1

Cardiovascular Assessment
Pain
Dyspnea
Fatigue
Palpitation
Syncope
Edema
Common Chief Complaints
Chest Pain
Cardiovascular
Pulmonary
G.I.
Musculoskeletal
Psychological
sudden or gradual
time episode lasted
cyclic nature
provokes
physical exertion
rest
emotional experience
eating
coughing
cold temperatures
Onset and Duration
2
aching
sharp
tingling
burning
pressure
stabbing
crushing
clinched fist sign
Character
where ?
radiation
relief with rest or position change
Location
interference with activity
need to stop all activity until subsides
disrupts sleep
how severe on a scale of 0 to 10
Severity
P
a
i
n
anxiety
dyspnea
diaphoresis
dizziness
nausea / vomiting
faintness
cold clammy skin
cyanosis, pallor
swelling or edema
Associated Symptoms
3
Duration and circumstances of onset
Aggravates or relieves
Affect on activity level
Pulmonary congestion or increased
pulmonary venous and capillary pressure
Cough
Paroxysmal nocturnal dyspnea (PND)
Orthopnea
Dyspnea
heart beats that seem fast, slow, irregular,
forceful, throbbing
cause - smoking, exercise, stress, caffeine
usually occurs at the cardiac apex/
substernal/ neck
usually but not always develop from cardiac
dysrhythmias
Palpitation
Important information to obtain includes:
Pulse rate (if obtained)
Regular versus irregular rhythm (if obtained)
Circumstances of occurrence
Duration
Associated symptoms (chest pain,
diaphoresis, syncope, confusion, dyspnea)
Previous episodes, frequency
Medications (drug stimulant or alcohol use)
Palpitations
Brief loss of
consciousness
Inadequate cerebral
blood flow
Cardiac and non-
cardiac causes
Associated with
palpitation
arrhythmia
unusual exertion
sudden turning of neck
(carotid sinus effect)
looking upward (vertebral
artery occlusion
change in posture
Syncope
4
Syncope is Serious if
Occurring with exercise
Associated with palpitations or irregular
rhythms
Family history of
Recurrent syncope, or
Sudden death
Pre-syncope aura (nausea, weakness,
lightheadedness)
Circumstances of occurrence
Patient's position before the event
Severe pain
Emotional stress
Duration of syncopal episode
Symptoms before syncopal episode
(palpitation, seizure, incontinence)
Syncope--History
Edema
Increased capillary hydrostatic pressure
Displaces fluid from the capillaries into the
tissues
Edema
5
Unusual or persistent
Inability to keep up with contemporaries
Inability to maintain usual daily activities
Bedtime earlier
Cardiac Related Fatigue
Do not waste a lot of time with past history
Treatment is based on current symptoms
regardless of past history
Priority of Management
Prescription medications, particularly cardiac
medications
Other medical problems
Had any of the following?
Myocardial infarction or angina pectoris
Coronary artery bypass or angioplasty
Implanted pacemaker or ICD (internal defibrilator)
Heart failure
Hypertension
Diabetes
Chronic lung disease
Significant Past Medical History
age
smoking
diabetes
family history
obesity
elevated cholesterol
illicit drug use
Risk factors
6
Prescription Medications
nitroglycerine
beta-blockers
digoxin
diuretics
antihypertensives
other anti-dysrhythmics
Allergies
Medications
New onset chest pain
Chest pain unrelieved or
increasingly frequent
Change in LOC
NTG requirements
Dyspnea at rest
Orthopnea
Exertional dyspnea
Hemoptysis
Unexpected change in
cardiac rate or rhythm
Unexpected change in blood
pressure
Anxiety or restlessness
Diaphoresis / clammy skin
Crisis Assessment
Level of consciousness
Respirations
Pulse (rate, regularity)
Blood pressure
Pulse Oximetry
Initial Assessment
Look-listen-feel approach
Physical Examination
7
Skin color, capillary refill, skin moisture
Indications of adequate hemoglobin
