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Cardiac Arrhythmia Emergencies

Anthony F. Rossi, MD Director, Cardiac Critical Care Services Miami Childrens Hospital Miami, Fl

ECG Basics

Atrial Depolarization

HIS Bundle Depolarization

Ventricular Depolarization

NSR

Arrhythmia Categories

Tachycardias
SVT Junctional Ventricular

Bradycardia
SND HB

Asystolic

Mechanisms of Tachyarrythmias
Reentry Abnormal automaticity After deploarizations

Reentrant Arrhythmias

Paroxysmal
Acute start Acute termination No warm up

Can be started/terminated with premature beat

Reentrant Loop

PAC Causing Reentry

Abnormal Automaticity
warms up / cools downs not initiated by extrastimulus not terminated by extra stimulus no overdrive suppression

Abnormal Automaticity
1 2 0 3 4 0
threshold potential

-40

0 0 3 4 -40 -60
TP1 TP2 a

b
resting potential

SVT
Most common treated arrhythmia in children Almost never life-threatening in otherwise well children Infancy common presentation age May resolve as child matures

SVT: Presentation

Infants
Poor feeding Pallor S+S of CHF

Older Children
Palpitations Chest pain/discomfort

Orthodromic SVT

ECG Dx of SVT
AV recip tach AVN reentry PJRT -Short prlong rp

-fast-slow

r p

p r

SVT: Treatment

Adenosine
50-500 mcg/kg Rapid IV pushWide Complex Tachycardia after Adenosine Malignant MayAdministration to a Pediatric Postoperative Patient with transiently convert to NSR Congenital Heart Disease Transient SND, Pediatr Cardiol. 1995 Jan-Feb;16(1):36-7. Kipel et al. PVCs Systemic Vasodilatation most dangerous side effect

Overdrive pacing (TEP or use atrial wires) Cardioversion

SVT: Treatment

Synchronized Cardioversion Begin antiarrhythmic agents, then attempt adenosine/cardioversion at later date Drugs:
Digoxin (IV in sick babies) Procainamide Verapamil (contraindicated in pts < 1 yr) B-blocker

WPW

Delta wave

Short pr

WPW

WPW

Ebsteins (9%), L-TGA (1%), HCM (1%) Narrow complex tachycardia most common Digoxin is contraindicated (accelerated ventricular response) B-blocker or amiodarone

Initiation of SVT in WPW

NSR with pre-excitation

PAC

Narrow Complex SVT

Antidromic SVT

WPW with A Fib

Afib WPW

NSR?
18 yo s/p Mustard operation presents feeling tired Adenosine 6 mg iv push given

Diagnosis is atrial flutter (intra-atrial reentry) -treatment options include -cardioversion -overdrive pacing (TEP or transvenous) -medical cardioversion (class lll agent ibutilide)

SVT ?
NB infant with HR of 240 BPM

Adenosine 200 mcg/kg IV push

Atrial Flutter

Atrial Flutter
Most frequently seen in infants or older pts after atrial surgery (Mustard/Senning, Fontan) Treatment depends on duration and degree of hemodynamic compromise Is there evidence of SND?

Intraatrial Reentry (flutter)

A Flutter with 2:1 Conduction

Atrial Flutter

Rate control (ventricular response)


B-blocker Ca channel blocker Digoxin

Conversion
Cardioversion Pharmacologic (acute, sub-acute, chronic)

Atrial Flutter

SND
Need the ability to pace since SNRT may be very prolonged after cardioversion (overdrive suppression of SN) Epicardial wires Transvenous wires TE wire

Atrial Flutter

Death
Prolonged pause after conversion Rapid ventricular response in pt with structural heart disease Anesthesia induction (loss of sympathetic tone leads to hypotension and coronary perfusion problem)

Atrial Fibrillation

PJRT
P
8 yo girl transferred to the ER with Dx of DCM, severe LV dysfunction

PJRT
Atypical or fast-slow type SVT Incessant nature May cause tachycardia induced cardiomyopathy Resistant to drug therapy Terminates with adenosine, but only transiently

PVC
QRS is premature Morphology of QRS is different from baseline (did you see the po ECG?) QRS is prolonged ST abnormalities No PAC noted

Bigeminy

V Tach

V Tach

V Tach

Accurate Dx is essential prior to beginning Rx


SVT with aberrant conduction Assume V Tach 12 lead ECG if Stable
AV dissociation? Fusion bts? Rate < 250?

