1. Arrhythmias ED SHO TEACHING C Brown, August 2015

2. Aims  To be able to confidently recognise arrhythmias in patients presenting to the ED  To describe the principles of management of brady and tachyarrhythmias in the ED

3. Objectives  Overview of cardiac electrophysiology  Review of Resuscitation council guidelines for  ECG interpretation  Tachyarrhythmia management  Bradyarrhythmia management

4. Clinical Overview: Arrhythmia  Arrhythmias are common in the ED population either as a cause of or a consequence of their presenting complaint  The overarching principle is to decide if the patient is COMPROMISED or not as a result of their arrhythmia  Having a systematic approach to describing an arrhythmia helps in the diagnosis and subsequent management

5. A compromised position….  What “adverse features” may a patient with an arrhythmia have to indicate they are compromised?  SHOCK  SYNCOPE  MYOCARDIAL ISCHAEMIA  HEART FAILURE  The presence of these features indicate that a patient may be compromise and should mandate  Early senior involvement  Assessment of patient using ABCDE approach  Full monitoring  O2 + IV access  Management of reversible causes  Emergency management of arrhythmia instigated Resuscitation council UK

6. Rhythm Recognition UK Resuscitation Council 1. Is there electrical activity? 2. What is the ventricular (QRS) rate 3. Is the QRS rhythm regular or irregular 4. Is the QRS complex width normal or prolonged? 5. Is atrial activity present? 6. How is atrial activity related to ventricular activity?

7. Cardiac Electrophysiology

8. Electrophysiology & the ECG Ventricular depolarization Ventricular repolarization

10. Case 1  25 year old male, presented to ED with palpitations

12. How’s the Patient Remember the Steps  Is there electrical activity?  What is the ventricular (QRS) rate ?  Is the QRS rhythm regular or irregular ?  Is the QRS complex width narrow or broad ?  Is atrial activity (P wave) present ?  Is every P wave followed by a QRS and is every QRS preceded by a P wave ? Then  Does the tracing look normal ?  Where are any changes? Findings: Narrow Complex tachycardia or Supraventricular Tachycardia

13. Case 2  70 year old female admitted following a mechanical fall resulting in a fractured ankle requiring admission for ORIF.

15. Findings: Atrial Flutter How’s the Patient Remember the Steps Is there electrical activity? What is the ventricular (QRS) rate ? Is the QRS rhythm regular or irregular ? Is the QRS complex width narrow or broad ? Is atrial activity (P wave) present ? Is every P wave followed by a QRS and is every QRS preceded by a P wave ? Then Does the tracing look normal ? Where are any changes?

16. Case 3  50 year old female admitted with palpitations

18. Remember the Steps  Is there electrical activity?  What is the ventricular (QRS) rate ?  Is the QRS rhythm regular or irregular ?  Is the QRS complex width normal or prolonged ?  Is atrial activity present ?  How is atrial activity related to ventricular activity ? Then  Does it look normal ?  Where are any changes? Findings: Atrial Fibrillation How’s the Patient Remember the Steps Is there electrical activity? What is the ventricular (QRS) rate ? Is the QRS rhythm regular or irregular ? Is the QRS complex width narrow or broad ? Is atrial activity (P wave) present ? Is every P wave followed by a QRS and is every QRS preceded by a P wave ? Then Does the tracing look normal ? Where are any changes?

19. Case 4  A 45 year old male admitted with diarrhoea. PMH: Alcohol excess

21. Remember the Steps  Is there electrical activity?  What is the ventricular (QRS) rate ?  Is the QRS rhythm regular or irregular ?  Is the QRS complex width normal or prolonged ?  Is atrial activity present ?  How is atrial activity related to ventricular activity ? Then  Does it look normal ?  Where are any changes? Findings: Torsades de pointes How’s the Patient Remember the Steps Is there electrical activity? What is the ventricular (QRS) rate ? Is the QRS rhythm regular or irregular ? Is the QRS complex width narrow or broad ? Is atrial activity (P wave) present ? Is every P wave followed by a QRS and is every QRS preceded by a P wave ? Then Does the tracing look normal ? Where are any changes?

