Download Case Redlands August

Case Presentation
Ventricular Standstill
Ventricular Asystole with residual P
wave activity
29th August, 2012
History
• 85 year old female presented to Redland
hospital Emergency Department with a 4
week history of recurrent pre syncopal
episodes
• Lightheaded
• Dizzy
• Nausea
• Lasted no more than a few seconds
History
• Denies chest pain, palpitations, shortness of
breath, neurology or seizure activity
• Has never fully lost consciousness
• But with two of the episodes she did fall
• Has been otherwise well, eating, drinking and
no infective symptoms
Background
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Chronic obstructive pulmonary disease
Hypertension
Dyslipidemia
Gastro-oesophageal reflux disease
Denies history of ischaemic heart disease
Last in hospital 1952
Medications
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Indacaterol
Tiotropium
Ciclesonide
Irbesartan
Atorvastatin
Aspirin
Social
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Lives by herself in retirement village
Mobilises with a 4WW
Ex-smoker – quit 40 years ago
Occasional glass of wine
Examination
• Alert and oriented
• Blood pressure 132/68
• Pulse 110 on review but telemetry showed it
varied from 40 to 128 while in the emergency
department
• Heart sounds dual no murmurs
• Jugular venous pressure not elevated
• Remainder of physical examination unremarkable
Investigations
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Electrolytes and renal function normal
Full blood count normal
Troponin I - 0.01
CT brain done as an outpatient normal
CXR normal
Baseline ECG
Telemetry
Telemetry
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Several runs of complete heart block with
ventricular standstill overnight
Most were symptomatic: lightheadedness,
presyncope
No loss of consciousness
Impression
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Ventricular Standstill
Ventricular asystole with persistent p wave
activity
Unknown cause - likely old age
Diagnosis
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This as opposed to complete heart block
When QRS complex returned there was a
clear association between the P wave and
QRS and hence reflecting an intact AV node
Thus the cause was due to the ventricle being
unable to capture the impulse from the atria
Telemetry
Management
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Admitted HDU overnight on telemetry
Isoprenalin infusion 2mcg/minute started in
the AM
Morning transfer to PAH where a DDD
pacemaker was inserted the same day
Ambulance transfer had external pacing
available if needed
Discharged five days from PAH later with no
issues
Ventricular Standstill
• Pathophysiology
• Diagnosis
• Guidelines for Pacing
Conduction Pathway
(70x per minute)
(40-60x per minute)
(ventricle = 40x per minute)
Action Potentia Myocyte
QRS
ST
T wave
Pacemaker Action Potential
Causes
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Literature very scant
Hypoxemia, hyperkalemia, acute coronary syndromes
Closely associated with complete heart block
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Fibrosis and sclerosis of the cardiac skeleton associated with ageing
Ischaemic heart disease (40% of cases) - It is estimated that approximately 20 percent of patients
with an acute MI develop AV block: 8 percent with first degree; 5 percent with second degree; and
6 percent with third degree
Cardiomyopathy and myocarditis: SLE, viruses, Chagas
Congenital heart disease
Drugs: digoxin, calcium channel blockers(Verapamil, Diltiazem), beta blockers, amiodarone,
adenosine
Surgery/procedures - TAVI, VSD repair
Increased vagal tone e.g. carotid sinus massage
Numerous case reports: vagal nerve stimulation in the treatment of epilepsy,
defibrillator implantation and upper gastrointestinal variceal electrocoagulation
Escape Rhythm
• If third degree AV block occurs within the AV node, about
two-thirds of the escape rhythms have a narrow QRS
complex, ie, a junctional or AV nodal rhythm
• Block at the level of the bundle of His is also typically
associated with a narrow QRS complex
• Patients with trifascicular block have a sub-junctional escape
rhythm with a wide QRS complex
Escape Rate
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As a general rule, the more distal the block,
the slower will be the escape pacemaker.
Low pacemakers have a rate of 40 beats per
minute or less and often are unreliable,
resulting in a very slow rate or asystole.