oxygenation (pulse oximetry)
Indications of cardiac function (peripheral
perfusion)
Look
Look
jugular vein distention
volume or pressure
changes in the right
atrium
examine with head
elevated 45 degrees
Additional indicators of cardiac disease
Nitroglycerin patch
Midsternal scar from coronary surgery
Implanted pacemaker or automatic implantable
cardioverter-defibrillator (left upper chest;
abdominal wall)
Medic alert information
Look
Skin
Diaphoretic pale skin
is an indicator of peripheral vasoconstriction and
sympathetic stimulation
Cyanosis
is an indicator of poor oxygenation
Fever
is usually an indicator of infection
Feel
8
Palpation of chest wall
Arterial pulses
Sites
Rate/rhythm
Equality
Feel
Apical impulse
Visible and palpable force produced by the
contraction of the left ventricle
Pulse deficits
Noted by palpating or auscultating the apical
impulse and the carotid pulse simultaneously
Point of Maximal Impulse (PMI)
Peripheral or
presacral edema
Pulse
Rate
Regularity
Equality
Pulse deficit
Pulsus paradoxus
increases and decreases in
amplitude based on
respirations
pericardial tamponade,
constrictive pericarditis,
severe heart failure and lung
disease
Pulsus alternans
alternating pattern of a weak
pulse followed by a stronger
pulse
associated with severe LVF
Feel
Feel
peripheral/presacral edema
palpate against bony prominence
degrees from 0 to +4
+1 - 0 to 1/4"
+2 - 1/4 to 1/2
+3 - 1/2 to 1"
+4 - more than 1
Brawny edema
9
Lung sounds
Assess for equality
Assess for adventitious sounds that may
indicate pulmonary congestion or edema
Heart sounds
Listen
Heart Sounds
May be auscultated for:
Frequency (pitch)
Intensity (loudness)
Duration
Timing in cardiac cycle
Heart Sounds
S
1
closure of AV valves
S
2
closure of semilunar valves
S
3
lub-dub-da (heart failure)
S
4
bla-lub-dub
Decreased stretching (compliance)
of LV
Increased pressure in atria
S1
The lub of the lub-dub sound
produced by the heart
Occurs as the mitral and
tricuspid valves close
Marks the beginning of
ventricular systole
Best heard: at the apex of
the heart (fifth intercostal
space) - with the diaphragm
10
S2
The dub of the lub-dub sound
Occurs as the aortic and
pulmonic valves close
Marks the end of ventricular
systole
Best heard: at the second
intercostal space to the right
and left of the sternum (aortic
and pulmonic areas) - with
the diaphragm
http://www.easyauscultation.com/heart-
lung-sounds-reference-guide.aspx
S3
Associated with rapid ventricular
filling
Common: children, athletes, &
young adults
Abnormal in persons over age 30
Best heard at the apex with bell
Sounds like Ken-Tuck-Y -emphasis
on Tuck
Ken = S1, Tuck = S2, Y = S3
May be a warning sign of
impending congestive heart
failure
S4
Last of ventricular filling, tensing of
the atrioventricular valves, and
atrial contraction
Heard just before S1
Best heard: at the apex
with the bell
Sounds like Ten-nes-see: emphasis
on Ten
Ten = S4, Nes = S1, See = S2
http://www.easyauscultation.com/hea
rt-lung-sounds-reference-guide.aspx
Murmurs
turbulent blood flow through heart or the large
arteries
thrill - high flow rates
bruit - blowing sounds
Carotid artery bruit
Heart Sounds
http://www.wilkes.med.ucla.edu/inex.htm
http://depts.washington.edu/physdx/heart/
demo.html
11
ACLS
Use the Five Quadrads
Cardiac arrest
1. Primary CABD Survey
2. Secondary CABD Survey
Pre-arrest
3. OxygenIVmonitorfluids
4. TemperatureHRBPrespirations
5. Tanktankpumprate
The Five Quadrads: Details
1. Primary CABD
C = Circulation (CPR)
A= Airway
B = Breathing
D= Defibrillation (AED)
The Five Quadrads: Details
2. Secondary ABCD
A= Intubate patient
B = Assess intubation & secure tube
C = IV/IO access; rhythm/drugs
D= Differential Diagnosis (Think!)
