1. Arrhytmias
Tamás Ötvös m.d.
2013

2. Initial assessment and treatment
• Follow the ABCDE approach!
• Asses for adverse signs!
• Administration of high flow oxygen!
• Obtain intravenous access!
• Establish monitoring (ECG,BP,SpO2)!
• Record a 12-lead-ECG!
• Correct electrolyte abnormalities(K+,Mg+,Ca+)!
• Look for the cause of arrhytmia!

3. Initial assessment and treatment
• The treatment depends on the condition of the
patient! (stable vs. unstable)
• Anti-arrhytmic drugs:
– slower in onset
– for stable patients without adverse signs
• Electrical treatment (CV or PM) for unstable
patients

4. Adverse signs
Shock
• pallor, sweating, cold extremities (increased
sympathetic activity)
• impaired consciousness (reduced cerebral blood
flow)
• hypotension (systolic BP<90mmHg)

5. Adverse signs
Syncope
• loss of consciousness
• reduced cerebral blood flow

6. Adverse signs
Heart failure
• arrhytmias decrease coronary blood flow
• acute left ventricle failure
• acute right ventricle failure

7. Adverse signs
Myocardial ischaemia
• chest pain
• silent ischaemia

9. Unstable patient with tachycardia
• synchronized electrical cardioversion
• the shock is synchronized with the „R”-wave
• for broad-complex tachycardia start with 200J
monophasic or 120-150J biphasic
• for narrow-complex tachycardia start with 100J
monophasic or 70-120J biphasic
• If CV fails, amiodarone 300mg iv over 10-20min
and re-attempt CV

10. Stable patient with tachycardia
Regular broad-complex tachycardia
• Ventricular tachycardia
• Supraventricular tachycardia with bundle branch
block (for diff. diagnosis can give adenosine)
• Amiodarone 300mg iv. over 20-60 min. followed
by infusion of 900mg over 24 h.
• Other drugs: procainamide, nifekalan, sotalol

13. Stable patient with tachycardia
Irregular broad complex tachycardia
• AF with bundle branch block (treat as AF)
• Pre-excitation sy. (WPW,LGL) (avoid
adenosine, digoxin, verapamil, diltiazem)
• Polymorphic VT (torsade de pointes)(give
magnesium sulphate 2g over 10 min)

18. Stable patient with tachycardia
Regular narrow-complex tachycardia
• Sinus tachycardia
– can be physiological response
– e.g. pain, fever, anaemia, blood loss, heart failure
– NEVER try to treat!!!

20. Stable patient with tachycardia
Regular narrow-complex tachycardia
• AVNRT & AVRT (paroxysmal SVT)
– AVNRT is the commonest type (without any form of
heart desease) and benign
– AVRT is seen with WPW-sy (usually benign, often no
visible atrial activity on ECG)

21. AVNRT

22. Stable patient with tachycardia
Regular narrow-complex tachycardia
• Atrial flutter with regular AV conduction (often
2:1 block)
– Atrial rate 300/min

23. Atrial flutter 2:1 conduction

24. Stable patient with tachycardia
Treatment of regular narrow complex tachycardia
• If the patient is unstable attempt CV (until CV can try
adenosine)
• Start with vagal manoeuvres: carotid sinus massage or
the Valsalva manoeuvre
• Give adenosine 6mg,12mg,12mg
• Give a calcium channel blocker (e.g., verapamil or
diltiazem)

25. Stable patient with tachycardia
Irregular narrow-complex tachycardia
• AF or atrial flutter with variable AV-block
• If there are no adverse features, treatment options include:
– rate control by drug therapy
– rhythm control using drugs to encourage chemical cardioversion;
– rhythm control by electrical cardioversion;
– treatment to prevent complications (e.g., anticoagulation)

26. Atrial fibrillation

27. Stable patient with tachycardia
Atrial fibrillation
• The longer a patient remains in AF, the greater is the likelihood of
atrial clot developing.
• Patients who have been in AF for more than 48 h should not be
treated by cardioversion (electrical or chemical) until they have
received full anticoagulation or absence of atrial clot has been
shown by transoesophageal echocardiography.

28. Stable patient with tachycardia
Atrial fibrillation treatment
• If the aim is control the HR: beta-blockers or diltiazem, digoxin or
amiodarone in heart failure. (Magnesium)
• If the duration of AF<48hr, chemical cardioversion:
ibutilide, flecainide or dofetilide, amiodarone, propafenone.
• Or electrical CardioVersion!

29. Bradycardia
• HR<60/min
• Cardiac causes: e.g., myocardial infarction;myocardial
ischaemia; sick sinus syndrome
• Non-cardiac causes:e.g., vasovagal
response, hypothermia; hypoglycaemia;
hypothyroidism,raised intracranial pressure)
• Drug toxicity:e.g., digoxin; beta-blockers; calcium
channel blockers

30. SSS

31. 1st degree AV-block

32. Second degree AV-block(Mobitz-I)

33. Second degree AV-block(Mobitz-II)

34. Third degree AV-block

35. Treatment of bradycardia
• ABCDE approach
• Consider the potential cause of the bradycardia
and look for the adverse signs!
• Initial treatments are pharmacological, with
pacing being reserved for patients unresponsive
to pharmacological treatments or with risks
factors for asystole.

36. Treatment of bradycardia
• Atropin: 0.5mg in bolus, repeat it in 3-5min up to
3mg!
• Second line drugs:
– isoprenaline (5microgramm/min starting dose)
– adrenaline (2–10microgramm/min)
– dopamine (2–10microgramm/kg/min)
– theophylline (100–200mg slow intravenous injection)
– glucagon if beta-blockers or calcium channel blockers
are a potential cause of the bradycardia

37. Treatment of bradycardia
PACING
• Initiate transcutaneous pacing immediately if
there is no response to atropine!