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Cardiac Arrhythmias Co-assistenten 2014-2015 Dr. L. Al tmimi Department of anaesthesia University Hospitals Leuven 1 Cardiac Arrhythmias The normal ECG • Regular narrow-complex rhythm • Rate 60-100 bpm • Each QRS complex is proceeded by a P wave • P is upright in lead II & down going in lead aVR 2 Cardiac Arrhythmias The normal ECG • P wave: the sequential activation of the right & left atria. • QRS complex: right & left ventricular depolarization • ST-T wave: ventricular repolarization • U wave: origin for this wave is not clear - but probably represents "after depolarizations" in the ventricles 3 Cardiac Arrhythmias The normal ECG 4 Cardiac Arrhythmias The normal ECG • PR interval: time from onset of atrial depolarization to onset of ventricular depolarization. • QRS duration: duration of ventricular muscle depolarization. • QT interval: duration of ventricular depolarization & repolarization • RR interval: duration of ventricular cardiac. • PP interval: an indicator of atrial rate. 5 Cardiac Arrhythmias The normal ECG • PR Interval: 0.12 - 0.20 sec • QRS Duration: 0.06 - 0.10 sec • QT Interval (QT < 0.40 sec at HR = 70) • Poor Man's Guide to upper limits of QT: For HR = 70 bpm, QT<0.40 sec; for every 10 bpm increase above 70 subtract 0.02 sec, and for every 10 bpm decrease below 70 add 0.02 sec. For example: QT < 0.38 @ 80 bpm QT < 0.42 @ 60 bpm • Frontal Plane QRS Axis: +90° to -30° (in adult) 6 Cardiac Arrhythmias The normal ECG 7 Cardiac Arrhythmias The Sinoatrial node (SA node) • Is the primary pacemaker of the heart • These cells lies on the wall of the right atrium near superior vena cave entrance 8 Cardiac Arrhythmias Other cells exhibit automaticity are found in • Along the sulcusterminalis • In the coronary sinus ostium • Within the AV junction • In purkinje system 9 Cardiac Arrhythmias The atrioventricular node (AV node) • Specialized tissue lies between the atria and the ventricles near the opening of coronary sinus. • Conduct impulse from atria to ventricles. 10 Cardiac Arrhythmias 11 Cardiac Arrhythmias Mechanism of arrhythmia • Abnormal automaticity • Abnormal cardiac conduction • Or both 12 Cardiac Arrhythmias Causes of arrhythmia in operation room are not always possible to determine because of : • Physiologic imbalance • Effects of multiple drugs • Underlying myocardial disease 13 Cardiac Arrhythmias Mechanism of arrhythmia 14 Cardiac Arrhythmias Causes or risk factors of abnormal rhythm • Ischemia • Hypoxia • Myocardial injury • Sever hypothermia • Excessive catecholamine exposure • Acute electrolytes imbalance • Drug toxicity • Endocrine disease e.g. thyroid • Others 15 Cardiac Arrhythmias Sinus rhythms • Sinus bradycardia • Sinus tachycardia • Sinus arrhythmia 16 Cardiac Arrhythmias Sinus bradycardia • pulse : <60/min; rhythm: regular • P wave: normal, QRS : normal • If the HR<40 mostly not good tolerated • Treatment: • according to the causes • Atropine, Isoprenaline, P.M. 17 Cardiac Arrhythmias Sinus bradycardia 18 Cardiac Arrhythmias Causes of bradycardia • medication e.g. neostigmin, myoplegin , etc. • diseases e.g. hypothyroidism, after MI • hypothermia & hypoxia • halothane or gas anaesthesia in children • vagal stimuli • increased intracranial pressure • others 19 Cardiac Arrhythmias Sinus tachycardia • Heart rate >100 to 180/min • Rhythm is regular • P wave is normal • QRS is also : normal • Treatment depends on the causes • Beta blocker 20 Cardiac Arrhythmias Causes of sinus tachycardia • light anaesthesia, hypovolemia • pain, anxiety • hyperthyroidism • medication e.g. atropine • fever & anaemia • etc. 21 Cardiac Arrhythmias Sinus