12
The Five Quadrads: Details
3. OxygenIVmonitorfluids
Consider as 1 word:
oxygenIVmonitorfluids
Always right thing to do
Buys time to think
The Five Quadrads: Details
4. TempHRBPRR
Drives major CPR decisions
Most neglected information in ACLS
The Five Quadrads: Details
5. Tanktankpumprate*
How big is the tank
(systemic vascular resistance)?
How much is in the tank (volume)?
Pump working?
Too fast? Too slow?
*Also called the cardiovascular triad in the ACLS textbook
Primary CABD Survey
Focus: Basic CPR and Defibrillation
Check responsiveness
Activate emergency response system
Call for defibrillator
C = Circulation: pulse? chest compressions effective?
A = Airway: open the airway; suction as needed
B = Breathing: check breathing; ? air movement adequate;
provide positive-pressure ventilations as needed
D = Defibrillation: check rhythm; ? is defibrillator on the
way; shock VF/pulseless VT
13
Secondary ABCD Survey
A = Airway: place airway device as soon as you are able
to
B = Breathing: confirm proper placement by PE & End-
tidal CO2 detector
B = Breathing: can confirm proper placement by 2
nd
method
Esophageal detector devices
B = Breathing: prevent airway device dislodgment:
Use purpose-made tube holder, proven tape-and-tie, or
other technique
Backboard and CID
B = Breathing: monitor oxygenation and ventilation
Secondary ABCD Survey (contd)
C = Circulation: establish IV access via
venous or IO
C = Circulation: identify rhythm
C = Circulation: give rhythm- and
condition-appropriate drugs
D = Differential Diagnosis: search for
and treat identified reversible causes
Recommendation Classes
Class I
Definitely recommended
Interventions always
acceptable, safe, and
effective
Considered standard of
care
Interventions supported
by excellent research-
based evidence
Class IIa
Acceptable and useful
Interventions
acceptable, safe, and
useful
Considered intervention
of choice
Interventions
supported by good
research-based
evidence
Recommendation Classes
Class IIb
Acceptable and useful
Interventions
acceptable, safe, and
effective
Considered as an
optional or alternative
intervention
Interventions supported
by fair research-based
evidence
Indeterminate
Interventions in early
stages of research and
documentation or lack
sufficient quantity or
quality of research
No recommendation
until further research is
available
14
Recommendation Classes
Class III
Unacceptable, not useful; may be harmful
Intervention with no evidence of benefit; may
be harmful to patient
Evidence of benefit is completely lacking or
research suggests or confirms harm
VF Treated With CPR
and AED
15
AED Safety
With every analysis and shock:
no one touches patient!
Verbal: warning to bystanders
Im clear
Youre clear
Everybodys clear
Visual: check all clear
Physical: add hand gestures
Only then press to shock
Special Situations
Age: victim <8 years old?
Water: victim lying in
water?
Pacemaker or implanted
defibrillator: treatment
interference?
Transdermal medication
patches:
blocking pad placement?
Metal Surfaces: victim lying
on?
Withholding Resuscitation
Rigor mortis
Dependent lividity
Decapitation
Decomposition
Incineration
Valid DNR
Cardiac Arrest
Terminating Resuscitation
Indications for termination of resuscitation:
Patient over 18 years old.
Cause is presumed cardiac in origin.
Successful endotracheal intubation.
ACLS standards applied throughout the arrest.
On-scene effort >25 minutes, or four rounds of drug
therapy.
ECG remains asystolic or agonal.
Blunt trauma victims presenting with or developing
asystole.
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Cardiac Arrest
Terminating Resuscitation
Contraindications to termination of resuscitation:
Patient under 18 years old.
Arrest is of a treatable cause.
Present or recurring VF/VT.
Transient return of a pulse.
Signs of neurological viability.
Witnessed arrest.
Family or others opposed to termination of resuscitation.
Always follow local protocols related to termination of
resuscitation.
Support the family or others after termination of
resuscitation.
Coordinate with law enforcement as required.
