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PERIOPERATIVE ARRHYTHMIAS
Guided By- Dr. Vijeta khandelwal
Presented By-Dr. C.L. khedia
• Definition: Arrhythmia is defined as
"Abnormality of cardiac rate, rhythm or
conduction.
• Cardiac arrhythmias are the m...
Mechanisms of Arrhythmia
Production
• Re-entry (refractory tissue reactivated due to conduction
block, causes abnormal con...
Contributing factors and causes
1. Patient related factors-
• preexisting cardiac disease
• central nervous system disease...
Reversible cause of arrhythmia
• Hypoxemia
• Hypercarbia
• Hypotension
• Acidosis
• Light anesthesia
• Proarrhythemic drug...
Classification of Cardiac
Arrhythmias
• Heart rate (increased/decreased)
• Heart rhythm (regular/irregular)
• Site of orig...
• Bradyarrhythmias
• Sinus bradycardia
• Sinoatrial block
• Sinus arrest
• Atroventricular block
• Bundle branch block
• T...
Supraventricular tachyarrhythmias
• Sinus tachycardia
• Prematue atrial contractions (PACs)
• Atrial tachycardia
• Atrial ...
Anaesthetic considerations
• All patients undergoing anaesthesia and
surgery should have ECG monitoring.
• Lead II and V 5...
Waveform Analysis
– For each strip it is necessary to go through steps
to correctly identify the rhythm
1. Is there a P-wa...
• Normal
– Heart rate = 60 – 100 bpm
– PR interval = 0.12 – 0.20 sec
– QRS interval <0.12
– SA Node discharge = 60 – 100 /...
• Cardiac cycle
– P wave = atrial depolarization
– PR interval = pause between atrial and
ventricular depolarization
– QRS...
Normal Sinus Rhythm
Heart
Rate
Rhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
60 -
100
Regular
Before each QRS,
Identical
.12...
• Normal Sinus Rhythm
– Sinus Node is the primary pacemaker
– One upright uniform p-wave for every QRS
– Rhythm is regular...
Sinus Bradycardia
Heart
Rate
Rhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
<60 Regular
Before each QRS,
Identical
.12 - .20 ...
• Sinus Bradycardia
– One upright uniform p-wave for every QRS
– Rhythm is regular
– Rate less than 60 beats per minute
• ...
Perioperative causes of Sinus Bradycardia-:
1. Vagal stimulation- Oculocardiac reflex, Celiac
plexus stimulation(traction ...
Perioperative T/T-
- In asymptomatic pt no t/t requires
- In Mildly symptomatic pts, underlying factors
should be eleminat...
•
Sinus Tachycardia
Heart
Rate
Rhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
>100 Regular
Before each QRS,
Identical
.12 - ....
• Sinus Tachycardia
– One upright uniform p-wave for every QRS
– Rhythm is regular
– Rate is greater than 100 beats per mi...
Treatment-:
-correcting underlying cause of symp. Stimulation.
-Beta blockers may be employed to lower heart rate
and decr...
Sinus Arrhythmia
Heart
Rate
Rhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
Var. Irregular
Before each QRS,
Identical
.12 - .2...
• Sinus Arrhythmia
– One upright uniform p-wave for every QRS
– Rhythm is irregular
• Rate increases as the patient breath...
Premature Atrial Contraction (PAC)
Heart
Rate
Rhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
NA Irregular
Premature &
abnorma...
– Premature Atrial Contraction (PAC)
• One P-wave for every QRS
– P-wave may have different morphology on ectopic beat,
bu...
• Sign and symptoms
-PACs arises from ectopic foci in atria. Typical
symptoms include an awareness of a fluttering
or a he...
Perioperative T/t-:
1. Avoidance of ppt. factors and sympathetic
stimulation.
2. Pharmacological T/t required only if the ...
Atrial Fibrillation
Heart
Rate
Rhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
Var. Irregular Wavy irregular NA <.12
Atrial Rh...
• Atrial Fibrillation
– No discernable p-waves preceding the QRS complex
• The atria are not depolarizing effectively, but...
• Atrial Fibrillation (con’t)
– Often a chronic condition, medical attention only
necessary if patient becomes symptomatic...
Perioperative management-
-If new onset of AF, surgery should be postponed if possible
untill control of dysrhythmia.
-T/t...
Atrial Flutter
Heart Rate Rhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
Atrial=250
– 400
Ventricular
Var.
Irregular Sawtooth...
• Atrial Flutter
– More than one p-wave for every QRS complex
• Demonstrate a “sawtooth” appearance
– Atrial rhythm is reg...
