Serious Cardiac Arrhythmia

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Serious Cardiac Arrhythmia

• ?????
• 10.09

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Introduction

• palpitation
• Arrhythmia
• clinical significance

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• Arrhythmia can be dangerous or life-threatening
  if they cause a severe hemodynamic upset .
  Symptoms such as Fainting,Shock, Angina,Heart
  failure, sudden cardiac arrest .
• ?????????????????????????????????????????

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• normal conduction system

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• Tacharrhythmia include
• Premature beats ventricular atrial
• Tachycardia ventricular
• 
  supraventricular
• Fibrillation/flutter atrial
• ventricular
• Wolff-Parkinson-White syndrome

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• Bradyarrhythmia include
• Sinus bradyarrhythmia
• atrioventricular junctional rhythm
• idioventricular rhythm
• Atrioventricular block
• Bradycardia associated with intraventricular block

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Life-threateaning arrhythmias

• paroxysmal ventricular tachycardia(PVT)
• Ventricular flutter and fibrillation(VF)
• Paroxysmal supraventricular tachycardia(PSVT)
• Atrial fibrillation(very fast ventricular beat)
• Serious atrioventricular block (type ?
  second-degree AVB and third-degree AVB )

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VPB (ventricular premature beat)

• PVC (premature ventricular contraction)
• Causes 1.without obvious cause and benign.
• 2.electrolyte abnormalities in
  the blood
• 3. coronary artery disease
• 4.excessive smoking, alcohol
  consumption, caffeine, certain medications, and
  some illicit drugs.
• Symptoms   palpitations, dizziness, chest pain,
• shortness of breath, the sensation of stopped or
  skipped beats .

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Lown's System for Grading VPB

• Grade 0 no VPB
• Grade I A VPBlt30per hour,lt1 per minute
• B VPBlt30 per hour,gt1 per
  minute
• Grade ? VPBgt30 per hour
• Grade ? polymorphic VPB
• Grade ? A Pair VPB
• B Salve VPB
• Grade ? RonT VPB

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Treatment

• 1. Lidocaine 75-100mg iv.slowly, resume after
  5-10 minues if needed, followed by a continuing
  1-3mg/min ivdrip . But the gross of first one
  hour couldnt exceed 300 mg.
• 2.Propafenone 70mg iv slowly(5-10 minutes),
  once again after 30minutes,the gross couldnt
  exceed 280mg.
• 3.Amiodarone 150mg-300mg add to 5 glucose 100ml
  ivdrip in 30 minutes.
• 4. Beta blockers, especially to no heart disease.

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• 5. When companied with slow arrhythmias ,
  atropine or isoproterenol should be used.
• 6. If VPB is caused by digitalis toxicity, stop
  using digitalis ,complement kalium and use
  dilantin(100mg/20mlNS iv. Slowly)
• 7. If VPB is caused by acute heart failure,
  digitails should be used to improve the heart
  function.

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Paroxysmal Tachycardia

• Characteristic
• 1.Usually lasts seconds to minutes
• 2.Causes a heart rate of 150-250 beats per
  minute.
• 3.Usually begins and ends abruptly
• 4.Many people will have periodic episodes
• 5.Most are concerned with reentrant

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• Ventricular tachycardia(VT)

•   
• characterized by 3 or more consecutive
  premature ventricular beats
• VT is classified as nonsustained (lasting less
  than 30 seconds) and sustained(usually 30 sec
  duration or requir resuscitative intervention).
• Monomorphic or polymorphic.

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• VT is a potentially lethal
• The vast majority of VT occur in people
• with organic heart disease
• VT can occur in AMI, cardiomyopathy(???),
  myocarditis(???), and following heart surgery
  anti-arrhythmic medications or from altered blood
  chemistries (such as a low kalium level), pH
  changes, or insufficient oxygenation.

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• Symptoms    palpitations, dizziness ,
  Fainting, Shortness of breath , Angina, Shock,
  Heart failure.
• Symptoms may start and stop suddenly.
• ECG broad QRS complex, independent P wave ,
  fusion or capture beats .The heart rate may be
  160 to 240.