arrhythmia • Normal increase in HR occurs during inspiration, more seen in children • Rhythm is irregular • Normal QRS after each wave • No treatment is required 22 Cardiac Arrhythmias Atrial rhythms • Premature atrial complexes • Atrial flutter • Atrial fibrillation • Supraventricular tachycardia & nodal rhythm • Wolff-Parkinson-White (WPW) 23 Cardiac Arrhythmias Premature atrial complexes • Occur as single or repetitive events and have unifocal or multifocal origins. • The ectopic P wave is often hidden in the ST-T wave of the preceding beat. 24 Cardiac Arrhythmias Atrial flutter • Atrial rate between 250-350 bpm • A saw-tooth appearance (F waves) is in leads II, III, aVF &V1. • Variable degrees of AV block is 25 Cardiac Arrhythmias Atrial flutter • Usually results from a re-entrant circuit located totally within the atrial wall. • It is generally associated with heart disease - e.g. rheumatic heart disease (with mitral stenosis). • Hemodynamic compromise may warrant electrical cardioversion. 26 Cardiac Arrhythmias Atrial flutter treatment • Digoxine • Synchronal defibrillation • Beta-blocker • Verapamil • Amiodarone 27 Cardiac Arrhythmias Atrial fibrillation (AF) • Most common arrhythmia; risk increases with age. • Irregular fibrillating atrial waves at a rate of 300-600 bpm, best seen in leads II, III, aVF &V1. • Absence of P waves • Fibrillation is may caused by numerous microentry circuits within the atrial muscle. • Ventricular rate is irregularly irregular with AV block 28 Cardiac Arrhythmias Atrial fibrillation (AF) 29 Cardiac Arrhythmias Clinical significance of AF • AF is usually associated with chronic heart disease. • Also in hyperthyroidism, pulmonary embolism & COPD • DC may be required in the acute cases with hemodynamic compromise. • Anticoagulation is always necessary 30 Cardiac Arrhythmias AF Differential diagnosis includes • Atrial flutter with an irregular ventricular response • Multifocal atrial tachycardia which is usually irregular Rx: • Digoxine • Amiodarone • Beta-blocker • Verapamil • Synchronal defibrillation 31 Cardiac Arrhythmias Supraventricular tachycardia (SVT) • Is a rapid rhythm of the heart in which the origin of the electrical signal is either the atria or the AV node. 32 Cardiac Arrhythmias Possible symptoms of SVT • Pulse rate of 140 – 200/ min or faster. • Palpitations & Angina may be triggered by an episode of SVT. • Dizziness & Dyspnoea Treatment • Verapamil, beta blocker, or even Amiodarone • Synchronic defibrillation in some occasion 33 Cardiac Arrhythmias Junctional rhythm • HR : variable, 40 tot 180/min • Rhythm : regular • P wave: High nodal before QRS Mid nodal in QRS Low nodal after QRS • QRS : normal 34 Cardiac Arrhythmias Junctional tachycardia • The AV node initiates electrical activity in the heart. • An ECG of a Junctional rhythm commonly presents with an inverted "P" wave due AV nodal origin of electrical signal 35 Cardiac Arrhythmias Treatment of junctional rhythm • No treatment is usually needed unless low cardiac output • Atropine or isoprenaline if junctional bradycardia • Deeping of the anaesthesia • Beta-blocker in nodal tachycardia 36 Cardiac Arrhythmias Wolff-Parkinson-White (WPW) syndrome • Is a congenital abnormality. • Presence of abnormal conductive tissue between the atria and the ventricles. • Is often associated with supraventricular tachycardia (SVT). 