LIFE THREATENING ARRHYTHMIAS

Stefan Hoengk , ICU Ag.Nikolaos

BASIC UNDERSTANDING OF ECG

4 ALGORYTHM TO TREAT

ANTIARRHYTHMIC DRUGS

SAFE USE OF DEFIBRILLATOR

 HOW TO READ AN ECG
• 1- IS THERE ELECTRICAL ACTIVITY?

• 2- WHAT IS THE (QRS) RATE?

• 3- IS THE QRS REGULAR OR IRREGULAR?

• 4- IS THE COMPLEX WIDTH NORMAL OR PROLONGED?

• 5- IS THERE ARTRIAL ACTIVITY PRESENT?

• 6- HOW IS THE ARTRIAL ACITIVITY RELATED TO

VENTRAL ACTIVITY?
 Wide QRS SVT versus VT
Supraventrikular tachykardia:
• slowing or termination by vagal tone
• Onset with premature p wave
• P and QRS rate and rhythm linked, e.g. 2:1, ventricular activation depends
on artrial discharge
• rSR` in V1
• Long short cycle sequence
Ventricular tachykardia:
• Fusion beats
• Capture beats
• AV dissociation
• P and QRS rate and rhythm linked that artrial activation depends on
ventricular discharge, e.g. 2:1 VA block, in 25 %
• Compensatory pause
• Left axis deviation with QRS duration >140 ms
• various QRS contours: monomorphic, polymorphic, torsades, right or
leftbundle contour
• But: ventricular tachykardia is the most common cause of wide QRS
tachykardia
 QRS morphology in VT
• QRS >140 msec and left axis deviation

• QRS right bundle branch block: monophasic or biphasic

in V1. R in V1 > R`, small R and a large S or QS in V6

• LBBB: right axis. Negative deflection in V1 deeper than

in V6
R wave > 40 millisecond in V1
In V6 small Q-large R or QS

• QRS all similar from V1 to V6, either all positive or all

negative
 Wolf-Parkinson-White

• PQ < 0,12 msec

• Delta wave, positive in V1 type A, negative
type B
• QRS >0.12 msec
• ST Elevation or Decension
• Inversion of T wave opposite to Delta
wave
 Bradykardia
(includes rates inappropiately slow for haemodynamic state)

Adverse signs
systolic BP<90
Heart rate <40
Yes Ventricular arrhythmia No
Requiring supression
Heart failure
Atropine
500 μg iv

Satisfactory response? ------------------------------ Yes -----------------------------

Risk of asystole?
Yes
recent asystole
Interim measures Mobitz II AV Block
Atropin 500 μg iv, Complete heart block
Repeat to max 3 mg. with broad QRS
Trancutaneous (extern) Ventricular pause> 3s
pacing or
Epinephrine iv.
2-10 μg/min
Seek expert help, arrange observe
transvenous pacing
 Broad complex tachykardia
(treat as sustained ventricular tachykardia)

Pulse? No use VF protocol

Yes

Adverse signs?
Systolic BP < 90 mm Hg Seek expert help
No Chest pain Yes
If potassium know to
be low, see panel Heart failure Synchron DC shock
Rate> 150 / min 100, 200, 360 J

Amiodarone 150 mg iv, Give potassium chloride

over 10 min or
Lidocaine iv. 50 mg over 2
min repeated every 5 min
to a max dose of 200mg
up to 60 mmol, max rate --------- If potassium level low
30 mmol / h
Give magnesium sulfate 50 % iv
5 ml in 30 min Amiodarone 150 mg,
over 10 min

Seek expert help

further cardioversion
As necessary
Synchronised DC shock
100, 200, 360 J
Refractory cases: Amiodarone,
If necessary further Lidocaine, Procainamide, Sotalol
Amiodarone 150 mg iv over 10 min or overdrive pacing, caution:
then 300 mg over 1 h and repeat drug induced myocardial depression
shock
 Atrial fibrillation
High Risk? Intermediate risk? Low risk?
Heart rate >150 Rate 100-150 Heart rate <100
Ongoing chest pain breathlessness Mild or no symptoms
Critical perfusion Good perfusion

yes
Yes, seek Yes, seek
expert help
expert help
Onset to be known
Within 24 hours
Immediate heparine No Yes
Synchronized shock
100,200,360 J Consider anticoag Heparin
Heparin, Warfarin Amiodaron 300mg
later synchron in 1 h, repeat once
Amiodarone 300 mg DC shock or Flecainide
over 1 hour, repeat 100-150mg iv over
Poor perfusion
one No Yes
30 min and/or
and/or known
synchr DC shock
structural heart dis
Onset known to be
within 24 hours? Onset known to be
within 24 hours?
No Yes No Yes

Initial rate control attempt cardioversion

Initial rate control attempt cardioversion
beta Blocker oral or iv Heparin
Amiodarone 300 mg in Heparin
Verapamil iv or po Flecainid 100-150mg iv
1 h, may be repeated Synchron DC shock with
Diltiazem iv or po over 30 mins
once 100, 200, 360 J
Digoxin iv or po Amiodaron 300 mg iv
AND Heparin Amiodaron 300 mg
or consider anticoag over 60 min, repeat
Warfarin in 1 h may be
for later synchronized Once
later synchron DC repeated once
DC shock Synchron DC shock
 Narrow Complex Tachykardia
(presumed supraventrikular tachycardia)

Pulseless (heart Narrow complex

Artrial fibrillation
Rate usually>250) tachykardia

oxygen and
Follow AF algorithm
iv access

Vagal manoeuvres
Synchron DC shock caution if possible digitalis toxicity,
100,200,360 J acute ischaemia, carotid bruit for
carotid massage

Adenosine 6 mg by rapid iv bolus, followed,

if necessary with up to 3 doses each 12 mg
every 1 to 2 min, Caution in WPW!!