VF/Pulseless VT
Drugs to Learn
Epinephrine
Vasopressin
Amiodarone
Lidocaine
Magnesium sulfate
17
Epinephrine
Adrenergic agonist (catecholamine)
Primary benefit in cardiac arrest is the
alpha
1
effects
Increases perfusion pressures
1 mg IVP, repeat every 3 to 5 minutes
during pulseless state
follow with 20 ml flush
2 min of CPR
Vasopressin
Anti-diuretic hormone
in high dose is a powerful vasoconstrictor
post-resuscitation does not increase cardiac
ischemia or irritability
40 U IV, single dose 1 time only
half life 10 to 20 min
Give in place of the 1
st
or 2
nd
dose of
Epinephrine
Antiarrhythmic Drug Classifications
Class 1 (Na
+
Channel Blockers)
1A Slows Phase 0 depolarization
1B Shortens Phase 3 repolarization
1C Markedly slows Phase 0
depolarization
Class II ( Adrenergic Blocker)
Suppresses Phase 4 depolarization
Class III (K
+
Channel Blocker)
Prolongs Phase 3 repolarization
Class IV (Ca
++
Channel Blocker)
Decrease action potential
Other
18
Antiarrhythmics
Class I
Lidocaine (IB)
Procainamide (IA)
Class II
Esmolol
Metoprolol
(Lopressor)
Propranolol (Inderal)
Class III
Amiodarone
Sotalol (Betapace)
Class IV
Diltiazem (Cardizem)
Verapamil
Other
Adenosine
(Adenocard)
Digoxin
Magnesium Sulfate
Amiodarone (IIb)
Antiarrhythmic
primarily Class III (K
+
Channel Blocker)
also has Class I, II, & IV effects
& adrenergic blocking properties
300 mg IVP/IO; if unsuccessful repeat
150 mg
large needle (foams)
max. cumulative dose: 2.2 g in 24 hours
very long half-life
Amiodarone Toxicity
Pulmonary disorders
GI intolerance
Tremor, ataxia, dizziness
Thyroid disorders
Liver toxicity
Muscle weakness
Neuropathy
Blue skin (iodine accumulation in skin)
Lidocaine (Indeterminate)
Alternative to Amiodarone
Antiarrhythmic
Class IB (Na
+
Channel Blockade)
Shortens Phase 3 repolarization (refractory period) &
duration of the action potential
Does not affect contractility or conduction
Useful in ventricular arrhythmias related to increased
automaticity or re-entry
1.0 - 1.5 mg/kg IVP first dose, consider repeating
0.5-0.75mg/kg to maximum dose of 3 mg/kg
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Lidocaine Toxicity
Mainly CNS
slurred speech
paresthesia
twitching & tremors
changes in mental status
visual disturbances
seizures
Cardiac arrhythmias
Hypotension
Magnesium Sulfate
Produces systemic & coronary vasodilation
Possesses antiplatelet activity
Suppresses automaticity in partially
depolarized cells
Protects myocytes against calcium overload
under conditions of ischemia
by inhibiting calcium influx especially at the time
of reperfusion
Drug of choice in torsades de pointes
Magnesium Sulfate
1 to 2 g IVP/IO loading dose for Torsades
Torsades de pointes
Polymorphic VT.
Caused by the use of certain
antidysrhythmic drugs.
Exacerbated by coadministration
of antihistamines; azole
antifungal agents and macrolide
antibiotics; erythromycin,
azithromycin, and clarithromycin.
Dysrhythmias Originating
in the Ventricles
20
Dysrhythmias Originating
in the Ventricles
Torsades de pointes
Typically occurs in nonsustained bursts.
Prolonged QT interval during breaks.
QRS rates from 166300.
RR interval highly variable.
Treatment
Do not treat as standard VT.
Administer magnesium sulfate 12 g diluted in 100
ml D5W over 12 minutes.
Amiodarone 150300 mg is also effective.
VF/Pulseless VT:
Return of Spontaneous Circulation (ROSC)
Let Secondary ABCD Survey Guide Post-resuscitation
Care
A= maintain open, protected airway
A= stabilize airway devices; avoid dislodgment
B = monitor ventilation (CO
2
) and oxygenation (O
2
)
C = monitor rhythm; give rhythm-appropriate medications
D= if defibrillation occurred after use of antiarrhythmic
agent, then continue maintenance infusion of same agent
D= if defibrillation occurred prior to antiarrhythmic and
rhythm does not contraindicate consider initial bolus and
then continued maintenance of antiarrhythmic
C = to maintain BP and HR: consider fluid (check breath
sounds); use dopamine or dobutamine (avoid
epinephrine, isoproterenol, norepinephrine)
Cardiac Arrest
Postresuscitation Management
Manage dysrhythmias and problems as presented.
