- stable v. unstable (AMS, hypotensive, angina chest pain (ischemia), SOB (HF?, esp restrictive); unstsable->electricity; stable->ECG-> narrow (His purkinje) v wide (focal point spread via cell 2 cell/gap junctions; or bundle, or SVT w/ aberrancy (bundle with high heart rate; aberrancy means conducted other than His purkinje)-> regular v irregular -> identify rhythm Treat: underlying cause to correct? Rate v rhythm control (depends on etiology); anticoagulation Wide complex tachycardia Ddx- - Monomorphic VT - Polymorphic VT (ischemic v torsatdes) - SVT with aberrancy Tx- Amiodarone bolus 150mg over 10min, followed by gtt (careful of cardioversion) Unstable gets electricity (200J): synchronize CDV for SVT or monomorphic VT (organized rhythms), defib for VF Torsades: beta-agonist (isoproterenol, pacing) + Mg The wonkier it looks, the more likely its ischemic; the worse it looks, the worse it is Amiodarone is the DOC for almost all tachyarrythmia VT vs. SVT with aberrancy: Brugada criteria 1. Is there an absence of RS complex in all precordial leads (V1-V6)? (ex. neg deflection everywhere, or pos deflection everywhere) DIRECTION a. Yes: VT (SN 21%; Sp 100%); all neg or all pos- start from apex going up is VT b. NO 2. Is the R to S interval> 100msec (2.5 boxes/ wide) in one precordial lead? HOW DOES IT SPREAD THROUGH MYOCARDIUM (fast via His or slow via gap junction) a. Yes: VT (Sn66%, Sp: 98%) b. NO 3. Is there AV dissociation? a. Yes: VT (Sn 82%, Sp 98%) b. No (saying ventricle listens to atria) Polymorphic VT->torsade->Mg then isoprel Unstable narrow complex tachycardia Tx: peristable: try amiodarone; unstable: synchronized cardioversion Irregular (afib) v regular -> P waves (no- AVNRT, same- flutter, 3 different- MAT, Wonky (not positive in V2)- atrial tachy) Stable narrow complex tachycardia Dx: vagal (carotid massage, orbital pressure), adenosine Tx: depends on rhythm; usually BB or CCB Afib/Aflutter; sinus tach (treat underlying), AVnRT (BB/CCB, ablation), Atach (BB/CCB, ablation), MAT (CCB, ablation), WPW (procainamide/electricity->ablation; amio in real life) Adenosine: blocks AV node; purpose: reveal underlying atrial activity (because shh ventricle); dosing: 6mg->12 if no response Warning: 12 ECG (need to see the atrial activity-> the purpose); zoll pads, feels like Death, avoid in wpw Afib or aflutter - onset <48hr (clots unlikely exist; cardiovert w amio) v >48hr (clots likely exist; dont cardiovert): -rate control (<110bpm; dont need to get to perfect rate) - IV: Meoprolol, diltiazem (avoid esmolol b/c halflife too short, verapamil b/c halflife too long) - PO: all of the above - digoxin (careful in renal failure, Rx interactions): HF in afib; cardiomyopathy; good because doesnt cardiovert - rhythm control (cardioversion) - amiodarone (IV, gtt, PO) - DC synchron Amiodarone: mechanism: does everything; use: all tachy arrhythmias; pharmo: lipophilic- large Vd, long life - bolus: 150mg over 10 min (no limit on number of boluses because quickly goes into adipose; most beta-blockade so highest risk for hypotension) - 24hr gtt - load- amount to appropriately treat the arrhythmia, NOT to reach steady state in circulation o Atrial 6-8g, ventricular 10-12g - Maintenance: lowest effective (atrial 200, ventricle 400) - Rare acute lung injury
(Computing 14) A. Aguilera, D. Ayala (Auth.), Professor Dr. Guido Brunnett, Dr. Hanspeter Bieri, Professor Dr. Gerald Farin (Eds.) - Geometric Modelling-Springer-Verlag Wien (2001)