37 Cardiac Arrhythmias Wolff-Parkinson-White (WPW) syndrome 38 Cardiac Arrhythmias Wolff-Parkinson-White (WPW) syndrome • Presence of a short PR interval (<120 ms) • A wide QRS complex of longer than 120 milliseconds with a slurred onset of the QRS waveform producing a delta wave in the early part of QRS • Secondary ST-T wave changes 39 Cardiac Arrhythmias Treatment of WPW • Asymptomatic patients with the WPW shown are not treated. Drug therapy: according to the arrhythmia associated with WPW. Digoxine is contraindicated in WPW with AF. Amiodarone or procainamide may help. Electrical ablation • Symptomatic tachyarrhythmias • Occupations in which the development of symptoms would put themselves or others at risk (e.g. truck drivers or airline pilots • Selected asymptomatic patients Surgical ablation 40 Cardiac Arrhythmias Ventricular arrhythmias • Ventricular extrasystole • Ventricular tachycardia • Ventricular fibrillation 41 Cardiac Arrhythmias Ventricular extrasystole • Also called premature ventricular contraction (PVC) or ventricular premature beat (VPB) • Is a form of irregular heart beat in which the ventricle contracts prematurely 42 Cardiac Arrhythmias Possible triggers for ventricular extrasystole ( PVC ) • Anxiety/Stress • Chocolate ,Caffeine, Cocaine or other stimulant • Calcium/magnesium imbalance • Dehydration , Exercise, Hormonal imbalance • Hypercapnia (CO2 poisoning) • Hyperstimulation of the Vagus nerve • Lack of sleep/exhaustion 43 Cardiac Arrhythmias What is this arrhythmia? Ventricular tachycardia usually caused by reentry, and most commonly seen in patients following myocardial infarction. 44 Cardiac Arrhythmias Ventricular tachycardia • HR : 100 tot 300/min • Rhythm: regular • P top : through VT • QRS :wide complex 45 Cardiac Arrhythmias Ventricular tachycardia • VT can be monomorphic or polymorphic with prolong QT interval (torsade de pointes ) 46 Cardiac Arrhythmias Ventricular tachycardia (VT) treatment • Synchronous defibrillation • Xylocaïne • Bretyllium • Amiodarone • Beta-blocker 47 Cardiac Arrhythmias Ventricular arrhythmias: “ Torsade de pointes” Rx: • Withdrawal of any offending drugs and correction of electrolyte abnormalities • Intravenous magnesium sulfate • Potassium repletion to 4.5 to 5 mmol/liter • Beta blockers combined with cardiac pacing as acute therapy for patients with TdP and sinus bradycardia • Intravenous lidocaine • Non-synchronous defibrillation 48 Cardiac Arrhythmias Ventricular tachycardia 49 Cardiac Arrhythmias Ventricular fibrillation • Ventricular fibrillation has been described as "chaotic asynchronous fractionated activity of the heart" (Moe et al. 1964). • No cardiac output • Treatment is : CPR 50 Cardiac Arrhythmias Rhythms Produced by Conduction Block • AV Block (relatively common) – 1st degree AV block – 2nd degree AV block Type 1 – 2nd degree AV block Type 2 – 3rd degree AV block • SA Block (relatively rare) 51 Cardiac Arrhythmias 1st Degree AV Block • Prolongation of the PR interval, which is constant. • All P waves are conducted 52 Cardiac Arrhythmias 2nd Degree AV Block: Mobitz I or Wenckebach block • Progressive prolongation of the PR interval until a P wave is not conducted. 53 Cardiac Arrhythmias 2nd Degree AV Block: Mobitz II • Constant PR interval with intermittent failure to conduct 54 Cardiac Arrhythmias 3rd Degree (Complete) AV Block • No relationship between P waves and QRS complexes • Relatively constant PP intervals and RR intervals • Greater number of P waves than QRS complexes 55 Cardiac Arrhythmias Bundle branch block 56 Cardiac Arrhythmias Right bundle branch block 57 Cardiac Arrhythmias Left bundle branch block 58 Cardiac Arrhythmias Left bundle branch block 59 Cardiac Arrhythmias Left bundle branch block Patient with LBBB in whom a PA catheter is being placed may need availability of transcutaneous PM because of the risk of inducing Right BBB & thus complete heart block during passage of the PA catheter 60 Cardiac Arrhythmias success 61