Syncope is most common in this group
Signs and Symptoms
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Dizziness/lightheadedness
Presyncope
Syncope (Stokes-Adams attacks)
Ventricular tachycardia
Ventricular fibrillation
Exacerbation of the symptoms of heart
failure and angina pectoris
Management
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Correct reversible causes: myocardial ischemia, increased vagal tone, and drugs.
Multiple case reports have demonstrated this.
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Resolution of complete heart block after prednisolone in a patient with systemic
lupus erythematosus. Lupus [0961-2033] Lim, L-T Year:2005 Volume:14 Issue:7
Page:561 -563
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Complete heart block induced by intravenous metoclopramide. Anales de
medicina interna [0212-7199] Huerta Blanco, R
Year:2000 Volume:17
Issue:4 Page:222 -223 (Spanish)
Pharmacotherapy
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Emergent setting, atropine may also be effective by
reversing the decrease in AV nodal conduction induced by
vagal tone.
Australian therapeutic guidelines recommend:
Atropine 0.5 - 1.5mg IV can be given every 15 minutes
If atropine not effective and trancutaneous pacing not
available
Adrenalin infusion 2 - 10 mcg IV/minute or Isoprenaline
20mcg bolus followed by infusion at 1 - 4 mcg/hour
Pacing
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Transcutaneous pacing should be provided if
there is no resolution with pharmacotherapy
Most patients will need permanent pacing in
the absence of an acutely reversible cause
2008 American College of Cardiology/American Heart
Association/Heart Rhythm Society (ACC/AHA/HRS)
Levels of Evidence
Pacemaker Indications
• Class I Indication
• Permanent pacemaker implantation is indicated for third
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degree and advanced second-degree AV block at any
anatomic level in awake, symptom-free patients in sinus
rhythm, with documented periods of asystole greater than
or equal to 3.0 seconds or any escape rate less than 40 bpm,
or with an escape rhythm that is below the AV node. (Level
of Evidence: C)
I.e. pause > 3 seconds or pulse <40 or wide QRS escape with
no pre existing aberrancy
Pacemaker Indications
• Class I Indication
• Permanent pacemaker implantation is indicated for third
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degree and advanced second-degree AV block at any
anatomic level in awake, symptom-free patients with AF and
bradycardia with 1 or more pauses of at least 5 seconds or
longer. (Level of Evidence: C)
I.e. in AF the pause needs to be 5 seconds in absence of
symptoms (as opposed to 3 seconds in sinus rhythm)
Pacemaker Indications
• Class I Indication
• Permanent pacemaker implantation is indicated for third
degree and advanced second-degree AV block at any
anatomic level associated with bradycardia with symptoms
(including heart failure) or ventricular arrhythmias presumed
to be due to AV block. (Level of Evidence: C)
• I.e. if they have symptomatic heart block
Pacemaker Indications
• Class I Indication
• Permanent pacemaker implantation is indicated for third
degree and advanced second-degree AV block at any
anatomic level associated with arrhythmias and other
medical conditions that require drug therapy that results in
symptomatic bradycardia. (Level of Evidence: C)
• I.e. if they have another medical condition such as AF that
needs drug treatment and this cannot be modified then they
can have a pacemaker
Pacemaker Indications
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Class IIa
Permanent pacemaker implantation is
indicated for third degree and advanced
second-degree AV block at any anatomic
level associated with neuromuscular diseases
with AV block, such as myotonic muscular
dystrophy, Kearns-Sayre syndrome, Erb
dystrophy (limb-girdle muscular dystrophy)
Level of Evidence B
Pacemaker Indications
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Class IIa
Permanent pacemaker implantation is
indicated for asymptomatic persistent thirddegree AV block at any anatomic site with
average awake ventricular rates of 40 bpm or
faster if cardiomegaly or LV dysfunction is
present or if the site of block is below the AV
node. (Level of Evidence: B)
Pacemaker Indications
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Class IIa
Permanent pacemaker implantation is
