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 ) Chest pain Common causes: Ischemic heart disease ( myocardial infarction); ➔ Retrosternal pain, may radiate to the shoulder, arm, and jaw - Crushing, squeezing, burning. - Brought on by exertion and relieved with rest. - Exposition to cold can also include cardiac pain - Breathing and changing position do not change the discomfort. Spondyloarthritis; refers to any joint disease of the vertebral column. As such, it is a class or category of diseases rather than a single, specific entity. It differs from spondylopathy, which is a disease of the vertebra itself, but many conditions involve both spondylopathy and spondyloarthropathy. ➔ Dorsal location of pain intercostal radiation - Position-dependent - Not linked to exertion, maintains at rest  Pneumonia / pleuritis ➔ Typical anamnesis; - Pain in a limited area of the chest - Breathing dependent - Pleural friction sound may be heard Chest trauma Gastroesophageal reflux; ➔ Usually occurs because of spicy meals, discomfort is higher in laying patients Hiatus hernia Herpes Zoster; ➔ Unilateral intercostal location - Pain can precede skin eruption and persist for weeks after skin healing Aortic dissection Spontaneous Pneumothorax; ➔ Sudden onset dyspnea; - Unilateral pleuritic chest pain - Emphysema is a common background - Typical symptoms (no breathing sounds on one side, hyperresonance to percussion) may be absent when the air space in narrow - Absence of lung sliding in US Pulmonary embolism Chest pain diagnosis depend on: ○ Location ○ Character ○ Timing ○ Position dependence ○ Palpation dependence ○ Exertional dependent Locations: ○ Retrosternal (coronary disease, esophageal disorders) ○ Along the ribs (zoster) ○ Back (vertebral column disease, aortic dissection) ○ Pleuritic chest wall pain (rare, pneumonia, PE, pneumothorax) Character: ○ Burning ○ Radiate to the jaw or left arm Respiratory failure Initial assessment: - Mental status - Objective symptoms of dyspnea - Respiratory rate - Cyanosis - Auscultation - Arterial blood gasses - Pulse oximetry - Capnometry 1. Type I respiratory failure or hypoxaemic ( PaO2 45 ) 3. No cyanosis can occur in anemia patients 4. Initial symptomatic treatment is with oxygen therapy 5. Capnometry serves as a noninvasive way to measure the partial pressure of carbon dioxide CO2 in an exhaled breath. Respiratory rate: - Adult 10-14/min - 5.yo old child 20/min - Newborn avg. 40/min - Tidal volume; 6-8 ml/kg PO2 (partial pressure of oxygen) reflects the amount of oxygen gas dissolved in the blood. (PCO2) is the measure of carbon dioxide within arterial or venous blood. Bicarbonate HCO3. It's a by-product of your body's metabolism. Your blood brings bicarbonate to your lungs, and then it is exhaled as carbon dioxide. Your kidneys also help regulate bicarbonate. Bicarbonate is excreted and reabsorbed by your kidneys. This regulates your body's pH, or acid balance. Bicarbonate also works with sodium, potassium, and chloride. These substances are called electrolytes. These are often measured at the same time as bicarbonate. SaO2 is the combined form of oxygen and hemoglobin 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 - Arrhythmias - Myocardial infarction - Hypertensive crisis - Brain stroke Symptomatic treatment - Nitroglycerine ( vasodilator ) - Diuretics - lowers the BP , increases urinary output & reduces the pressure on the heart - Oxygen Therapy 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 patients with either low oxygen such as pneumonia or high carbon dioxide such as COPD.  ❖ Hi-Flow ➔ A bridge between non-invasive and mechanical ventilation → delivers 30-80 l / min of warmed & humidified oxygen → increases mean airway pressure ❖ Non-invasive ventilation (NIV) ➔ Is a type of mechanical ventilation that provides respiratory support without the need for an invasive procedure, like intubation. Instead, it uses a mask or similar interface to deliver air or a mixture of gases (usually oxygen and air) to the patient's airways. ➔ Types of NIV: - CPAP → Continuous positive airway pressure is a form of positive airway pressure ventilation in which a constant level of pressure greater than atmospheric pressure is continuously applied to the upper respiratory tract of a person. - BiPAP → This delivers two levels of pressure — higher during inhalation and lower during exhalation. It's useful for patients with conditions like COPD or more severe respiratory issues. ❖ CPAP ➔ Patient spontaneous breathing is required ➔ Airways are safe ( patient is conscious) ➔ Require Large sealed facemask ➔ Airways pressure continuously elevated ➔ Allos to reach high O2 concentration → CPAP 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 ❖ Mechanical mandatory ventilation: - 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. ➔ Airways need to be secured with endotracheal intubation ( ETT) ➔ Patient respiratory drive is absent or inadequate ➔ Paralytics & deep analgosedation is usually required  ❖ Passive oxygen therapy: ➔ Patient spontaneous breathing required ➔ Airways are safe ( patient is conscious ) ➔ Nasal cannula for low flow ( 2 l / min ) ➔ Non-rebreather mask with a reservoir ( allows to reach 40-60% oxygen concentration) Extracorporeal oxygenation (ECMO ): is a form of life support for people with life-threatening illness or injury that affects the function of their heart or lungs. keeps blood moving through the body and keeps blood gasses (oxygen and carbon dioxide) in balance 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. Intracranial hematoma ❖ Epidural hematoma ➔ Typically associated with skull fractures ➔ Lucid interval ➔ Fixed dilated pupil on one side ➔ Collateral hemiparesis ❖ Subdural hematoma ➔ Slow and delayed progress of symptoms ➔ From headache to coma ➔ In acute hematoma rapid development of mass effect ❖ Intracerebral hematoma ➔ Usually as consequence of brain contusion ➔ Symptoms include various neurological deficits. ❖ Brain concussion ➔ Brief loss of consciousness ➔ Retrograde amnesia ➔ Disorientation ➔ Normal CT-scan ➔ Sequela - sleep, behavior & emotional disturbances ❖ Diffuse axonal injury ➔ High energy injury ➔ Disruption of axons ➔ Coma without focal neurological deficits ➔ High mortality rate ❖ Elevated intracranial pressure ➔ Decreased level of consciousness ➔ Nausea & vomiting ➔ Dilated pupils ( one or both ) ➔ Bradycardia ➔ Elevated blood pressure ➔ Respiratory rate disturbances ( cheyne-stroke )  ➔ Risk of herniation ❖ Subarachnoid hemorrhage ➔ Sudden onset of headache at its maximal intensity ➔ Often caused by the disruption of an aneurysm ➔ Loss of consciousness, seizure, vomiting, photophobia ➔ Focal neurological symptoms are often absent What are the benefits of elevating the upper body? The position of the abdomen in regards to the diaphragm it facilitates ventilation In head trauma: its beneficial in order to decrease intracranial pressure which decreases the risk of brain edema, intracranial hematomas, concussions ❖ Spinal cord injuries ➔ Palpitation along the spine ➔ Strength of muscles ➔ Sensory examination ➔ Respiratory chest mobility ➔ No stimulation from adrenal gland due to the injury as a result no effects of catecholamines stimulation ➔ Neurogenic shock → hypotension without symptoms of adrenergic stimulation ( bradycardia, warm skin) → epinephrine , atropine ➔ Lack of patient immobilization may cause additional neurologic damage. ❖ Craniofacial injuries ➔ Eye injuries  - Non.penetrating, chemical irritation etc → Lavage with normal saline - Penetrating → sterile dressing ➔ Nose injuries - Risk of blood aspiration ❖ Mandible injuries → intubation may be very difficult ( avoid paralytics if possible ) Abdominal trauma ➔ Risk of massive hemorrhage ➔ Solid organ rupture ➔ Great vessel rupture ➔ Tubular organ rupture Initial assessment of abdominal injury: - Ultrasound → Focused assessment sonography in trauma (FAST ) To diagnose hemorrhage in trauma setting ideally it takes 120 - Bp- Decreased - RR > 30 - Mental status- confused, somnolent ❖ Blood loss of >2000ml >40% - HR >140 - BP- decreased - RR>35 - Mental status- unconscious ❖ Lethal triad”, phenomena linked together ( triad of death) ➔ Coagulopathy  ➔ Acidosis ➔ Hypothermia ❖ Monitoring ➔ NIBP/IBP ➔ USG vena cava inferior, less than 50% in fluid overload (rigid). Small changes in diameter ➔ Diuresis, renal function- reflect visceral blood flow ➔ etCO2, intubated patients. Exhaled air CO2, how many particles of co2 can go in inhaled air can be related to lung values. 