• Peioperative T/t-
-T/t depends on hemodynamic stability of
patient.
-If AF is hemodymamically sig. the T/t is
cardiovers...
Atrial Rhythms
• Atrial Flutter
– Atrial flutter is classified as a ratio of p-waves
per QRS complexes (ex: 3:1 flutter 3 ...
• Rhythms that originate at the AV junction
• Junctional rhythms do not have
characteristic p-waves.
Junctional Rhythms
Premature Junctional Contraction PJC
Heart
Rate
Rhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
Usually
normal
Irregular
Prema...
• Premature Junctional Contraction (PJC)
– P-wave can come before or after the QRS complex,
or it may lost in the QRS comp...
Accelerated Junctional
Heart
Rate
Rhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
Var. Regular
Inverted, absent or
after QRS
<...
• Accelerated Junctional Rhythm
– P-wave can come before or after the QRS
complex, or lost within the QRS complex
• If p-w...
Junctional Tachycardia
Heart
Rate
Rhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
>100 Regular
May be inverted or
hidden
Short...
• Junctional Tachycardia
– P-wave can come before or after the QRS complex or
lost within the QRS entirely
• If a p-wave i...
• Perioperative T/t-
-Junctional rhythm is not frquent during GA.
-Transient Junctional rhythm require no T/t
-Loss of AV ...
Ventricular Rhythms
Premature Ventricular Contraction (PVC)
Heart
Rate
Rhythm P Wave
PR
Interval
(sec.)
QRS
(Sec.)
Var. Ir...
Ventricular Rhythms
• Premature Ventricular Contraction (PVC)
– The ectopic beat is not preceded by a p-wave
– Irregular r...
Ventricular Rhythm
• Premature Ventricular Contraction
– Classify as rare, occasional, or frequent
– Classify as unifocal,...
Ventricular Rhythm
• Premature Ventricular Contraction
– Classify as unifocal, or multifocal PVC’s
– Unifocal-originating ...
Ventricular Rhythm
• Premature Ventricular Contraction
– Bigeminy
• A PVC occurring every other beat
– Also seen as Trigem...
Ventricular Rhythm
• Dangerous PVC’s
– R on T
– Runs of PVC’s
– 3 or more
considered Vtach
• Causes of PVCs
- Arterial hypoxemia
- MI
- Myocarditis
- SNS activation
- Hypokalemia/Hypomagnesemia
- Digitalis toxicit...
• Prioperative T/t-
-During anaesthesia, if pt exhibits 6 or more PVCs
per minute and repetetive or multifocal forms,
ther...
Ventricular Rhythms
Ventricular Tachycardia
Heart
Rate
Rhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
100 –
250
Regular
No P ...
Ventricular Rhythms
• Ventricular Tachycardia
– No discernable p-waves with QRS
– Rhythm is regular
– Atrial rate cannot b...
Ventricular Rhythms
• Ventricular Tachycardia
– THIS IS A DEADLY RHYTHM
• Check patient:
– If patient awake and alert, mon...
Ventricular Rhythms
Ventricular Fibrillation
Heart
Rate
Rhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
0 Chaotic None NA None
Ventricular Rhythms
• Ventricular Fibrillation
– No discernable p-waves
– No regularity
– Unable to determine rate
– Multi...
Asystole
Heart
Rate
Rhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
None None None None None
Asystole
• No p-waves
• No regularity
• No Rate
• This rhythm is associated with death
– Check patient and leads
– No puls...
Heart Block
First Degree Heart Block
Heart
Rate
Rhythm P Wave
PR Interval
(sec.)
QRS
(Sec.)
Norm. Regular
Before each QRS,...
Heart Block
– First Degree Heart Block
• P-wave for every QRS
• Rhythm is regular
• Rate may vary
• Av Node hold each impu...
Heart Block
Second Degree Heart Block
Mobitz Type I (Wenckebach)
Heart
Rate
Rhythm P Wave
PR Interval
(sec.)
QRS
(Sec.
)
N...
Heart Block
• Second Degree Heart Block
• Mobitz Type I (Wenckebach)
– Some p-waves are not followed by QRS complexes
– Rh...
Heart Block
Second Degree Heart Block
Mobitz Type II (Classical)
Heart
Rate
Rhythm P Wave
PR
Interval
(sec.)
QRS
(Sec.)
Us...
Heart Block
• Second Degree Heart Block
• Mobitz Type II (Classical)
– More p-waves than QRS complexes
– Rhythm is irregul...
Heart Block
Third Degree Heart Block
(Complete)
Heart
Rate
Rhythm P Wave
PR
Interval
(sec.)
QRS
(Sec.)
