2 Objectives Recognize signs and symptoms of symptomatic bradycardia Recognize causes and treatment for symptomatic bradycardiaDescribe indications for TCP and doses of drugs used to treat bradycardia: atropine, dopamine and epinephrineRecognize signs and symptoms and treat symptomatic bradycardiaRecognize signs and symptoms and treat tachycardia
3 Rhythm for bradycardia Sinus bradycardiaFirst degree AV blockSecond degree AV blockType I (Wenckeback / mobitz I)Type II ( Mobitz II)Third degree AV block
4 Symptomatic bradycardia Patient have heart rates in the normal sinus range but these rates are inappropriate or insufficient for them. This is called functional or relative bradycardia (for eg. A heart rate of 70/min is too slow for a patient in cardiogenic shock.A symptomatic bradycardia exists clinically when 3 criteria are presentThe heart rate is slowThe patient has symptomsThe symptoms are due to the slow heart rate.
5 Signs and symptoms Symptoms Signs Chest discomfort or pain, shortness of breathDecreased level of consciousnessweakness, fatigue, light – headedness, dizziness or syncopeSignsHypotension, drop in BP on standing (orthostatic hypotension)Diaphoresis, pulmonary congestion, frank congestive heart failure or pulmonary edemaBradycardia related frequent premature ventricular complexes or VT
6 Management A Maintain patent airway B Assist breathing as needed; give oxygen in case of hypoxemia; monitor oxygen saturationCMonitor blood pressure and heart rate; obtain and review 12-lead ECG; establish IV accessDConduct a problem focused history and physical examination; search for and treat possible contributing factors
7 If patient has poor perfusion secondary to bradycardia Give atropine as first line treatmentAtropine 0.5mg IV – may repeat to a total dose of 3 mgIf atropine is ineffectiveTranscutaneous pacingOrDopamine 2 to 10 mcg/kg per minute (chronotropic or heart rate dose)Epinephrine 2 to 10 mcg/min
8 TRANSCUTANEOUS PACING IndicationsHemodynamically unstable bradycardiaSymptomatic Sinus bradycardiaMobitz type II Second degree AV blockThird degree AV blockPrecautionsTCP is contraindicated in severe hypothermia and not recommended for asystoleConscious patients require analgesia for discomfortDo not assess the carotid pulse to confirm mechanical capture; electrical stimulation causes muscular jerking that may mimic the carotid pulse.
9 Steps to perform TCP Step Action 1 Place pacing electrodes on the chest according to package instructions2Turn the pacer ON3Set the demand rate to approximately 60/min. This rate can be adjusted up or down (based on patient clinical response) once pacing is established4Set the current milliampered output 2 mA above the dose at which consistent capture is observed (safety margin)
10 Unstable TachycardiaUnstable tachycardia exists when the heart rate is too fast for the patient’s clinical condition and the excessive heart rate causes symptoms or an unstable condition because the heart isBeating so fast that cardiac output is reduced. This can cause pulmonary edema, coronary ischemia and reduced blood flow to vital organsBeating ineffectively so that coordination between atrium and ventricles or the ventricles themselves reduces cardiac output
11 Rhythms for unstable tachycardia Atrial fibrillationAtrial flutterReentry supraventricular tachycardia (SVT)Monomorphic VTPolymorphic VTWide complex tachycardia or uncertain type
12 Symptoms and signs Hypotension Altered mental status Signs of shock Ischemic chest discomfortAcute heart failure
13 ManagementLook for signs of increased work of breathing (tachypnea or intercostal, suprasternal retractions)Give oxygen, if indicated and monitor oxygen saturationObtain an ECG to identify the rhythmEvaluate the blood pressureEstablish IV accessIdentify and treat reversible causes.
14 If the patient is unstable but has a pulse with regular uniform wide complex VT (monomorphic VT) Treat with synchronized cardioversion and an initial shock of 100 J monophasic waveform)If there is no response to the first shock increasing the dosage in a step wise pattern is reasonableArrhythmic with a polymorphic QRS appearance (polymorphic VT) such as torsades de pointes will usually not permit synchronization. If patient has polymorphic VTTreat as VF with high energy unsynchronized shocks ( defibrillation doses)
15 When to use synchronized shocks Unstable SVTUnstable atrial fibrillationUnstable atrial flutterUnstable regular monomorphic tachycardia with pulsesWhen to use unsynchronized shocksFor a patient who is pulselessFor a patient demonstrating clinical deterioration (in prearrest) such as those with severe shock or polymorphic VT, when you think a delay in converting the rhythm will result in cardiac arrestWhen you are unsure whether monomorphic or polymorphic VT is present in the unstable patientShould the unsynchronized shock cause VF (occurring in only a very small minority of patients despite the theoretical risk), immediately attempt defibrillation
16 Synchronized cardioversion Sedate all conscious patients unless unstable or deteriorating rapidlyTurn on the defibrillator (monophasic or biphasic)Attach monitor leads to the patient and ensure proper display of the patient’s rhythm. Position adhesive electrode (conductor) pads on the patientPress the SYNC control button to engage the synchronization mode.Look for markers on the R wave indicating sync mode.
17 6. Adjust monitor gain if necessary until sync markers occur with each R wave 7. Select the appropriate energy level 8. Announce to team members: “charging defibrillator – stand clear” 9. Press the CHARGE button 10. Clear patient when the defibrillator is charged 11. Press the SHOCK button 12. Check the monitor. If tachycardia persists, increase the energy level (joules) Activate the sync mode after delivery of each synchronized mode after delivery of synchronized shock.
19 Narrow QRS with regular rhythm Attempt vagal maneuversValsalva maneuver or carotid sinus massage will terminate about 25% of SVTsGive adenosineIf SVT does not respond to vagal maneuvers:Give adenosine 6 mg as a rapid IV push in a large (eg anticubital) vein over 1 sec. follow with a 20 ml saline flush and elevate the arm immediatelyIf SVT does not convert within 1 to 2 mins, give a seond dose of adenosine 12 mg rapid IV push following the same procedure above
20 Summary Recognize signs and symptoms of symptomatic bradycardia Recognize causes and treatment for symptomatic bradycardiaDescribe indications for TCP and doses of drugs used to treat bradycardia: atropine, dopamine and epinephrineRecognize signs and symptoms and treat symptomatic bradycardiaRecognize signs and symptoms and treat tachycardia