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Slide 1 :

ACLS updated Management of Symptomatic Bradycardia and Tachycardia 2006.02.23 R ? ? ?

Slide 2 :

For patients with acute coronary ischemia, the greatest risk for serious arrhythmias occurs during the first 4 hours after the onset of symptoms. ECG monitoring should be established as soon as possible.

Slide 3 :

Principles of Arrhythmia Recognition and Management

Slide 4 :

Total patient assessment. Ventilation, oxygenation, heart rate, blood pressure, and level of consciousness. Signs of inadequate organ perfusion.

Slide 5 :

If bradycardia produces signs and symptoms that persist despite adequate airway and breathing, prepare to provide pacing. For symptomatic high-degree AV block, provide transcutaneous pacing without delay. If the tachycardic patient is unstable with severe signs and symptoms related to tachycardia, prepare for immediate cardioversion.

Slide 6 :

If the patient with tachycardia is stable, determine if the patient has a narrow-complex or wide-complex tachycardia and then tailor therapy accordingly. Call for expert consultation regarding complicated rhythm interpretation, drugs, or management decisions.

Slide 7 :

Bradycardia

Slide 8 :

6H + 5T Hypovolemia Toxins Hypoxia Tamponade, cardiac Hydrogen Tension pneumothorax Hyper/HypoK Thrombosis (cardiac/ pul) Hypoglycemia Trauma (IICP) Hypothermia

Slide 9 :

Therapy Pacing (class I): transcutaneous/transvenous Atropine (class IIa) 0.5 mg IV every 3 ~ 5 minutes to a maximum total dose of 3 mg. Second line (class IIb) epinephrine, dopamine, glucagon

Slide 10 :

Tachycardia

Slide 11 :

Classification of Tachyarrhythmias Narrow–QRS-complex — Sinus tachycardia — Atrial fibrillation — Atrial flutter — AV nodal reentry — Accessory pathway–mediated tachycardia — Atrial tachycardia (ectopic and reentrant) — Multifocal atrial tachycardia (MAT) — Junctional tachycardia

Slide 12 :

Wide–QRS-complex — Ventricular tachycardia (VT) — SVT with aberrancy — Pre-excited tachycardias (advanced recognition rhythms using an accessory pathway)

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Slide 16 :

Supraventricular Tachycardia

Slide 17 :

Therapy Preferred initial therapeutic choices --Vagal Maneuvers: terminate 20~25% reentry SVT. --Adenosine--6 mg (class I), then 12 mg, 12 mg. --safe and effective in pregnancy. --3 mg if given by central venous access. Second-line --Calcium Channel Blockers --Beta-blockers

Slide 18 :

Irregular Tachycardias Atrial Fibrillation and Flutter

Slide 19 :

Therapy Rate control versus Rhythm control AF > 48hrs, anticoagulation first (keep INR 2~3); Electric or pharmacologic cardioversion should not be attempted in these patients unless the patient is unstable or the absence of a LA thrombus is documented by TEE. Magnesium (LOE 3), diltiazem (LOE 2), and beta-blockers (LOE 2) for rate control. Amiodarone, ibutilide, propafenone, flecainide, digoxin, clonidine, or magnesium can be considered for rhythm control.

Slide 20 :

Wide-Complex Tachycardia

Slide 21 :

Evaluation First: stable or unstable Second: 12-lead ECG Third: rhythm --- regular: VT or SVT with aberrancy --- irregular: AF with aberrancy pre-excited AF (AF with WPW) polymorphic VT

Slide 22 :

Therapy Regular Wide-Complex Tachycardias ---SVT: adenosine ---monomorphic VT ---symptomatic: synchronized cardioversion. ---stable: amiodarone (IIa), 150 mg, 10min (2.2 g, 24 hr)

Slide 23 :

Polymorphic (Irregular) VT

Slide 24 :

Therapy Unstable: unsynchronized shocks. Polymorphic VT with long QT (torsades de pointes VT): magnesium. Polymorphic VT (normal QT interval): amiodarone Torsades de pointes associated with bradycardia and drug-induced QT prolongation: isoproterenol or ventricular pacing.

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Atrial fibrillation — Atrial flutter — AV nodal reentry — Accessory pathway–mediatedVentricular tac more Atrial fibrillation — Atrial flutter — AV nodal reentry — Accessory pathway–mediatedVentricular tachycardia (VT) — SVT with aberrancy — Pre-excited less
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