30 –
60
Regular
Pre...
Heart Block
• Third Degree Heart Block (Complete)
– There are more p-waves than QRS
complexes
– Both P-P and R-R intervals...
• Anaesthetic management
-Previous placement of a transvenous pacemacker or
availability of of transcutaneous cardiac paci...
MODALITIES FOR TREATMENT OF
ARRHYTHMIA
• Antiarrhythmic drugs
. All such drugs may aggravate or produce
arrhythmias and th...
Drugs affecting different parts of the
heart
Management of Arrythmia’s
• ECG and rhythm information
• should be interpreted within the context of
total patient assessm...
• In both unstable and symptomatic cases
• Provider must make an assessment whether
it is the arrhythmia that is causing t...
• If patient with severe hypoxemia becomes
hypotensive and develops bradycardia
• Bradycardia is not the primary cause of
...
Supraventricular Tachycardia
• (Supraventricular - a rhythm process in which
the ventricles are activated from the atria o...
• QRS typically narrow (in absence of bundle
branch block); thus, also termed narrow QRS
tachycardia
• Usually paroxysmal,...
Vagal maneuver
• Valsalva maneuver or carotid sinus massage
• Terminate up to 25% of PSVTs
• For other SVTs
• May transien...
Adenosine ( if regular)
• If PSVT does not respond to vagal maneuvers
• Give 6 mg of IV adenosine as a rapid IV push
throu...
Narrow-complex irregular
tachycardia
• Atrial fibrillation with uncontrolled
ventricular response
• MAT
• sinus rhythm/tac...
Rate Control
• Unstable patients
• Prompt electric cardioversion
• Stable patients
• Ventricular rate control as directed ...
Ventricular arrhythmias
• Non-sustained ventricular
arrhythmias
- routinely seen in the absence of cardiac
disease- may no...
NSVT after - cardiopulmonary bypass, unstable
patients with marginal perfusion may
deteriorate with recurrent episodes of ...
Sustained VT
• two categories: monomorphic and
polymorphic.
• monomorphic VT - the amplitude of the QRS
complex remains co...
Therapy for monomorphic wide
complex tachycardia
• If the etiology of the rhythm cannot be
determined
• QRS monomorphic, r...
• If the wide-complex tachycardia proves to be
SVT with aberrancy
• transiently slowed or converted by
adenosine to sinus ...
For patients who are stable with
likely VT
• IV antiarrhythmic drugs or elective
cardioversion is the preferred treatment
...
Wide-complex irregular
rhythm
• Should be considered preexcited atrial
fibrillation
• Expert consultation is advised
• Avo...
Polymorphic (Irregular) VT
• First step
• Stop medications known to prolong the QT
interval
• Correct electrolyte imbalanc...
Prolong QT interval (Torsades de
pointes)
• The management of torsades de pointes
differs markedly from other forms of VT,...
Perioperative%20%20%20%20%20%20%20%20 arrhythmias
Perioperative%20%20%20%20%20%20%20%20 arrhythmias
Perioperative%20%20%20%20%20%20%20%20 arrhythmias
Perioperative%20%20%20%20%20%20%20%20 arrhythmias
Perioperative%20%20%20%20%20%20%20%20 arrhythmias
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  1. 1. PERIOPERATIVE ARRHYTHMIAS Guided By- Dr. Vijeta khandelwal Presented By-Dr. C.L. khedia
  2. 2. • Definition: Arrhythmia is defined as "Abnormality of cardiac rate, rhythm or conduction. • Cardiac arrhythmias are the most frequent perioperative cardiovascular abnormalities in patients undergoing both cardiac and non-cardiac surgery. • The occurrence of arrhythmias have been reported in 70% of patients subjected to general anaesthesia for various surgical procedures.