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?????
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Q-T???????????(Tdp)
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(QT????Tdp)?????. ????????????????5???3?????
?,
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?????????????????(?)??????????(?)
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?????????(Idioventricular rhythm)
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?????????(???)
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Treatment

• VT may turn to Ventricular fibrillation and
  should be interrupt immediately.
• 1. Electrical defibrillation or cardioversion (
  synchronized cardioversion) to those sustained
  VT with serious hemodynamic obstacle(such as
  angina,low pressure ,heart failure)
• Boxing / Coughing repeatedly

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• 2. Intravenous anti-arrhythmic medication
• Lidocaine, 50-100mg????,????5-10??????????????
  ????300mg,?????????1-3mg/???????
• Procainamide, ?????5??100mg,?????1.0g,???????1-
  4mg/?????
• Propafenone, 70mg/?,????,???10-20???????,????,??
  ?????280mg
• Amiodarone ??150mg,???5?????,????????0.5-1mg/??
  ???

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• Sustained ventricular tachycardia

• No pulse Pulse present
• Treat as VF Stable
  Unstable
• O2
  O2
• IV access
  IV access
• Lidocaine
  Cardiovert 50J
• Proccainamide
  100J
• Cardiovert as in
  200J
• unstable patients
  360J

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• 3. RFCA for selected tachycardia.
• 4. Implantable cardioverter defibrillator (ICD).
  
• for many chronic (long-term)
• ventricular
  tachycardia
• 5. Treatment of underlying cardiac disorders,
  correct blood metabolic disturbance.
• 6.??VT?????????????25???20ml??10???100ml?
  ?,??Q-T??,??????????,???0.5µg/min,???2-3µg/min?

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Ventricular fibrillation (VF)

• fatal
• coronary heart disease congenital heart disease
  hypertension heart disease electrical attack
• Symptoms sudden cardiac arrest (loss of
  heartbeat), and does not contract, thus failing
  to pump blood which requires CPR.

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??P???,???????????????,QRS?T?????,??150-300?/?
??QRS-T?????,??????????????????????,??250-500?/mi
n,???lt0.5mV???,gt0.5mV???
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Treatment

• 1.CPR Boxing
• 2. Electrical defibrillation (asynchronized
  cardioversion). 200-360J
• 3. Intravenous anti-arrhythmic medications
• such as Lidocaine, Bretylium, Amiodarone
• Adrenalin 1mg iv.
• 4. AICD(???????)

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Paroxysmal supraventricular tachycardia
(PSVT)

• PSVT can be initiated in the SA node atria or
  the atrial conduction pathways or in the AV node
  
• include SNRT(sinus node reentrant tachycardia),
• IART(intra-atrial reentrant
  tachycardia),
• AVNRT(atrial-venticular node reentrant
  tachycardia),
• AVRT (atrial-venticular reentrant
  tachycardia),
• AAT(automatic atrial tachycardia),
• CAT(chaotic atrial tachycardia)
• thereinto AVNRTand AVRT occupy 90.

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• Causesexcessive smoking, caffeine, or alcohol
  use
• digitalis toxicity,and so on. It occurs
  most often
• in young people and infants
• Symptoms may start and stop suddenly, and can
  last for a few minutes or several hours. whether
  or not they are potentially dangerous depends on
  heart rate ,duration and basal heart disease
• Symptoms Palpitations(??) , Anxiety, Shortness
  of breath ,Chest tightness ,Dizziness(??),
  Fainting(??),Shock, Angina,Heart failure.

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• ECG 1.regular, rapid heart rate. The heart rate
  may be 150 to 250 beats per minute (bpm)
• 2.QRS narrow,often initiated by
  a premature atrial beat with a critical PR
  interval
• 3.Between episodes of PSVT, the
  heart rate is normal (60 to 100 bpm).
• An electrophysiology study (EPS) is often
  necessary for an accurate diagnosis, and to
  recommend the best treatment.

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1.???????????AVNRT ?PSVT???60,??-????-???1
???????-??AVNRT
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?-??AVNRT
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2.?????????(AVRT) ???????PSVT

• Reentry using an accessory pathway which links
  the atria and ventricles bypassing the
  atrioventricular node---WPW
• WPW ECG character short P-R interval , a
  ?-wave,and a wide QRS complex.

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???????????????????,?5??????????????????(P')???QRS
?????,??180/min?
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????????????,QRS????,?????
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PSVT??????????PVT???
???? PSVT
PVT
???? ?? 35?
50? ??
???????? ????????,?

