?Wide Complex Tachycardia

1
?Wide Complex Tachycardia
2
Scenario 4

• 51 Year Old Male.
• Presents with 3 hours of chest/epigastric pain,
  nausea .
• PMHx GERD, Borderline HTN, 2 PPD smoker.
• To ED.

3
Initial ECG
4
Right Sided Chest Leads
5
ST Evolution
6
Treatment

• Aspirin, Clopidogrel, Nitrate, O2, ?BB, Statin.
• Heparin /- 2b/3A.
• Emergent Cath vs. lytics
• 100 Occlusion of Large Cx Marginal Branch.
• Stented.

7
Coronary Dominance
8
Scenario 5

• 84 Year Old Male
• Presents to PCP for fatigue.
• PMHx HTN, PAD.
• Occasionally dizzy.
• Fall for unexplained reason last week.

9
Initial ECG
10
Initial ECG
11
Rhythm Strip
12
Bradycardia Algorithm
13
Conduction system
14
Complete Heart Block

• No atrial impulses reach the ventricle.
• Thus, leads to escape rhythms.
• Junctional or ventricular (Narrow vs. wide).
• AV Node supplied by RCA in 90 of people.
• Etiology Increased vagal tone, fibrosis,
  ischemia, infiltrative disease, myocarditis, SBE,
  Myotonic MD, hyperkalemia, rate slowing drugs,
  ablations, alcohol septal ablations.

15
Complete Heart Block

• CHB is a Class 1 recommendation for a PPM
  irregardless of symptoms in the absence of a
  STEMI
• Other Class 1 Recommendations Advanced second
  degree AV Block, Mobitz 1 or 2 with symptoms,
  Mobitz 2 with wide QRS or chronic bifascicular
  block, exercise induced second or third degree AV
  Block in the absence of ischemia.

16
Treatment of CHB

• Correct reversible causes.
• Atropine 0.5mg IV (Max 3mg).
• Transcutaneous pacing.
• Epinephrine/Dopamine drips.
• Consider Glucagon if BB Overdose.
• Transvenous Pacing.
• Permanent Pacemaker.

17
Treatment of CHB
18
Scenario 6

• 68 YO Male
• PAF 2006
• Recurrence 7/2010- Converted spontaneously after
  IV Diltiazem and BB.
• Jan 2011 Awoken from sleep. Flip Flopping
• Abn Nuke distal IL ischemia.
• PMHx HTN, dyslipidemia.

19
Initial ECG
20
ED Management

• IV Diltiazem 25 mg bolus and 10 mg/hr gtt.
• BP drops to the 80s sys
• IVF and stop drip
• BP rebounds and drip restarted without bolus.
• BP drops 80s systolic.
• Why hypotensive?

21
Why hypotensive?

• ?Dry
• ?PE
• ?Coronary ischemia
• ?Tamponade
• ?Sepsis
• ?Aortic Stenosis
• ?Mitral Stenosis

22
Solution

• Took Metoprolol ER 150, Valsartan 320, Amlodipine
  10.
• 2 Liters of IVF
• Calcium Gluconate
• Resume IV Cardizem.
• ?Why not use Dig?
• ?Any argument for CV?

23
IV Diltiazem
24
Management

• PRECIPITANTS!!! (When did it occur?)
• CHADS21 (HTN)
• ?Heparin/Enoxaparin
• ?Warfarin/Dabigatran
• ?Cardioversion ? Need for TEE prior.
• ?AntiArrhythmic
• ?Ablation

25
Where do clots hide?
26
Left Atrial Appendage Thrombus
27
Post Cardioversion
28
CHADS2 Score

• CHF 1 point
• Hypertension 1 point
• Age gt 75 1 point
• DM 1 point
• Stroke/TIA/EP 2 points

29
Why Anticoagulate?
30
Scenario 7

• 30 YO Male.
• Presents with sharp, pleuritic chest pain.
• URI symptoms 3 weeks ago.
• Normal vitals. No fever.
• Mild leukocytosis, negative trop. Other labs WNL.
• Found leaning over his tray table in the ED.
• CXR unremarkable.
• Funny sound heard on heart auscultation.
• Called for ? STEMI although doubted by ED staff
  secondary to age.

31
Initial ECG
32
Acute Pericarditis-ECG Changes

• Stage 1 Diffuse ST Elevation/PR Depression.
• Stage 2 Normalization of above changes.
• Stage 3 Diffuse T wave Inversion.
• Stage 4 Normalization of T waves.
• Why are changes diffuse?
• How do you differentiate from a STEMI?
• What does ECHO show? Exam?

33
Acute Pericarditis - Etiologies

• Inflammatory/Autoimmune
• Drugs
• Metabolic
• Trauma
• Cardiac

• Radiation
• Malignancy
• Infectious
• idiopathic

34
Pericarditis - Treatment

• Treat underlying cause.
• Nsaid/Aspirin.
• Colchicine.
• Steroids.
• Pericardiocentesis.
• Pericardial Window.