Arrhythmias Notes PDF

Arrhythmias Tachycardias: Broad complex tachycardia Irregular rhythm ➔ Magnesium 2g over 10 minutes Regular rhythm ➔ 1) vagal maneuvers 2) Adenosine 6 mg rapid I.V ( if unsucc. + 12 mg if unsuccessful + 18 mg ) If ineffective ➔ Procainamide 10-15 mg/ kg over 20 min or Amio...

Arrhythmias Tachycardias: Broad complex tachycardia Irregular rhythm ➔ Magnesium 2g over 10 minutes Regular rhythm ➔ 1) vagal maneuvers 2) Adenosine 6 mg rapid I.V ( if unsucc. + 12 mg if unsuccessful + 18 mg ) If ineffective ➔ Procainamide 10-15 mg/ kg over 20 min or Amiodarone 300 mg I.V over 10-60 min If ineffective ➔ Synchronized shock up to 3 attempts Narrow complex tachycardia ‘ Irregular rhythm ( probable atrial fibrillation ) ➔ 1) control HR with beta-blocker or ccb ( diltiazem ) 2) consider digoxin or amiodarone if evidence of heart failure 3) anticoagulant if duration >48h Regular ➔ 1) vagal maneuvers 2) Adenosine 6 mg rapid I.V ( if unsucc. + 12 mg if unsuccessful + 18 mg ) If ineffective ➔ Give Verapamil , ccb diltiazem or beta-blocker If ineffective ➔ Synchronized shock up to 3 attempts Bradycardia Access with ABCDE approach: ➔ Give O2 if SpO2 6.5mmol/l Exclude pseudohyperkalemia Empirical treatment for arrhythmias in hyperkalemia is suspected MILD hyperkalemia ( K+ 5.5 -5.9 mmol/l ) & SEVERE ( K+ >6.5 mmol/l ) ➔ Monitor serum K+ & blood glucose ➔ Consider cause of hyperkalemia & prevent recurrence Moderate K+ ( 6.0-6.4 mmol/l ) ECG changes : Peaked T-waves, Flat or absent P-waves , broad QRS-complexes , bradycardia or VT If Present ➔ 10 ml 10% calcium chloride IV or ➔ 30 ml 10% calcium gluconate IV If persist with ecg changes same treatment for as below Absent ECG changes ➔ Insulin - Glucose IV infusion - Glucose 25g with 10 units insulin over 15-30 min IV If pre -treatment blood glucose < 7.0 mmol/l ➔ 10% glucose infusion at 50 ml / hour for 5 h ( 25g ) Respiratory failure Cardiac arrest from acute pulmonary embolism is the most serious clinical presentation of venous thromboembolism, in most cases originating from a DVT. Diagnosis: “ confirmed pulmonary embolism’ as a probability of PE enough to indicate the need for specific treatment. “ 1) Clinical history and assessment 2) Information about past medical history, predisposing factors, and medication that may support diagnosis of pulmonary embolism should be obtained. 3) capnography and echocardiography (if available) 4) If a 12-lead ECG can be obtained before onset of cardiac arrest, changes indicative of right ventricular strain may be found:  - Inversion of T waves in leads V1 V4 - QR pattern in V1, - S1 Q3 T3 pattern (i.e. a prominent S wave in lead I, a Q wave and inverted T wave in lead III), - Incomplete or complete right bundle-branch block. Signs of PE: - Cardiac arrest commonly presents as PEA. - Low ETCO2 readings (about 1.7 kPa/13 mmHg) Common symptoms preceding cardiac arrest during PE: sudden onset of dyspnoea, pleuritic or substernal chest pain, Cough, haemoptysis, syncope signs of DVT in particular (unilateral lower extremity swelling) Hypotension Tachycardia Approach & treatment of PE: ❖ Pulmonary embolism Cardiac arrest prevention Follow the ABCDE approach. Airway: ➔ Treat life-threatening hypoxia with high-flow oxygen. Breathing: ➔ Consider pulmonary embolism (PE) in all patients with sudden onset of progressive dyspnoea and absence of known pulmonary disease (always exclude pneumothorax and anaphylaxis). Circulation: ➔ Obtain 12-lead ECG (exclude acute coronary syndrome, look for right ventricle strain). ➔ Identify haemodynamic instability and high-risk PE. ➔ Perform bedside echocardiography. ➔ Initiate anticoagulation therapy (heparin 80 IU/kg IV) during diagnostic process, unless signs of bleeding or absolute contraindications. ➔ Confirm diagnosis with computed tomographic pulmonary angiography (CTPA). ➔ Give rescue thrombolytic therapy in rapidly deteriorating patients. Consider surgical embolectomy or catheter-directed treatment as alternative to rescue thrombolytic therapy in rapidly deteriorating patients. Exposure:  ➔ Request information about past medical history ➔ predisposing factors, and medication that may support diagnosis of pulmonary embolism: Previous