???????
???????WPW
?????? ?PSVT?
?VT?
???????
??????? EKG QRS???????P'??P-?
?????,????
QRS??lt0.14''
QRSgt0.14'' ?????????
?????lt-300
??????????? ??????????
??? V1rSR
V1R,QR?RS QRS?
V6qRS
V6S,rs?qR ????SVT???????
????VT??????? ??ATP gt90??
gt90??
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SNRT
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IART   ???????P'??????P???,???115?/min,P'-P'??
,
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PAAT
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Treatment

• 1.Electrical cardioversion to those have serious
  hemodynamic obstacle(such as angina,low blood
  pressure ,heart failure)or no effect in
  medication.
• no digitails . 50-100J
• 2.vagal nerve excitement
• (????????????????)
• Valsalva maneuver
• carotid arteries massage
  
• vomit

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• 3.Medications
• Adenosine(??) 10-20mg in 3-5seconds iv
• ?????????????????????????????
• Verapamil 5mg diluted iv.
• ???????????????????????
• Cedilande 0.4mg diluted iv.
• Beta-blockers
• Propafenone(????) 70mg iv slowly(5-10
  minutes), once again after 30minutes,280mg/day
• Amiodarone
• ????????????????,?????????,?????,???
  ?????????????,?????????????????????

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• 4.Radiofrequency catheter ablation (RFCA) -- a
  curative procedure introduced in the 1990's which
  is currently the treatment of choice for most
  PSVT's (AVNRTand AVRT )

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?QRS????

• 1.Wide-Complex Tachycardia(?QRS????)
• ????????,?????????????????gt100?/?,QRS??gt0.12s
• ????????? ???????
  ????????????150mg/10min iv
• 2. Narrow-Complex Tachycardia(?QRS????)
• ??lt100?/?,QRS??lt 0.12s ???1)?? 2)?? 3)?? 4)??5)
  AVNRT 6) AVRT
• ????????? ????????????????????????
  ??????????

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Fast Atrial fibrillation

• Causes dysfunction of the sinus node
• ???????????,????????????????????????????????????
  ????????????

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• Symptoms  palpitations Dizziness,
• Fainting Fatigue Shortness of breath
  Breathing difficulty, Angina, Shock, Heart
  failure.
• ??????,???????????????????

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• ?????
• ?P???,?????(??,??,??????),???350-600?/???R-R????,
  ????180?/??????,?????????,????250?/??
  ?QRS?????QRS??????(????????????,???????,????)

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???????????????? A.?????? B.??????
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• AF with WPW
• particularly dangerous because conduction of
  impulses to ventricular may be by means of
  by-pass pathway rather than through the A-V node
  and excessive ventricular rates may lead to
  VF.Ventricular rates may up to 300beats/min.
• Digitalis and Verapamil are contraindicated(??),
  may result a faster ventricular rate.
• Electrical cardioversion is the first choice.
• RFCA
• PropafenoneAmiodarone

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Treatment

• control of the ventricular raterestoration
  sinus rhythm and prevention of emboli.
• 1.Electrical cardioversion to those with serious
  hemodynamic upset(such as angina,low pressure
  ,heart failure) and WPW syndrome.
• 50-150J
• 2.Administration of intravenous drugs, such as
  PropafenoneAmiodarone .

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• Chronic condition of AF.
• 1.Medication may include beta-blockers, calcium
  channel blockers, digitalis
• 2. blood thinners, such as heparin or Warfarine,
  Aspirine to reduce the risk of a thromboembolic
  event.
• 3. Some selected patients may require a
  radiofrequency ablation.

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Sinus arrest and SSS

• 1. Sinus arrest(????) ???????????????
• ??gt2s ??, gt 5s ??, gt 10s ?????
• 2. Sick sinus syndrome,SSS(????????)
• ?????????????????? ??
• ???? 1)?? HRlt50?/?
• 2)????????? 3)?????
• 4)????

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Serious atrioventricular block(AVB)

• Include type ? second-degree AVB and
  third-degree AVB
• Symptoms that are due to decreased cardiac
  output Dizziness,Fainting Confusion Fatigue
  Shortness of breath lying down Angina,Heart
  failure,Adams-stokes attacks .

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type ? second-degree AVB (31)
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third-degree AVB (?????????????)QRS???????,??39?/
?
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Treatment

• 1.Etiology therapy Treatment of AMI,
  correction of blood chemistries. To
  myocarditis or after surgery
• Dexamethasone 10-30mg/d ivdrip 3-5days.
• 2. Medications including
• Atropine 0.3-0.6mg im.or iv.
  every10-15 minutes ??????????????????,????????????
  ???,??????????????
• Isoproterenol(??????)1-2µg/min ivdrip

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• 3.An artificial pacemaker.
• Temporary /permanent transvenous pacemaker
• ????????????????????????????????????????????
  ????????????

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