Handling Arrhythmias

Diagnosing Dysrhythmias

Amal Mattu, MD Professor and Vice Chair Dept. of Emergency Medicine University of Maryland School of Medicine Baltimore, Maryland [email protected]

Diagnosing Dysrhythmias

Amal Mattu, MD Lectures.umem.org/SEMA [email protected]

Outline

• Brief overview of diagnosis – Bradycardias and AV Blocks – Tachycardias – Other dysrhythmias • Cases Bradycardias and AV Blocks • Bradycardias – sinus rhythm • arises from the sinus node • usual sinus rate is > 60 • “sinus” = upright P waves in I, II, III, aVF – junctional rhythm • arises from the AV junction • usual junctional rate is 40-60 – ventricular rhythm • usual rate is 20-40 • wide-complex rhythm

Bradycardias and AV Blocks • Bradycardias – sinus rhythm • arises from the sinus node • usual sinus rate is > 60 • “sinus” = upright P waves in I, II, III, aVF – junctional rhythm • arises from the AV junction • usual junctional rate is 40-60 – ventricular rhythm • usual rate is 20-40 • wide-complex rhythm

Sinus Bradycardia (Rate 45)

Junctional Rhythm (Rate 50)

Ventricular Rhythm (Rate 32)

Atrioventricular Blocks

• 1st degree AV block – 1 P wave for every QRS complex – PR intervals prolonged (> 0.2 sec) but constant 1st Degree AV Block

Atrioventricular Blocks

• 2nd degree AV block – Type I (Mobitz I, Wenkebach) • P waves constant • PR intervals gradually increase, leading up to a dropped QRS complex 2nd Degree AV Block, Type I

Atrioventricular Blocks

• 2nd degree AV block – Type II (Mobitz II) • P waves constant • PR intervals are constant, but there are dropped QRS complexes 2nd Degree AV Block, Type II

2nd Degree AV Block (2:1)

Atrioventricular Blocks

• 3rd degree AV block (complete heart block) – P waves constant – QRS complexes constant – PR intervals vary • there is no apparent association between the P waves and the QRS complexes 3rd Degree (Complete) AV Block

Tachycardias

• Diagnosis is based on – Narrow or wide QRS complexes – Regular or irregular QRS complexes – Atrial activity (P-waves or flutter waves) Tachycardias

• Narrow regular tachycardias – sinus tachycardia • one P wave with every QRS – supraventricular tachycardia • P waves may be hidden or may follow the QRS complex (“retrograde atrial activity”) – atrial flutter (usually with 2:1 conduction) • 2 atrial beats for every QRS complex • usually see “sawtooth” pattern of atrial beats • must look carefully for atrial activity; is often obvious in only 1 or 2 leads Tachycardias

Sinus Tachycardia Supraventricular tachycardia

Atrial Flutter with 2:1 Conduction

Tachycardias

• Narrow irregular tachycardias – atrial fibrillation • no distinct regular atrial activity – atrial flutter with variable conduction • regular atrial activity (F-waves) present – multifocal atrial tachycardia • P-waves present, but irregular and with ≥ 3 different morphologies • usually associated with pulmonary disease, especially COPD, and theophylline toxicity Tachycardias

Atrial Flutter With Variable AV Conduction

Multifocal Atrial Tachycardia

Tachycardias

• Wide regular tachycardias – sinus tachycardia with aberrant conduction • P-waves present – ventricular tachycardia (VT) • P-waves often hidden, but occasionally seen (AV dissociation) • ventricular rate must be > 120 bpm – supraventricular tachycardia (SVT) with bundle branch block • P-waves often hidden Tachycardias

Supraventricular Tachycardia

Supraventricular Tachycardia (Baseline ECG)

Tachycardias

• Wide regular tachycardias – Important points: • No reliable way of ruling out VT on 12-lead ECG • Always assume a regular wide complex tachycardia without distinct P-waves is VT and treat as VT! Wide Regular Tachycardias

• Ventricular tachycardia • Ventricular tachycardia • Ventricular tachycardia • Ventricular tachycardia • Sinus tachycardia with BBB • SVT with BBB Wide Regular Tachycardias

• Ventricular tachycardia • Ventricular tachycardia • Ventricular tachycardia • Ventricular tachycardia • Sinus tachycardia with BBB • SVT with BBB No!! Tachycardias

• Wide irregular tachycardias – atrial fibrillation with bundle branch block • ventricular rate rarely exceeds 200 beats/min • QRS complexes have the identical morphology – atrial fibrillation with pre-excitation (e.g. Wolff-Parkinson-White syndrome) • ventricular rate may approach 300 beats/min! • at very rapid rates, appears regular (but it’s not!) – often misdiagnosed as VT • QRS complexes vary in morphology Tachycardias

Atrial Fibrillation With LBBB

Atrial Fibrillation With WPW

Other Arrhythmias

• Polymorphic ventricular tachycardia – rapid regular wide QRS complexes – QRS complex morphology varies in amplitude or shape – Torsades de pointes  Other Arrhythmias