Be alert for PEA.
Transport rapidly:
Take care to protect intubation and IV access.
21
Asystole
Cardiac Arrest Management
Asystole
Causes: Hs
Hypoxia (CNS events)
Hypokalemia/hyperkalemia
(and other electrolytes)
Hypothermia/hyperthermia
Hypoglycemia/hyperglycemia
Hypovolemia (tank/anaphylaxis, gravid)
Hydrogen ion (Acidosis)
Causes: Ts
Trauma
Tamponade
Thrombosis (pulmonary)
Thrombosis (coronary)
Toxins/Tablets (ODs, drugs, etc)
Tension (pneumothorax, asthma)
22
P
Q
R
S
T
U
PR
interval
ST
segment
Flat P=

PR longer=

QT interval prolongs:

Tall, peaked=

Wider=

Flatter=

Depressed=
Hyperkalemia
Shortened=
Hypercalcium

BBBs=
Hypercalcium
Hypomagnesium
Tricyclics
Neuroleptics

Wide-complex tachys, VT, VF=

Hyperkalemia

Hyperkalemia
Hypomagnesium
Hyperkalemia
Hypocalcemia
Tricyclics
Neuroleptics
Ca channel blockers
Hyperkalemia
-Blockers
Hypomagnesium
Hypercalcium
-Blockers
QRS
interval
QT
interval
Hypercalcemia
Tricyclics
Neuroleptics
Ca channel blockers
Hyperkalemia
Hypocalcium
Tricyclics
Neuroleptics
U waves=
Hypokalemia
EKG clues
Treatment of Urgent
Hyperkalemia
Antagonize:
Immediate: Calcium chloride 10% solution
(100mg/1ml)
5 to 10 ml IVP (500mg-1000mg) over 2 to
5 minutes
Shift:
Next: Sodium bicarbonate, 1 mEq/kg IVP
over 5 minutes (Increase cellular uptake of
Potassium)
Shift (contd):
Then: insulin + glucose
Regular insulin: 10 U IV + 1 amp (50 g)
glucose
Nebulized albuterol 10 to 20 mg nebulized
over 15 minutes
(Increases Plasma Insulin)
Remove:
furosemide (Lasix): 40 to 80 mg IV
Kayexalate: 15 to 50 g + sorbitol
Dialysis (peritoneal or hemodialysis)
Treatment of Urgent
Hyperkalemia
Treatment of Urgent
Hyperkalemia
Pneumothorax
Definition
Entry of air into pleural space, causing
lung collapse
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Tension Pneumothorax
Definition
Air under pressure
Venous return inhibited
Mediastinum displaced
Vena cava kinked
Cardiac output decreased
Cardiovascular collapse developed
Tension Pneumothorax
Clinical manifestations in patient with spontaneous
breathing
Respiratory distress
Florid face (Red and round)
Tracheal deviation
Distended neck veins
Tachycardia
Hypotension
Tension Pneumothorax
Treatment
Provide as soon as diagnosis is apparent
to prevent cardiovascular collapse and cardiac
arrest
Use large-bore needle tap
Tension Pneumothorax
Equipment
14-gauge catheter-over-needle device
Technique
Cleanse overlying skin
Insert needle at 2nd or 3rd intercostal space,
midclavicular line, over top of rib
Leave catheter in pleural space
24
Tension Pneumothorax
Complications of treatment
Misdiagnosispneumothorax created
Lung laceration
Internal mammary or intercostal
vessel laceration
Hemothorax
Cardiac Tamponade
Pathophysiology
blood or fluid fills the
pericardial space,
compressing the heart
chambers
increasing intracardial
pressure
obstruction of venous
return
stroke volume and
cardiac output fall
Cardiac Tamponade
Clinical signs
No pulse with CPR
J VD
Electrical alternans
History
Tricyclic Antidepressant (TCAs)
Overdose
Toxins
Sodium Bicarbonate 1mEq/kg IV bolus
25
Hs and Ts
Hypothermia/Hyperthermia
Hypoglycemia/Hyperglycemia
Hypovolemia