  3. 3. Mechanisms of Arrhythmia Production • Re-entry (refractory tissue reactivated due to conduction block, causes abnormal continuous circuit. eg accessory pathways linking atria and ventricles in Wolff-Parkinson- White syndrome) • Injury or damage (pathology) to the cardiac conduction systems • Abnormal pacemaker activity/ automaticity in non- conducting/conducting tissue (eg. ischaemia) • Delayed after-depolarisation (automatic depolarisation of cardiac cell triggers ectopic beats, can be caused by drugs eg digoxin)
  4. 4. Contributing factors and causes 1. Patient related factors- • preexisting cardiac disease • central nervous system disease • Old age 2.Anaesthesia related factors • Tracheal intubation • general anaesthetics • regional anaesthesia • Electrolyte imbalance and abnormal arterial blood gases • Central venous cannulation
  5. 5. Reversible cause of arrhythmia • Hypoxemia • Hypercarbia • Hypotension • Acidosis • Light anesthesia • Proarrhythemic drugs • Cardiac ischemia • Electrolyte imbalance • Hypothermia • Mechanical irritation: PAC, Chest tube
  6. 6. Classification of Cardiac Arrhythmias • Heart rate (increased/decreased) • Heart rhythm (regular/irregular) • Site of origin (supraventricular / ventricular) • Complexes on ECG (narrow/broad)
  7. 7. • Bradyarrhythmias • Sinus bradycardia • Sinoatrial block • Sinus arrest • Atroventricular block • Bundle branch block • Tachyarrhythmias • Supraventricular arrhythmias • Ventricular arrhythmias
  8. 8. Supraventricular tachyarrhythmias • Sinus tachycardia • Prematue atrial contractions (PACs) • Atrial tachycardia • Atrial flutter/fibrillation (AF) • Atrioventricular nodal reentrant tachycardia (AVNRT) • Atrioventricular reentrant tachycardia (AVRT) Ventricular tachyarrhythmias • Premature ventricular contractions (PVCs) • Ventricular tachycardia (VT) • Monomorphic vs Polymorphic VT • Ventricular flutter/fibrillation (VF)
  9. 9. Anaesthetic considerations • All patients undergoing anaesthesia and surgery should have ECG monitoring. • Lead II and V 5 are superior for arrhythmia detection and diagnosis before the appearance of physical signs.
  10. 10. Waveform Analysis – For each strip it is necessary to go through steps to correctly identify the rhythm 1. Is there a P-wave for every QRS? • P-waves are upright and uniform • One P-wave preceding each QRS 2. Is the rhythm regular? • Verify by assessing R-R interval • Confirm by assessing P-P interval 3. What is the rate? • Count the number of beats occuring in one minute • Counting the p-waves will give the atrial rate • Counting QRS will give ventricular rate
  11. 11. • Normal – Heart rate = 60 – 100 bpm – PR interval = 0.12 – 0.20 sec – QRS interval <0.12 – SA Node discharge = 60 – 100 / min – AV Node discharge = 40 – 60 min – Ventricular Tissue discharge = 20 – 40 min
  12. 12. • Cardiac cycle – P wave = atrial depolarization – PR interval = pause between atrial and ventricular depolarization – QRS = ventricular depolarization – T wave = ventricular depolarization
  13. 13. Normal Sinus Rhythm Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) 60 - 100 Regular Before each QRS, Identical .12 - .20 <.12 Sinus Rhythms
  14. 14. • Normal Sinus Rhythm – Sinus Node is the primary pacemaker – One upright uniform p-wave for every QRS – Rhythm is regular – Rate is between 60-100 beats per minute Sinus Rhythms
  15. 15. Sinus Bradycardia Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) <60 Regular Before each QRS, Identical .12 - .20 <.12 Sinus Rhythms
  16. 16. • Sinus Bradycardia – One upright uniform p-wave for every QRS – Rhythm is regular – Rate less than 60 beats per minute • SA node firing slower than normal • Normal for many individuals • Identify what is normal heart rate for patient Sinus Rhythms
  17. 17. Perioperative causes of Sinus Bradycardia-: 1. Vagal stimulation- Oculocardiac reflex, Celiac plexus stimulation(traction on mesentry), laryngoscopy, Abdominal insufflation, Nausea and ECT 2. Drugs- Beat blocker, Cal channel blocker, opioids (fentanyl/sufentanyl) 3. Succinylcholine 4.Hypothermia 5. Hypothyroidism 6. Atheletic heart syndrome 7. SA node disease or ischemia
  18. 18. Perioperative T/T- - In asymptomatic pt no t/t requires - In Mildly symptomatic pts, underlying factors should be eleminated - In severly symptomatic pts, those with chest pain or syncope, immediate transcutaneous/transvenous pacing is required. - Atropine 0.5 mg Iv every 3-5 min(max 3mg) may be given. It should be noted dose of atropine (<0.5mg) can cause further slowing of HR. - An epinephrine or dopamine infusion may be titrated while awaiting cardiac pacing.