pulmonary embolism or deep venousthrombosis(DVT) ➔ Surgery or immobilization within the past four weeks. Active cancer. Clinical signs of DVT. Oral contraceptive use or hormone replacement therapy. Long-distance flights. Pulmonary edema treatment: Disorder-specific treatment - Arrythmias - Mycardial infarction - Hypertensive crisis - Brain stroke Symptomatic treatment - Nitroglycerine ( vasodilator ) - Diuretics - lowers the BP , increases urinary output & reduces the pressure on the heart - Oxygentherapy Treatment: ? stabilize the patient with oxygen therapy Spontaneous pneumothorax: Sudden onset of chest pain Unilateral pleuritic pain Emphysema can be a common background Typical symptoms include; ➔ Absent breathing sound on one side ➔ Hyperresonant in precautions ( may be absent when the air space is narrow ) ➔ Absence of lung sliding in US Tension pneumothorax: An increasing intrapleural pressure which compresses the heart, great vessels & lungs Symptoms: ➔ Chest pain, respiratory effort, shock neck vein distention , cyanosis Treatment: ➔ needle aspiration 2nd intercostal space midclavicular line Or 4-5 intercostal space midaxillary line, ( midaxillary region doesn't have any intercostal vessels as midclavicular therefore its safer,apart from that sometimes the body reject the needle in as the first option) ➔ Finger thoracostomy Acute asthma exacerbation: ➔ Beta mimetics for inhalation (salbutamol aerosol 0,1 mg/dose; salbutamol nebulization 5mg) ➔ Hydrocortisone iv ( prednisolone) ➔ Magnesium sulfate ➔ Theophylline (give very slowly risk of BP drop best way is infusion 15 to 20 mins) Asthma & COPD guidelines: Cardiac arrest prevention Airway  Ensure a patent airway. Treat life threatening hypoxia with high flow oxygen. Titrate subsequent oxygen therapy with pulse oximetry (SpO2 94 98% for asthma; 88 92% for chronic obstructive pulmonary disease (COPD)). Breathing Assess respiratory rate, accessory muscle use, ability to speak in full sentences, pulse oximetry, percussion and breath sounds; request chest X-ray. Look for evidence of pneumothorax/tension pneumothorax. Provide nebulised bronchodilators (oxygen driven for asthma, consider air driven for COPD). Administer steroids (Prednisolone 40 -50 mg or hydrocortisone 100 mg). Consider IV magnesium sulphate for asthma. IV aminophylline or salbutamol. Circulation Assess heart rate and blood pressure attach ECG. Obtain vascular access. Consider IV fluids. Type of chronic pulmonary disease (COPD) Treatment: oxygen therapy, Bronchodilator, steroids Chronic bronchitis and emphysema are both forms of COPD. They cause similar symptoms but affect different parts of your lungs. Chronic bronchitis causes swelling and mucus in your airways, or tubes, that bring air in and out of your lungs. Emphysema affects the small air sacs at the end of your airways (alveoli) and causes them to collapse. People with COPD often have some damage to both their airways and alveoli. Pulmonary fibrosis: Pulmonary fibrosis is scarring and thickening of the tissue around and between alveoli. These changes make it harder for oxygen to pass into the bloodstream. ❖ Mechanical ventilators can be used to assist breathing in patient with either low oxygen such as pneumonia or high carbon dioxide such as COPD.  ❖ Is a ventilator mode that enables partial mechanical assistance. This ventilator mode will provide a set number of breaths at a fixed tidal volume, but a patient can trigger a spontaneous breath with the volume determined by patient effort. ❖ CPAP (continuous positive airway pressure) is a machine that uses mild air pressure to keep breathing airways open while sleeping. Can be used to treat sleep disorder breathing such as sleep apnea Extracorporeal oxygenation Severe damage of pulmonary tissue with deep hypoxia Respiratory support (V-V setting) Circulatory and respiratory support (A-V setting) (a) veno-venous (V-V) ECMO, (b) veno-pulmonary (V-P) ECMO, and (c) veno-venoarterial (V-VA) ECMO. ECMO is a form of life support for people with life-threatening illness or injury that affects the function of their heart or lungs. ECMO keeps blood moving through the body and keeps blood gasses (oxygen and carbon dioxide) in balance