• Polymorphic ventricular tachycardia – rapid regular wide QRS complexes – QRS complex morphology varies in amplitude or shape – Torsades de pointes  PVT associated with prolonged QT Polymorphic Ventricular Tachycardia Polymorphic Ventricular Tachycardia (Torsades de pointes) Other Arrhythmias

• Accelerated idioventricular rhythm (AIVR) – often referred to as “slow ventricular tachycardia” – ventricular rhythm with rate between 40– 120 beats/min. – often misdiagnosed as VT when rates are 90-120 beats/min – often associated with reperfusion after acute myocardial infarction Accelerated Idioventricular Rhythm (AIVR)

Other Arrhythmias

• Ventricular fibrillation – extremely rapid disorganized ventricular activity – by definition, no pulse is present, patient is unresponsive – immediate defibrillation is essential! Ventricular Fibrillation Ventricular Fibrillation Summary

• Bradycardias and AV Blocks – diagnosis based on close attention to the PR intervals and the relationship between P wave and QRS complexes • Tachycardias – diagnosis based on • narrow vs. wide QRS complexes • regular vs. irregular • presence of atrial activity CASES #1: 48 yo. man started new BP medicine, now c/o lightheadedness; SBP 80.

#1: SR, 1st AVB, VR 95

#2: 57 yo. man who took too much of his BP medicine; SBP 80.

#2: JR, VR 40

#3: 70 yo. woman with 4 days of nausea, vomiting, malaise; SBP 80.

#3: ST, Mobitz I, VR 94

#4: 62 yo. man with SOB and chest pain; SBP 80.

#4: ST, 3rd degree AVB, JER, VR 48

#5: 85 yo. woman with syncope; SBP 120.

#5: SR, Mobitz II with 3:2 conduction, VR 50, LBBB

#6: 48 yo. man with chest pain; SBP 80.

#6: SR, 2nd degree AVB with 2:1 conduction, VR 40

#7: 44 yo. man c/o weakness; SBP 60.

#7: VER (rate 38), hyperkalemia

ECG Findings in Hyperkalemia

• Peaked Ts • Widening of the QRS • Prolonged PR • Flattening and eventual loss of Ps • Advanced AV blocks and sinus pauses • Pseudo-ACS  new BBBs, ST changes • Sine wave ECG Findings in Hyperkalemia

• Peaked Ts • Widening of the QRS • Prolonged PR • Flattening and eventual loss of Ps • Advanced AV blocks and sinus pauses • Pseudo-ACS  new BBBs, ST changes • Sine wave Severe Hyperkalemia

Severe Hyperkalemia Severe Hyperkalemia Severe Hyperkalemia Severe Hyperkalemia

Severe Hyperkalemia Moderate Hyperkalemia

After treatment…

Severe Hyperkalemia

Hyperkalemia (K+ 8.5)

Hyperkalemia (K+ 8.0)

ECG Findings in Hyperkalemia

• Peaked Ts • Widening of the QRS • Prolonged PR • Flattening and eventual loss of Ps • Advanced AV blocks and sinus pauses • Pseudo-ACS  new BBBs, ST changes • Sine wave #8: 65 yo. woman had a syncopal episode, now awake; SBP 78.

#8: SR, Mobitz I, VR 52, RBBB/LAFB

#9: 42 yo. woman with weakness; SBP 120.

#9: Mobitz II?

Mobitz I Mobitz I Mobitz I Mobitz I Mobitz I Mobitz I Mobitz II Mobitz II Mobitz II Mobitz II Mobitz II Mobitz II Mobitz II #9: 42 yo. woman with weakness; SBP 120.

#9: 42 yo. woman with weakness; SBP 120.

#9: SB, nonconducted PACs, VR 37

Nonconducted PACs misdiagnosed as Mobitz II

Nonconducted PACs misdiagnosed as Mobitz II Nonconducted PACs misdiagnosed as Mobitz II Nonconducted PACs misdiagnosed as Mobitz II Nonconducted PACs misdiagnosed as Mobitz II

Nonconducted PACs misdiagnosed as Mobitz II

Courtesy Steve Bohan, MD #10: 67 yo. woman with lightheadedness and nausea; SBP 70.

#10: Atrial flutter with variable AV conduction, VR 40

#11: 65 yo. man after syncope, now asymptomatic; SBP 120.

#11: ST, 3rd degree AVB, JER, VR 40

#12: 39 yo. man with palpitations and lighteadedness; SBP 130

#12: Atrial flutter with 2:1 conduction, VR 140 (misDx’d as ST)

Atrial Flutter Misdiagnosis

Always look for atrial flutter when the ventricular rate is 150 + 20!

Look for the flutter waves in all 13 leads, especially V1! Atrial Flutter Misdiagnosed As Sinus Tachycardia

Atrial Flutter Misdiagnosed As Supraventricular Tachycardia

Atrial Flutter Misdiagnosed As Sinus Tachycardia

Atrial Flutter Misdiagnosed As Supraventricular Tachycardia

Atrial Flutter Misdiagnosed As Sinus Tachycardia

#13: 60 yo. woman with lightheadedness; SBP 140.