Seek expert help Synchron DC shock

Choose from 100, 200, 360 J
Esmolol 40 mg over 1 min
Adverse signs?
+ infusion 4 mg / min
Systolic BP <90
Verapamil 5-10 mg iv No Yes Amiodarone 150 mg iv
Chest pain
Amiodaron 300mg iv over over 10 min, then
Heart failure
1h repeated once 300 mg over 1 h and
Heart rate>200
Digoxin 500 μg iv over repeat shock
30 min x 2
 ANTIARRHYTHMIC DRUGS
DRUG CLASS LEFT SINUS EXTRA PR QRS QT
VENTR RATE CARDIAC
FUNCTION
PROCAINAMID IA   ++   
LIDOCAINE IB   + 
MEXILETINE IB   + 
PROPAFENON IC    
FLECAINIDE IC    
AMIODARON III   ++  
DIGOXIN   ++  
ATROPINE   + 
ADENOSINE ?  
 AMIODARONE

• Indication: refractory fibrillation/pulseless VT

• Haemodynamic stable ventricular tachykardia and
other resistant tachyarrhythmias

• Dose: 300 mg diluted in 20 ml D5% after the first

three shocks

• Adverse effects: hypotension, bradykardia,

thyroid function, corneal microdeposits,
peripheral neuropathy, pulmonary firbrosis, QT
prolongation (cave Torsades de pointes)
 Magnesium Sulfate
• Indication: shock refractory ventricular fibrillation
in the presence of possible hypomagnesaemia
• Ventricular tachyarrhythmia in the presence of
possible hypomagnesemia
• Torsades de pointes

• Dose: 1-2 g iv in 1 – 2 min, may be repeated after

10-15 min, or 2,5 g in 30 min

• Actions: reduces the sensitivity of motor end

plate, depression of neurological and myocardial
function by acting as a physiological calcium
blocker
 Lidocaine
• Indications: refractory ventricular
fibriallation/pulseless VT when Amiodarone is
unavailable
• Haemodynamically stable ventricular tachykardia
as an alternative to Amiodarone

• Dose: initial Dose 100 mg iv, or 1 to 1-1.5 mg/kg,

additional bolus of 50 mg iv, no more then 3
mg/kg in the first hour

• Adverse effects: paraesthesiae, drowsiness,

confusion, convulsions, prolonged half life in liver
failure
 Adenosine
• Indications: Paroxysmal supraventricular tachykardia and
undiagnosed narrow complex tachykardia

• Dose: initial dose 6 mg rapidly iv, three further doses of 12

mg each possible, half life only 10-15 sec

• Action: slows conduction in AV node, stops reentry circuits

that include the AV node. Ventricular tachycardia will be
unchanged. No significant negative inotropic effects

• Adverse effects: strange feelings, chest pain, bronchospasm

in asthmatic patients. Enhancement by dipyridamole and
antagonism with theophylline.

• SOS: arterial fibrillation or flutter in WPW Adenosine may

increase conduction down the anomalous pathway resulting
in dangerously high ventricular rate
 Verapamil
• Indications: supraventricular tachykardia

• Dose: 5 to 10 mg over 2 min. Further 5 mg after 5 min

• Action: blocks Ca channels resulting in coronary artery

and peripheral vasodilation. Reduces conduction in AV
node

• Adverse effects: hypotension, never verapamil and

beta-blocker iv together. Increases digoxin plasma
level. Negative inotropic effect. Flushing. Headaches.

• SOS: don’t give in broad complex tachykardia of

ventricular of doubtful origin.
 Flecainide
• Indications: artrial fibrillation
• Supraventricular tachykardia associated with an
accessory pathway, Wolff-Parkinson-White-
syndrome

• Dose: 100-150 mg (2mg/kg) over 30 min

• Action: potent Na channel blocker. PR

prolongation and widening of QRS

• Adverse effects: significant negative inotropic

effect, hypotension, bradykardia, oral
paraesthesiae, blurring of vision
 Esmolol
• Indications: second line treatment for
supraventricular tachykardia
• Symptomatic sinus tachykardia

• Dose: 500 microgramm/kg Bolus in 1 min, then

50-100-150 mikrogramm/kg/min

• Action: ultrashort acting Beta 1 Blocker, half life 9

min

• Adverse effects: negative inotropic effect,

hypotension, heart block.
 Procainamide
• Indications: Ventricular Fibrillation
• Refractory wide complex tachykardia
• WPW, blocks accessory pathway, especially when
associated with artrial fibrillation

• Dose: loading dose 20 to 30 mg / min to a

maximum of 1g.
• Antiarrhythmic effect after 100 or 200 mg, usually
no more then 500 mg needed.

• Adverse effects: hypotension, proarrhythmic

effect.