Hydrogen Ions
Trauma
Tamponade
Thrombosis
Tablets
Tension
Asystole
Active search for do not resuscitation (DNR)
orders/status
Explicit criteria for stopping
Asystole
Family presence at resuscitation efforts
Survivor support plans
PEA
26
Critical ActionsPEA
Perform all steps in Primary CABD Survey
Operate monitor
Recognize PEA
Direct IV/IO access
Intubate when able (BVM adequate)
Critical Actions (contd)
Assess patient, name conditions causing PEA
Determine management
Administer fluid challenge
Administer epinephrine or vasopressin
1. Not assessing patient
2. Not considering possible causes of PEA
3. Only treating with epinephrine
4. Not troubleshooting
ventilation/intubating patient
5. Not giving volume infusion
6. Defibrillation
7. Not performing chest compressions
Common Perils and Pitfalls
27
Intubation
Airway Management
Monitoring Capnography Wave Form
During Ventilations and CPR CO2 on wave
form should steadily increase, showing
increase blood flow.
With ROSC CO2 should be 40-50mm Hg
Bradycardia
Drugs & Therapies to Learn
Atropine
Dopamine
Epinephrine
Transcutaneous pacing
28
Atropine
Anticholinergic
Dosage
Bradycardia
0.5mg rapid IVP may repeat every 3 - 5 minutes to a
total of 3mg
minimum dose in adult 0.5 mg (anything less may
worsen rate by paradoxical slowing of heart rate)
Atropine
Can be given ET
2 to 2.5 times the usual dose
Side Effects
tachycardia
increased myocardial irritability & automaticity
increased myocardial oxygen demand
Infusions
Dopamine (2-10mcg/kg/min)
Epinephrine (2-10mcg/min)
Tachycardia
29
Tachycardia - Step 1
Is the patient in sinus tach? Treat underlying cause
Is patient stable or unstable?
Patient has serious signs or symptoms? Look for
Chest pain (ischemic? possible ACS?)
Shortness of breath (lungs getting wet? possible CHF?)
Low blood pressure (orthostatic? dizzy? lightheaded?)
Decreased level of consciousness (poor cerebral
perfusion?)
Clinical shock (cool and clammy? peripheral
vasoconstriction?)
Are the signs and symptoms due to the rapid heart rate?
Step 2
Identify arrhythmia;
1. Narrow-complex tachycardia
2. Wide-complex tachycardia
3. Stable or unstable
4. Rhythm Regular or Irregular
Classify Specific Tachycardia
Atrial fibrillation/ flutter
Narrow-complex tachycardias
J unctional tachycardia
PSVT
Multifocal or ectopic atrial tachycardia
Wide-complex tachycardias of unknown
origin
? SVT with aberrant conduction
Wide-complex tachycardias
Monomorphic VT
Polymorphic VT with normal QT intervals
Polymorphic VT with abnormal QT intervals
Electrical Cardioversion
Immediate electrical cardioversion is
indicated for a patient with serious signs
and symptoms related to the tachycardia.
30
Indications for Synchronized
Cardioversion
Any unstable condition related to tachycardia
Chest pain
AMI
Shortness of breath
Acute onset pulmonary congestion/CHF
Decreased level of consciousness
Low blood pressure
Shock
Synchronized Cardioversion
Energy selection
Regular Narrow Complex tach: 50-100 J
increase stepwise
Irregular narrow-complex tach: 120-200 J
increase in stepwise
Regular wide complex tach: 100 J increase
stepwise
Polymorphic VT (treat like VF): Defib.