#13: Atrial fibrillation, VR 120, RBBB

#14: 65 yo. man with COPD exacerbation; SBP 75.

#14: MAT, VR 130

#15: 45 yo. man with history of CAD; SBP 120.

#15: VT, rate 180

#16: 38 yo. woman with palpitations and lightheadedness; SBP 110.

#16: SVT, VR 210

#17: 64 yo man with nausea and vomiting; SBP 115

#17: Atrial Fibrillation?????

73 yo woman with cough and wheezing

PACs  Atrial Trigeminy

53 yo man with vomiting and diarrhea

Junctional Trigeminy

95 yo woman with vomiting

Atrial Bigeminy

Sinus Rhythm, then Junctional Bigeminy

Mobitz I

Courtesy Steve Bohan, MD Mobitz II Causes of Grouped Beats (“Clumps”)

1. Premature contractions • often cause pauses after the clump • clumps of 2?  think bigeminy • clumps of 3?  think trigeminy 2. 2nd degree AV block • Mobitz I or Mobitz II

Causes of Grouped Beats (“Clumps”)

1. Premature contractions • often cause pauses after the clump • clumps of 2?  think bigeminy • clumps of 3?  think trigeminy 2. 2nd degree AV block • Mobitz I or Mobitz II

Anytime the rhythm is irregular, look for regular irregularity (clumps)! #17: 64 yo man with nausea and vomiting; SBP 115

#17: Atrial Fibrillation?????

#17: Atrial Fibrillation????? Look in all leads!!!

#17: ST with Mobitz I, VR 110 (misDx’d as atrial fibrillation)

Causes of Grouped Beats (“Clumps”)

1. Premature contractions • often cause pauses after the clump • clumps of 2?  think bigeminy • clumps of 3?  think trigeminy 2. 2nd degree AV block • Mobitz I or Mobitz II

Causes of Grouped Beats (“Clumps”)

1. Premature contractions • often cause pauses after the clump • clumps of 2?  think bigeminy • clumps of 3?  think trigeminy 2. 2nd degree AV block • Mobitz I or Mobitz II

Anytime the rhythm is irregular, look for regular irregularity (clumps)! Be careful of misdiagnosing atrial fibrillation! Be wary of “atrial fibrillation!”

1. The most over(mis-)diagnosed tachydysrhythmia 2. Before you dx Afib, take another look! #18: 47 yo. man with chest pressure; SBP 85.

#18: 47 yo. man with chest pressure; SBP 85.

#18: Atrial flutter with variable AV conduction, VR 167

#19: 22 yo. man with vomiting and diarrhea for 5 days, now with lightheadedness; SBP 75. #19: ST, VR 170 #20: 75 yo. man c/o palpitations and chest pain; SBP 80.

#20: SVT, VR 154

#21: 55 yo. woman c/o 24 hours of palpitations and lighheadedness; SBP 75.

#21: Atrial fibrillation, VR 152

#22: 57 yo. man 1 hour after thrombolytics for AMI; SBP 115.

#22: AIVR, VR 105

#23: 45 yo. alcoholic with syncopal episodes; suddenly loses pulses.

#23: Torsades de pointes; treatment after defibrillation???

#24: 26 yo. man with palpitations and severe lightheadedness; SBP 80.

#24: WPW with Atrial Fibrillation

WPW Syndrome WPW Syndrome

• Ventricular pre-excitation – 0.1–0.3% population – Classic triad • shortened PR interval • widened QRS interval • delta wave WPW Syndrome — NSR Normal Conduction WPW Syndrome WPW with Atrial Fibrillation

WPW with Atrial Fibrillation

Atrial Fibrillation With RBBB

WPW with Atrial Fibrillation

Atrial Fibrillation With LBBB

WPW with Atrial Fibrillation

WPW With Atrial Fibrillation WPW With Atrial Fibrillation WPW with Atrial Fibrillation

WPW with Atrial Fibrillation

WPW With Atrial Fibrillation

WPW with Atrial Fibrillation

• ECG appearance – Irregularly irregular tachycardia – Wide QRS complexes – QRS morphologies vary – Rates may approach 300 BPM • Treatment with AV nodal blockers can be deadly!

WPW with Atrial Fibrillation

• Treatment with amiodarone resulted in patient decompensation – Boriani, et al (Am Heart J, 1996) – Gaita, et al (Drugs, 1992) – Schutzenberger, et al (Int J Cardiol, 1987) – Sheinman, et al (BMJ, 1982) WPW with Atrial Fibrillation

Summary

Remember…

• Just because electrocardiography is a basic skill in EM… Remember…

• Just because electrocardiography is a basic skill in EM doesn’t mean that our skills should be basic. Remember…

• Just because electrocardiography is a basic skill in EM doesn’t mean that our skills should be basic. • You must be the experts in electrocardiography! Questions/Comments: [email protected]

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