson JL, et al. Management of

patients with atrial fibrillation: a report

• f the American College of Cardiology/

American Heart Association Task Force

• n Practice Guidelines. J Am Coll
• Cardiol. 2013 May 7;61(18):1935-44.

Bibliography

• Neumar RW, et al. Part 8: adult

advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2;122(18 Suppl 3):S729-67

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Bibliography

• Electrocardiography in Emergency
• Medicine. Editors: Mattu A, Tabas J,

and Barish R. ACEP Publishing 2007.