Synchronized Cardioversion
Premedicate with both a sedative and an
analgesic if appropriate
Sedatives
Diazepam 5 - 15 mg slow IV
Midazolam 1 - 2.5 mg slow IV (in elderly max
usually 1.5 mg)
Analgesics
Morphine 2 - 4 mg slow IV
31
Atrial Fibrillation:Evaluation
Focus
4 Clinical Features
1. Is patient clinically unstable?
2. Is cardiac function impaired?
3. Is WPW present?
4. Is duration of AF <48 or >48 hours?
Atrial Fibrillation:Treatment
Focus
4 Treatment Considerations
1. Treat unstable patients urgently
2. Control rate
3. Consider Consultation
4. Consider Converting rhythm (not priority in
field)
5. Provide anticoagulation if indicated
(not priority in field)
Narrow-Complex Tachycardias
Attempt to establish a specific diagnosis:
Obtain 12-lead ECG if available
Gather clinical information
Perform vagal maneuvers
Give adenosine as a therapeutic agent,
but it also serves as a diagnostic test
Narrow-Complex Tachycardias
Diagnostic efforts yield
Paroxysmal supraventricular
tachycardia (PSVT) reentry
Multifocal or ectopic atrial tachycardia
automaticity
J unctional tachycardia automaticity
Treatment based on two considerations
tachycardia due to reentry or automaticity
function of the heart preserved or impaired
32
Adenosine
Naturally occurring nucleoside
conduction velocity
refractory period
automaticity
stops re-entry rhythms
AV Node
Extremely short duration of action
Adenosine
very short half life (10 seconds)
6 mg then can repeat at 12 mg rapid
IVP with 20 ml bolus given (1 - 2
minutes between each dose)
Frequent short term side effects
flushing
chest pain and dyspnea
hypotension
Adenosine
Medications that decrease effectiveness
Caffeine
Theophylline
Medications that increase effectiveness
Carbamazepine (Tegretol)
Dipyridamole (Persantine)
Amiodarone
In patients with a pulse
150 mg in 100 ml to run over 10 min
followed by infusion 1 mg/min over 6 hours and
then 0.5 mg/min
not to exceed 2.2 g in 24 hours
33
Amiodarone
Side effects
hypotension
Bradycardia
Blue-green discoloring of skin (especially hands
or feet) late effect
Muscle twitching
Inhibits the entrance of calcium into cardiac
and smooth muscle cells of the coronary
and systemic arterial beds
smooth muscle tone and vascular resistance
contractility
conduction
refractory periods
Calcium Channel Blockers
CARDIZEM
(Diltiazem)
Indications
Control of rapid ventricular rate in atrial
fibrillation or atrial flutter
After Adenosine to treat refractory reentry SVT
with narrow QRS complex
Dosage
Initial dose: 0.25mg/kg over 2 minutes
If no response may be repeated in 15 minutes
0.35 mg/kg over 2 minutes
Verapamil
Indications
Control of rapid ventricular rate in atrial
fibrillation or atrial flutter
After Adenosine to treat refractory reentry SVT
with narrow QRS complex
Dosage
Initial dose: 2.5 to 5 mg IV bolus over 2-3 min
If no response may be repeated in 15 minutes
5 to 10 mg
34
Contraindications
Hypotension
Cardiogenic shock
Ventricular tachycardia
causes hemodynamic deterioration and V-fib
A-fib with WPW syndrome
Sick sinus syndrome
Acute MI
Caution with patients taking Beta=Blockers. Can cause a
AV Block
Adverse Reactions
Hypotension
Worsening CHF in patients with impaired
ventricular function
Second- or third-degree AV block
PVCs on conversion of PSVT to sinus
rhythm
usually transient with no clinical significance
Atrial Flutter
Caution
Use with digitalis or beta-blockers may
cause bradycardia and/or AV block
No well-controlled studies show safety for
use in pregnant women
Physically incompatible with
diazepam
furosemide
sodium bicarbonate
Stable Wide-Complex
Tachycardia
Ventricular or
Supraventricular with aberrant conduction?
35
Wide-complex Tachycardias of
Unknown origin
Two rules for managing stable patients
Rule 1. Wide-complex tachycardia should be
considered VT until proven otherwise.
Rule 2. Always remember Rule 1
Antiarrhythmic Infusion Drugs for Stable
Wide Complex Tachycardia
Procainamide
Amiodarone
Sotalol