32-43, normal ➔ blood gasses, lactate- sensitive marker of shock, tissue oxygenation and tissue blood flow. I shock visceral blood flow is decreased, the metabolism skips to aerobic to anaerobic. Co2 h2o are productive in aerobic Pitfalls: - no tachycardia in spinal cord injury and beta blocker treatment - normal BP despite massive hemorrhage - normal ecg despite cardiac arrest - In children, normal parameters can be maintained longer in adults followed by rapid collapse. → ( high ability of compensating ) vessels are empty, cardiac arrest, no blood flowà present normal on parameters. Always check pulse. - In elderly, drop in BP occurs early ❖ Consequences: - AKI - Acute hepatic failure - ARDS - DIC, disseminated intravascular - Paralytic ileus  ❖ Mechanism of dr. choli: Tissue injury- hypoxia- bowel barrier damage → release of inflammatory cytokines → TNF, IL-6, IL-8. Leads to SIRS, results to ARDS and MODS. Releases anti-inflammatory cytokines, CARS → prevents further damage, decreases level of immunological response à second heat, septic shock and the patient dies ❖ Early goals of treatment ➔ Provide tissue blood flow- iv fluids, catecholamines (central venous access), ephedrine(vasoconstrictors constrict peripheral arteries, elevated BP, tissue blood flow decreases) ➔ Provide blood oxygenation, oxygen therapy, airway management, ventilatory ➔ Maintain diuresis ❖ Errors - Ineffective management of external hemorrhage (blood in the stretcher) - Prolonged stay at scene of accident - Cold fluid, flow - warmers applied to the drain - Excessive fluid administration, dissolve clotting factors by administering crystalloids when the BP drops - Lack of thermal insultation Chest trauma: ❖ Pneumothorax ❖ Hemothorax ❖ Flail chest ❖ Pulmonary contusion ❖ Blunt cardiac injury ( cardiac contusion)  ❖ Aortic disruption ❖ Tracheoesophageal tree injury ❖ Cardiac tamponade Pneumothorax: ➔ Simple pneumothorax - Unilateral absence of breath sounds - Unilateral hyperresonant percussion - Subcutaneous emphysema (not always) ➔ Tension pneumothorax (as above ) - Increased respiratory work - Cyanosis - Symptoms of shock - Chest pain - Neck vein distension - Tracheal deviation ( late manifestation) Treatment: - Oxygen Therapy - Chest tube placement is not immediately required unless mechanical ventilation is applied - Sucking chest wound → Asherman chest seal ( dressing with a valve)  ❖ How to decompress? ➔ Cannula 2,1 mm) i >8 cm length ➔ Recommended 10 G ( TCCC) ➔ Finger thoracostomy → chest tube Hemothorax: - accumulation of blood in the pleural cavity - Trauma is the most common cause; blunt trauma or penetrating trauma - Spontaneous pneumothorax can lead to hemothorax as complications - Treatment include; oxygen therapy, hemodynamic support ( IV.fluids) , chest tube thoracostomy ) Flail chest: - Free chest wall segment ( two or more neighboring ribs fractured in two or more places) - Paradoxical motion of chest wall during respiration - Manual stabilization; ventilator. Cardiac tamponade: - fluid accumulates in the pericardial sac compressing the heart and leading to a decrease in cardiac output and shock. - Neck vein distension - Symptoms of shock - Symptoms similar to tension pneumothorax - Pericardiocentesis ( procedure performed to remove pericardial fluid from the pericardial sac) Pulmonary contusion: - type of lung injury that involves bruising of the lung tissue, typically caused by blunt trauma to the chest. - Blunt chest trauma is the most common cause - Symptoms include; dyspnea, cough, chest pain , signs of hypoxia. - Complications; hypoxemia, RF , pneumonia, ARDS - Treatment; oxygen therapy, Mechanical Ventilation: In severe cases where breathing is compromised, intubation and mechanical ventilation may be required. Pain management & Fluids. Blunt