indicated for secondor third-degree AV block
during exercise in the absence of myocardial
ischemia. (Level of Evidence: C)
Pacemaker Indications
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Class IIa
Permanent pacemaker implantation is
reasonable for persistent third-degree AV
block with an escape rate greater than 40
bpm in asymptomatic adult patients without
cardiomegaly. (Level of Evidence: C)
Pacemaker Indications
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Class IIa
Permanent pacemaker implantation is
reasonable for asymptomatic second-degree
AV block at intra- or infraHis levels found at
electrophysiological study. (Level of Evidence:
B)
Pacemaker Indications
• Class IIb
• Permanent pacemaker implantation may be considered for
neuromuscular diseases such as myotonic muscular
dystrophy, Erb dystrophy (limb-girdle muscular dystrophy),
and peroneal muscular atrophy with any degree of AV block
(including first-degree AV block), with or without symptoms,
because there may be unpredictable progression of AV
conduction disease. (Level of Evidence: B)
Pacemaker Indications
• Class III
• Permanent pacemaker implantation is not
indicated for asymptomatic first-degree AV
block. (Level of Evidence: B)
Pacemaker Indications
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Class III
Permanent pacemaker implantation is not
indicated for asymptomatic type I seconddegree AV block at the supra-His (AV node)
level or that which is not known to be intraor infra-Hisian. (Level of Evidence: C)
Pacemaker Indications
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Class III
Permanent pacemaker implantation is not
indicated for AV block that is expected to
resolve and is unlikely to recur 100 (e.g., drug
toxicity, Lyme disease, or transient increases
in vagal tone or during hypoxia in sleep apnea
syndrome in the absence of symptoms).
(Level of Evidence: B)
Choice of Pacemaker
• VVI pacing was most commonly used in the past, and is still
used in the emergent setting for temporary pacing
• Easier to implant and less expensive
• Synchrony between atrial and ventricular contraction is lost,
which is hemodynamically unfavorable.
• In order to maintain physiologic pacing, dual chamber pacing
is recommended.
• The advantages of physiologic pacing may be less significant
in very elderly patients with AV block
Pacing Modalities
Case Report
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Describe a case in which the haemodynamic
data from manual external, transthoracic and
transvenous pacing in ventricular asystole
was compared.
Case Report
• A 55-year-old Caucasian female with insulin treated type 2
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diabetes mellitus presented to the emergency department
with a 3-day history of diarrhoea, vomiting, abdominal pain
and malaise
Taken for an abdominal CT scan
Suffered a sudden asystolic cardiac arrest
Return of spontaneous circulation occurred after 3 min
advanced cardiac life support and the patient was admitted
to the intensive care unit following intubation and the
institution of intermittent positive pressure ventilation.
She required an infusion of adrenaline (epinephrine) at 0.14
μg/kg per min which was subsequently changed to
noradrenaline (norepinephrine) at 0.4 μg/kg per min.
Method
• The patient developed ventricular asystole with persisting
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electrocardiographic p wave activity.
2 boluses atropine - no effect
Manual external pacing (cardiac percussion) was commenced over
the lower end of the sternum at a rate of 52 beats/min and
electrical capture was evident electrocardiographically. This
generated a palpable pulse and a blood pressure (BP) of 108/62
mmHg with a mean arterial pressure (MAP) of 78 mmHg.
Transthoracic pacing resulted in capture at 90 mA and produced a
BP of 140/71 (MAP 105) mmHg at a rate of 80 beats/min.
Transvenous pacing resulted in an BP of 148/76 (MAP 112) mmHg
at a heart rate of 90 beats/min.
Results
Conclusion
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Our data demonstrate that manual external
pacing is as effective as transvenous and
transthoracic pacing, as long as electrical
capture occurs. Training in resuscitation
should stress the usefulness of this technique
as a temporary measure while more
definitive pacing methods are prepared.
Critique
One patient
Emergency environment
Did not compare percussion to standard CPR
The End