  19. 19. • Sinus Tachycardia Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) >100 Regular Before each QRS, Identical .12 - .20 <.12 Sinus Rhythms
  20. 20. • Sinus Tachycardia – One upright uniform p-wave for every QRS – Rhythm is regular – Rate is greater than 100 beats per minute due to increased SA node discharge sec. to sympathetic stimulation (physiological/pathological /pharmacological response) • Usually between 100-160 (>160 SVT) • Can be high due to anxiety, stress, fever, medications (anything that increases oxygen consumption) Sinus Rhythms
  21. 21. Treatment-: -correcting underlying cause of symp. Stimulation. -Beta blockers may be employed to lower heart rate and decrease myocardial o2 demand(if pt is not hypovolemic). -supplemental O2 to increase supply in response to increase demand. -Avoidance of vagolytic drug (pancuronium) intraoperatively
  22. 22. Sinus Arrhythmia Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Var. Irregular Before each QRS, Identical .12 - .20 <.12 Sinus Rhythms
  23. 23. • Sinus Arrhythmia – One upright uniform p-wave for every QRS – Rhythm is irregular • Rate increases as the patient breathes in • Rate decreases as the patient breathes out – Rate is usually 60-100 (may be slower) – Variation of normal, not life threatening Sinus Rhythms
  24. 24. Premature Atrial Contraction (PAC) Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) NA Irregular Premature & abnormal or hidden .12 - .20 <.12 Atrial Rhythms
  25. 25. – Premature Atrial Contraction (PAC) • One P-wave for every QRS – P-wave may have different morphology on ectopic beat, but it will be present • Single ectopic beat will disrupt regularity of underlying rhythm • Rate will depend on underlying rhythm • Underlying rhythm must be identified • Classified as rare, occasional, or frequent PAC’s based on frequency Atrial Rhythms
  26. 26. • Sign and symptoms -PACs arises from ectopic foci in atria. Typical symptoms include an awareness of a fluttering or a heavy heart beat. -Precipitated by excessive caffeine, stress, alcohol, nicotine and hyperthyroidism. -Often occur at rest and become less frequent by exercise. -second most arrhythmias asso. With MI.
  27. 27. Perioperative T/t-: 1. Avoidance of ppt. factors and sympathetic stimulation. 2. Pharmacological T/t required only if the PACs trigger sec. dysrhythmias. 3. Usually suppressed by calcium channel blocker or Beta blocker.
  28. 28. Atrial Fibrillation Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Var. Irregular Wavy irregular NA <.12 Atrial Rhythms
  29. 29. • Atrial Fibrillation – No discernable p-waves preceding the QRS complex • The atria are not depolarizing effectively, but fibrillating – Rhythm is grossly irregular – If the heart rate is <100 it is considered controlled a- fib, if >100 it is considered to have a “rapid ventricular response” – AV node acts as a “filter”, blocking out most of the impulses sent by the atria in an attempt to control the heart rate Atrial Rhythms
  30. 30. • Atrial Fibrillation (con’t) – Often a chronic condition, medical attention only necessary if patient becomes symptomatic – Patient will report history of atrial fibrillation. – Symptoms range from palpitation to angina pectoris, CHF, pul. Oedema and hypotension – Often associated with fatigue and generalized weakness. – Predisposing factors are :RHD, hypertension, thyrotoxicosis, IHD, chronic COPD, pericarditis and pulmonary embolus. Atrial Rhythms
  31. 31. Perioperative management- -If new onset of AF, surgery should be postponed if possible untill control of dysrhythmia. -T/t of AF during Sx depends on hemodynamic stability of pt. -if hemodynamically significat, the T/t is cardioversion -Synchronized electrical cardioversion (100 to 200 J) is most effective. -Pharmacological cardioversion by IV amiodarone (pref.drug), diltiazem or verapamil may be attempted. -Pt with chronic AF should be maintained on their antidysrhythmic drugs with close attention to serum electrolyte(K &Mg). -Manage the transition on and off IV and oral anticoagulation.
  32. 32. Atrial Flutter Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Atrial=250 – 400 Ventricular Var. Irregular Sawtooth Not Measur- able <.12 Atrial Rhythms
  33. 33. • Atrial Flutter – More than one p-wave for every QRS complex • Demonstrate a “sawtooth” appearance – Atrial rhythm is regular. Ventricular rhythm will be regular if the AV node conducts consistently. If the pattern varies, the ventricular rate will be irregular – Rate will depend on the ratio of impulses conducted through the ventricles – Most commonly atrial rate compared to ventricular rate 2:1 (if atrial rate is 300bpm and 2:1 conduction,pt can present with venticular rate of 150 with sign and symptoms) Atrial Rhythms
  34. 34. • Peioperative T/t- -T/t depends on hemodynamic stability of patient. -If AF is hemodymamically sig. the T/t is cardioversion, synchronized elec. Cardioversion satarting at 50 J is indicated. -Pharmacological control of ventricular response with IV amiodarone, diltiazem or verapamil may be tried, if vital signs are stable.