cardiac injury ( cardiac contusion): - injury to the heart muscle, typically caused by blunt trauma to the chest - Symptoms; chest pain, shortness of breath , palpitation, hypotension, signs of heart failure, syncope may also occur due to the arrhythmias or reduced CO. Aortic disruption: - traumatic aortic rupture or aortic transection, most common causes are blunt trauma or penetrating Anaphylaxis Anaphylaxis is a severe, rapid-onset systemic allergic reaction that can be life-threatening. Immediate recognition and treatment are crucial to prevent death. Causes: Common triggers include: ○ Foods (especially in children). ○ Drugs (e.g., antibiotics, anesthesia). ○ Insect stings or bites. Symptoms: Airway problems: Swelling of lips, tongue, uvula. Breathing issues: Dyspnea (shortness of breath), wheezing, bronchospasm, stridor, reduced airflow, and hypoxemia. Circulation issues: Hypotension, shock, and cardiac arrest. Skin/mucosal changes: Generalized urticaria, flushing, or itching, though these may not always be present. Neurological: Altered mental state, seizures, or sudden collapse. Treatment: 1. Adrenaline (Epinephrine): ○ First-line treatment for anaphylaxis. ○ Administer intramuscular (IM) adrenaline early: Dose: 0.5 mg IM (for adults) in the anterolateral thigh. Repeat after 5 minutes if no improvement. ○ Adrenaline auto-injectors (0.3 mg or 0.15 mg) can be used as an alternative. 2. Remove the trigger: ○ Stop suspected drugs or remove stingers (from insect stings) immediately.  3. IV fluids: ○ Anaphylaxis causes hypotension due to vasodilation and fluid loss. ○ Administer 500 ml of crystalloids (e.g., sodium chloride) over 5–10 minutes. ○ Larger volumes may be needed for refractory anaphylaxis. 4. Oxygen therapy: ○ Provide high-flow oxygen and titrate to keep oxygen saturation between 94-98%. 5. IV adrenaline (in specialist settings): ○ Use for patients who need more aggressive treatment. ○ Requires continuous monitoring (ECG, blood pressure). 6. Other drugs: ○ Consider glucagon (1–2 mg IV) for patients on beta-blockers if adrenaline is ineffective. ○ Other vasopressors (e.g., vasopressin, noradrenaline) can be used for refractory cases. 7. Steroids and antihistamines: ○ Not recommended for immediate anaphylaxis management. Steroids may be used for asthma-like symptoms or refractory shock. 8. Cardiac arrest management: ○ Follow standard Advanced Life Support (ALS) protocols, with a focus on IV adrenaline and addressing reversible causes (fluids, oxygen). Hyperthermia: occurs when the body’s ability to regulate its temperature fails, leading to a core temperature rise beyond what is normally maintained by homeostasis. It can be caused by environmental factors or excessive internal heat production. Causes: Environmental Heat Exposure: The body absorbs heat faster than it can lose it through thermoregulatory mechanisms (e.g., high temperatures, humidity). Excessive Exercise: Heat generation from physical exertion can overwhelm the body's ability to cool down.  Systemic Inflammatory Response: Heat stroke can trigger an inflammatory response similar to SIRS (Systemic Inflammatory Response Syndrome). Symptoms: 1. Heat Syncope: ○ Mild hyperthermia, fainting, dizziness. ○ Core temperature: Often normal or slightly elevated. 2. Heat Exhaustion: ○ Symptoms: Thirst, weakness, dizziness, anxiety, syncope, and core temperature usually >37°C. ○ Symptoms improve with rest and hydration. 3. Heat Stroke: ○ Severe hyperthermia: Core temperature >40°C. ○ Neurological symptoms: Altered mental state, seizures, coma. ○ Other symptoms: Tachycardia, tachypnea, hypotension. ○ Mortality: Approximately 10%, and up to 33% when combined with hypotension Treatment: 1. Heat Syncope: ○ Move to a cool environment. ○ Passive cooling and administration of oral fluids. 2. Heat Exhaustion: ○ Move to a cool environment, lie patient flat. ○ Administer IV fluids (isotonic or hypertonic), 1-2 L crystalloids at 500 ml/h. ○ Cooling is often unnecessary but can involve cold water immersion, ice packs, or evaporative cooling. 3. Heat Stroke: ○ Rapid cooling is essential: Cool patient to