22. Case 5  80 year old female admitted following a collapse

24. Remember the Steps  Is there electrical activity?  What is the ventricular (QRS) rate ?  Is the QRS rhythm regular or irregular ?  Is the QRS complex width normal or prolonged ?  Is atrial activity present ?  How is atrial activity related to ventricular activity ? Then  Does it look normal ?  Where are any changes? Findings: Ventricular Tachycardia How’s the Patient Remember the Steps Is there electrical activity? What is the ventricular (QRS) rate ? Is the QRS rhythm regular or irregular ? Is the QRS complex width narrow or broad ? Is atrial activity (P wave) present ? Is every P wave followed by a QRS and is every QRS preceded by a P wave ? Then Does the tracing look normal ? Where are any changes?

25. Fusion & Capture beats A fusion beat (red arrow) occurs when a supraventricular and a ventricular impulse coincide to produce a hybrid complex. It indicates that there are two foci of pacemaker cells firing simultaneously: a supraventricular pacemaker (e.g. the sinus node) and a competing ventricular pacemaker (source of ventricular ectopics). The fusion beats are of intermediate width and morphology to the supraventricular (blue arrows) and ventricular complexes.

26. Management of Tachyarrhythmia's

27. Case 6  74 year old female awaiting sedation for dislocated shoulder. PMH: Angina

29. Findings: 1 st Degree Heart Block > 5 little squares How’s the Patient Remember the Steps Is there electrical activity? What is the ventricular (QRS) rate ? Is the QRS rhythm regular or irregular ? Is the QRS complex width narrow or broad ? Is atrial activity (P wave) present ? Is every P wave followed by a QRS and is every QRS preceded by a P wave ? Then Does the tracing look normal ? Where are any changes?

30. Case 7

32. Findings: 2 nd Degree Heart Block 2:1 block How’s the Patient Remember the Steps Is there electrical activity? What is the ventricular (QRS) rate ? Is the QRS rhythm regular or irregular ? Is the QRS complex width narrow or broad ? Is atrial activity (P wave) present ? Is every P wave followed by a QRS and is every QRS preceded by a P wave ? Then Does the tracing look normal ? Where are any changes?

33. Case 8

35. Remember the Steps  Is there electrical activity?  What is the ventricular (QRS) rate ?  Is the QRS rhythm regular or irregular ?  Is the QRS complex width normal or prolonged ?  Is atrial activity present ?  How is atrial activity related to ventricular activity ? Then  Does it look normal ?  Where are any changes? Findings: 2 nd Degree Mobitz Type 1 AV Block Wenckebach How’s the Patient Remember the Steps Is there electrical activity? What is the ventricular (QRS) rate ? Is the QRS rhythm regular or irregular ? Is the QRS complex width narrow or broad ? Is atrial activity (P wave) present ? Is every P wave followed by a QRS and is every QRS preceded by a P wave ? Then Does the tracing look normal ? Where are any changes?

36. Case 9  85 year old man. Referred by GP as ?TIA episodes. Diverted to ED en route as unresponsive in ambulance.

38. Remember the Steps  Is there electrical activity?  What is the ventricular (QRS) rate ?  Is the QRS rhythm regular or irregular ?  Is the QRS complex width normal or prolonged ?  Is atrial activity present ?  How is atrial activity related to ventricular activity ? Then  Does it look normal ?  Where are any changes? Findings: 3 rd Degree Heart Block How’s the Patient Remember the Steps Is there electrical activity? What is the ventricular (QRS) rate ? Is the QRS rhythm regular or irregular ? Is the QRS complex width narrow or broad ? Is atrial activity (P wave) present ? Is every P wave followed by a QRS and is every QRS preceded by a P wave ? Then Does the tracing look normal ? Where are any changes?

40. And finally…..  Make sure you can recognise this one!