  35. 35. Atrial Rhythms • Atrial Flutter – Atrial flutter is classified as a ratio of p-waves per QRS complexes (ex: 3:1 flutter 3 p-waves for each QRS) – Not considered life threatening, consult physician if patient symptomatic
  36. 36. • Rhythms that originate at the AV junction • Junctional rhythms do not have characteristic p-waves. Junctional Rhythms
  37. 37. Premature Junctional Contraction PJC Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Usually normal Irregular Premature, abnormal, may be inverted or hidden Short <.12 Normal <.12 Junctional Rhythms
  38. 38. • Premature Junctional Contraction (PJC) – P-wave can come before or after the QRS complex, or it may lost in the QRS complex • If visible, the p-wave will be inverted – Rhythm will be irregular due to single ectopic beat – Heart rate will depend on underlying rhythm – Underlying rhythm must be identified – Classify as rare, occasional, or frequent PJC based on frequency – Atria are depolarized via retrograde conduction Junctional Rhythms
  39. 39. Accelerated Junctional Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Var. Regular Inverted, absent or after QRS <.12 <.12 Junctional Rhythms
  40. 40. • Accelerated Junctional Rhythm – P-wave can come before or after the QRS complex, or lost within the QRS complex • If p-waves are seen they will be inverted – Rhythm is regular – Heart rate between 60-100 beats per minute • Within the normal HR range • Fast rate for the junction (normally 40-60 bpm) Junctional Rhythms
  41. 41. Junctional Tachycardia Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) >100 Regular May be inverted or hidden Short <.12 Normal <.12 Junctional Rhythms
  42. 42. • Junctional Tachycardia – P-wave can come before or after the QRS complex or lost within the QRS entirely • If a p-wave is seen it will be inverted – Rhythm is regular – Rate is between 100-180 beats per minute • In the tachycardia range, but not originating from SA node – AV node has sped up to override the SA node for control of the heart – Junctional rhythm often result in AV dyssynchrony and a junctional tachycardia can severly impaired Cardiac output. Junctional Rhythms
  43. 43. • Perioperative T/t- -Junctional rhythm is not frquent during GA. -Transient Junctional rhythm require no T/t -Loss of AV synchrony during a junctional rhythm may result in MI, heat failure or hypotension -Atropine 0.5 mg can be used to treat hemodynamically significat junctional rhythms
  44. 44. Ventricular Rhythms Premature Ventricular Contraction (PVC) Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Var. Irregular No P waves associated with premature beat NA Wide >.12
  45. 45. Ventricular Rhythms • Premature Ventricular Contraction (PVC) – The ectopic beat is not preceded by a p-wave – Irregular rhythm due to ectopic beat – Rate will be determined by the underlying rhythm – QRS is wide and may be bizarre in appearance – Caused by a irritable focus within the ventricle which fires prematurely
  46. 46. Ventricular Rhythm • Premature Ventricular Contraction – Classify as rare, occasional, or frequent – Classify as unifocal, or multifocal PVC’s • Unifocal-originating from same area of the ventricle; distinguished by same morphology
  47. 47. Ventricular Rhythm • Premature Ventricular Contraction – Classify as unifocal, or multifocal PVC’s – Unifocal-originating from same area of the ventricle; distinguished by same morphology – Multifocal-originating from different areas of the ventricle; distinguished by different morphology
  48. 48. Ventricular Rhythm • Premature Ventricular Contraction – Bigeminy • A PVC occurring every other beat – Also seen as Trigeminy, Quadrigeminy
  49. 49. Ventricular Rhythm • Dangerous PVC’s – R on T – Runs of PVC’s – 3 or more considered Vtach
  50. 50. • Causes of PVCs - Arterial hypoxemia - MI - Myocarditis - SNS activation - Hypokalemia/Hypomagnesemia - Digitalis toxicity - Caffeine, cocaine,Alcohol - Mechanical irritation-(CV or Pulm. Artery catheter)
  51. 51. • Prioperative T/t- -During anaesthesia, if pt exhibits 6 or more PVCs per minute and repetetive or multifocal forms, there is increased risk of developing life threatining dysrhythmia. -T/t include a D/d of possible cause and t/t of that cause, while t/t of cause, the immediate availability of a defibrillator should be confirmed. -Beta blockers are the most successful drug, amiodarone,lidocaine and other antiarhythmic are indicated if the PVCs progress to VT or ferquent to cause hemodynamic instability.