May be life threatening

V Tach: Treatment
Clinical condition Underlying disease state

Structurally normal heart CHD Myocarditis DCM

Am J Cardiol. 1996 Jul 1;78(1):82-3

Comparison of procainamide and lidocaine in terminating sustained monomorphic ventricular tachycardia.


Gorgels AP, van den Dool A, Hofs A, Mulleneers R, Smeets JL, Vos MA, Wellens HJ.

V Tach: Treatment
-Procainamide converted 80% V tach

- Lidocaine stable V tach Hemodynamicallyconverted 20%(sustained)

Procainamide Amiodarone Lidocaine

V Tach: Long QT

Congenital
Intense emotions, vigorous activity, awakening Auto Dom: RomanoWard Auto Rec: Jervell and Lange-Nielsen B-blocker, pacing, AICD

Acquired
Pause dependent, short-long-short QRS sequence Antiarrhythmics, phenothiazines and tricyclics, low K, low Mg DC causative agent, IV Mg, K, temp pacing, isoprel

V Tach: Treatment

Hemodynamically unstable
Cardioversion!!!

Torsade de Pointes

Long Qt

V Tach: Long QT

Acquired (drug induced)


Quinidine Hypokalemia

Congenital

Arrhythmias After CHS


Occur in > 25% of patients (CHOP) <10% MCH (JET 0.9%, CHB requiring pacemaker 0.15%) Risk Factors At Risk myocardium (long standing hypertrophy, volume load, etc.) Myocardial ischemia, cardioplegia Ventriculotomy Electrolyte Disturbances Majority of clinically significant arrhythmias occur with first 48 hours of surgery Marino BS, et al Circulation 2000
Hoffman TM, et al Ped Cardiol 2002 Fishberger SB, et al Cardiol Young 2007

Acute Arrhythmias Associated with CH Surgery

V Tach (early or late)


Older pts (re-do po TOF, history of ventriculotomy) Sicker hearts Coronary perfusion problems (ischemia)

JET (early ONLY)


NB and infants VSD closure (any VSD including TOF, TGA/VSD) Fontan

Acute Arrhythmias Associated with CH Surgery

Atrial Flutter/Fib (usually late)


History of Mustard/Senning, Fontan History of ASD repair (usually older pt) Fontan operation

SND (late or early)


All above plus: AVC BiGlenn

CHB (early or late)


VSD closure (any type) L-TGA (any intra-cardiac surgery)

IV Amiodarone

2-5 mg/kg IV over 30 mins


hypotension: volume, Ca++, slow infusion Bradycardia early and LATE! Dangerous w/o ability to pace (cause SND)

repeat in 1 hour if arrhythmia control is not satisfactory AV pace if ventricular rate allows add procainamide if poor response o cool to 35 C

CHB

Congenital
1/20,000 births

Acquired
Post surgery
Usually related to VSD closure

CHD: L-TGA myocarditis

Bradycardias
SND Second degree heart block

Mobitz 1 Mobitz 2

Complete heart block

Sinus Bradycardia

Most common bradyarrhythmia in the ICU Usually related to hypoxia and airway problems
Treat underlying cause Atropine Epinephrine Isuprel

Seen in pts with increased ICP


Treat underlying cause

SND

Most commonly seen in pts with a previous history of Mustard/Senning Operation Fontan operation BiGlenn Occasionally noted acutely following surgery Often associated with atrial arrhythmias (flutter:tachy-brady syndrome) Important historically because drug therapy may exacerbate Pauses of > 3 sec often noted after termination of tachycardia

Mobitz 1 (Wenckebach)

Increasing PR interval leading to block Shortest PR after blocked beat Block occurs in AV node (above HIS) May be related to drugs which block the AV node, or increased vagal tone Usually benign Rarely requires treatment Occurs in pts with normal conduction system

Mobitz II

No PR prolongation Block occurs below AVN (distal to HIS) Pathologic

Requires close observation May progress May require treatment

CHB

CHB

Treatment
Depends on symptoms Acute treatment includes
Atropine Epinephrine Isuprel Pacing

Post surgical CHB requires permanent pacing Transient HB in PO period may progress to CHB later in life

Trifascicular Block
1. Ist degree AVB PR=0.22 2. RBBB 3. LAHB

Electrical Alternans

Large Pericardial Effusion

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