  52. 52. Ventricular Rhythms Ventricular Tachycardia Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) 100 – 250 Regular No P waves corresponding to QRS, a few may be seen NA >.12
  53. 53. Ventricular Rhythms • Ventricular Tachycardia – No discernable p-waves with QRS – Rhythm is regular – Atrial rate cannot be determined, ventricular rate is between 150-250 beats per minute – Must see 4-6 beats in a row to classify as v- tach
  54. 54. Ventricular Rhythms • Ventricular Tachycardia – THIS IS A DEADLY RHYTHM • Check patient: – If patient awake and alert, monitor patient and call physician – Pt with symptomatic or unstable VT or SVT cardioverted immediately. – If vitals signs stable and VT is persistent or recurrent after cardioversion, Amiodarone 150mg over 10min should be given, other drugs may be used like procainamide,lignocaine or sotalol. – Pulseless VT requires immediate cardioversion/defibrillation and CPR. (If patient has no vital signs, call code and start CPR » Defibrillate)
  55. 55. Ventricular Rhythms Ventricular Fibrillation Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) 0 Chaotic None NA None
  56. 56. Ventricular Rhythms • Ventricular Fibrillation – No discernable p-waves – No regularity – Unable to determine rate – Multiple irritable foci within the ventricles all firing simultaneously – May be coarse or fine – This is a deadly rhythm • Patient will have no pulse • Call a code and begin CPR • Survival is best if defbrillation occcurs within 3-5 min
  57. 57. Asystole Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) None None None None None
  58. 58. Asystole • No p-waves • No regularity • No Rate • This rhythm is associated with death – Check patient and leads – No pulse • Begin CPR
  59. 59. Heart Block First Degree Heart Block Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Norm. Regular Before each QRS, Identical > .20 <.12
  60. 60. Heart Block – First Degree Heart Block • P-wave for every QRS • Rhythm is regular • Rate may vary • Av Node hold each impulse longer than normal before conducting normally through the ventricles • Prolonged PR interval – Looks just like normal sinus rhythm Cuases- increased vagal tone, digitalis toxicity, inferior wall MI and myocarditis. -Usually asymptomatic and rarely require T/t. -Elimination of drugs that slows AV conduction or clinical factors that enhance vagal tone can reverse 1st degree block.
  61. 61. Heart Block Second Degree Heart Block Mobitz Type I (Wenckebach) Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec. ) Norm. can be slow Irregular Present but some not followed by QRS Progressively longer <.12
  62. 62. Heart Block • Second Degree Heart Block • Mobitz Type I (Wenckebach) – Some p-waves are not followed by QRS complexes – Rhythm is irregular • R-R interval is in a pattern of grouped beating – Rate 60-100 bpm – Intermittent Block at the AV Node • Progressively prolonged p-r interval until a QRS is blocked completely
  63. 63. Heart Block Second Degree Heart Block Mobitz Type II (Classical) Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Usually slow Regular or irregular 2 3 or 4 before each QRS, Identical .12 - .20 <.12 depends
  64. 64. Heart Block • Second Degree Heart Block • Mobitz Type II (Classical) – More p-waves than QRS complexes – Rhythm is irregular – Atrial rate 60-100 bpm; Ventricular rate 30-100 bpm (depending on the ratio on conduction) – Intermittent block at the AV node • AV node normally conducts some beats while blocking others • Mobitz type II block has high rate of progression to 3rd degree heart block. A cardiac pacemaker is mandatory in this situation.
  65. 65. Heart Block Third Degree Heart Block (Complete) Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) 30 – 60 Regular Present but no correlation to QRS may be hidden Varies <.12 depends
  66. 66. Heart Block • Third Degree Heart Block (Complete) – There are more p-waves than QRS complexes – Both P-P and R-R intervals are regular – Atrial rate within normal range; Ventricular rate between 20-60 bpm – The block at the AV node is complete • There is no relationship between the p-waves and QRS complexes. • Cardiac pacing is require in cases of 3rd degree block
  67. 67. • Anaesthetic management -Previous placement of a transvenous pacemacker or availability of of transcutaneous cardiac pacing is required before an anesthetic is administered for insertion of permanent cardiac pacemaker , -Isoproterenol may be required to maintain acceptable HR and acts as “chemical pacemaker” untill the artificial pacemaker is functional
  68. 68. MODALITIES FOR TREATMENT OF ARRHYTHMIA • Antiarrhythmic drugs . All such drugs may aggravate or produce arrhythmias and they may also depress ventricular contractility and must, therefore, be used with caution. • They are classified according to their effect on the action potential (Vaughan Williams' classification)
  69. 69. Drugs affecting different parts of the heart
  70. 70. Management of Arrythmia’s • ECG and rhythm information • should be interpreted within the context of total patient assessment • Providers must evaluate • Patient’s symptoms • Clinical signs • Ventilation, oxygenation, heart rate, blood pressure, signs of inadequate organ perfusion
  71. 71. • In both unstable and symptomatic cases • Provider must make an assessment whether it is the arrhythmia that is causing the patient to be unstable • Patient in septic shock with sinus tachycardia 140 / min is unstable • Electric cardioversion will not improve this patient’s condition
  72. 72. • If patient with severe hypoxemia becomes hypotensive and develops bradycardia • Bradycardia is not the primary cause of instability • Treating the bradycardia without treating the hypoxemia is unlikely to improve the patient’s condition
  73. 73. Supraventricular Tachycardia • (Supraventricular - a rhythm process in which the ventricles are activated from the atria or AV node/His bundle region) • Refers to supraventricular tachycardia other than afib, aflutter and MAT • Occurs in 35 per 100,000 person-years • Usually due to reentry—AVNRT or AVRT
  74. 74. • QRS typically narrow (in absence of bundle branch block); thus, also termed narrow QRS tachycardia • Usually paroxysmal, i.e, starting and stopping abruptly; called PSVT • Aetiology should be considered before therapy is instituted
  75. 75. Vagal maneuver • Valsalva maneuver or carotid sinus massage • Terminate up to 25% of PSVTs • For other SVTs • May transiently slow the ventricular rate • Potentially assist rhythm diagnosis but will not usually terminate such arrhythmias
  76. 76. Adenosine ( if regular) • If PSVT does not respond to vagal maneuvers • Give 6 mg of IV adenosine as a rapid IV push through antecubital vein followed by a 20 mL saline flush • If the rhythm does not convert within 1 to 2 minutes • Give a 12 mg rapid IV push using the method above
  77. 77. Narrow-complex irregular tachycardia • Atrial fibrillation with uncontrolled ventricular response • MAT • sinus rhythm/tachycardia with frequent atrial premature beats
  78. 78. Rate Control • Unstable patients • Prompt electric cardioversion • Stable patients • Ventricular rate control as directed by patient symptoms • IV nondihydropyridine calcium channel blockers Diltiazem are drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular rate
  79. 79. Ventricular arrhythmias • Non-sustained ventricular arrhythmias - routinely seen in the absence of cardiac disease- may not require drug therapy in the perioperative period. - Conversely, in patients with structural heart disease, these non-sustained rhythms do predict subsequent life-threatening ventricular arrhythmias.
  80. 80. NSVT after - cardiopulmonary bypass, unstable patients with marginal perfusion may deteriorate with recurrent episodes of NSVT may benefit from suppression with lidocaine or beta blockade. repletion of post-bypass hypomagnesaemia (MgCl2 2 g i.v.) reduces the incidence of NSVT after cardiac surgery.
  81. 81. Sustained VT • two categories: monomorphic and polymorphic. • monomorphic VT - the amplitude of the QRS complex remains constant • polymorphic ventricular tachycardia - the QRS morphology continually changes.
  82. 82. Therapy for monomorphic wide complex tachycardia • If the etiology of the rhythm cannot be determined • QRS monomorphic, regular • IV adenosine is relatively safe for both treatment and diagnosis • However, adenosine should not be given for unstable or irregular or polymorphic wide complex tachycardias • • It may cause degeneration of the arrhythmia to VF
  83. 83. • If the wide-complex tachycardia proves to be SVT with aberrancy • transiently slowed or converted by adenosine to sinus rhythm • If due to VT there will be no effect on rhythm (except in rare cases of idiopathic VT) • When adenosine is given for undifferentiated wide complex tachycardia • Defibrillator should be available
  84. 84. For patients who are stable with likely VT • IV antiarrhythmic drugs or elective cardioversion is the preferred treatment strategy • Amiodarone • Procainamide • Sotalol • Procainamide and sotalol should be avoided in patients with prolonged QT, CHF
  85. 85. Wide-complex irregular rhythm • Should be considered preexcited atrial fibrillation • Expert consultation is advised • Avoid AV nodal blocking agents • adenosine, calcium channel blockers, digoxin, and possibly β-blockers
  86. 86. Polymorphic (Irregular) VT • First step • Stop medications known to prolong the QT interval • Correct electrolyte imbalance • Acute precipitants: drug overdose or poisoning
  87. 87. Prolong QT interval (Torsades de pointes) • The management of torsades de pointes differs markedly from other forms of VT, and includes • i.v. magnesium sulfate (2±4 g), • repleting potassium, • and manoeuvres aimed at increasing the heart rate (atropine, isoprenolol or temporary atrial or ventricular pacing). • Haemodynamic collapse with torsades requires asynchronous DC counter shocks
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