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7/25/2019 Diagnostic and Management Approach of Bardycardia_dr.yuli
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Diagnostic and Management
Approach of BardycardiaBudi Yuli Setianto, MD, PhD
FIHA, FINASIM, FAsCC, FAPSIC
Department of Cardiology and Vasculer Medicine Faculty ofMedicine Gadjah Mada University-Functional Medical StaffSardjito Hospital Yogyakarta
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Case Scenario
An 80-year-old woman reports
feeling weak and short of breath
for 2 hours while walking shortdistances. She feels exhausted
moving from the car to the ED
stretcher. On physical exam she
is pale and sweaty; HR = 35 bpm;BP = 90/60 mm Hg; RR = 18 rpm.
Rhythm: see next slide.
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80-Year-Old Woman:
Symptomatic Bradycardia
Identify A, B, and C
Which one is most likely
to be her rhythm?
3
A
B
C
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Rhythms to Learn
Sinus bradycardia
Heart blocks
1stdegree
2nddegree type I
2nddegree type II
3rddegree
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Cardiac Conduction System 1
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Left bundle branch
Posterior division
Anterior division
Purkinje fibersRight bundle branch
Bundle of His
AV node
Internodal pathways
Sinus node
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Cardiac Conduction System 2
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Rates of Intrinsic
Cardiac Pacemakers
Primary pacemaker
Sinus node (60-100 bpm)
Escape (Subsidiary) pacemakers
AV junction (40-60 bpm)
Ventricular (
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Determining the Rate
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Determining the Rate
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Analyzing Rhythm Strips
Key questions
Are QRS complexes present?
Are P waves present?
How is the P wave related to the
QRS complex?
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Relationship of P Waves and QRS
Complexes
Every P wave is followed by a QRS complex
with a normal PR interval
Every P wave is followed by a QRS complex but
the PR interval is prolonged
Some P waves are notfollowed by a QRS
complex; more P waves than QRS complexes
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What Is This Rhythm?
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Sinus Bradycardia
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What Is This Rhythm?
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First Degree AV Block
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Diagnosis?
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Second Degree AV Block Type I
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Diagnosis?
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Second Degree AV Block Type II
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What Is This Rhythm?
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Third Degree AV Block Type III
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Differentiation of Second- and
Third-Degree AV Blocks
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More Ps than QRSs
PR fixed?
no
QRSs thatlook alikeregular?
no
yes
yes
yes
2nd-degree AV blockFixed
Mobitz II
3rd-degree AV block
2nd-degree AV blockVariableMobitz I
Wenckebach
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Bradycardia Algorithm (1 of 2)
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Bradycardia
Heart Rate less than 60 bpm andinadequate for clinical condition
Maintain patent airway; assist breathing as needed
Give oxygen
Monitor ECG (identify rhythm), blood pressure, oximetry
Establish IV access
Serious signs or symptoms of poor
perfusion caused by the bradycardia
(eg. acute altered mental status, ongoing chest pain,
hypotension or other signs of shock)
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Bradycardia Algorithm (2 of 2)
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Observe/Monitor
Prepare for transvenous pacing Treat contributing causes Consider expert consultation
PoorPerfusion
AdequatePerfusion
Prepare for transcutaneous
pacing;use without delay for
high degree block (type II
second -degree block or third-
degree AV block)
Consider Atropine 0.5 mg/IV
while awaiting pacer. May
repeat to a total dose of 3 mg. If
ineffective, begin pacing.
Consider Epinephrine (2 to 10
g/min) or dopamine (2 to 10
g/kg/min infusion while
awaiting pacer or if pacing
ineffective.
Reminders
If pulseless arrest develops go to
Pulseless Arrest Algorithm Search for and treat possible contributing
factors:
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo/Hyper-kalemia
Hypoglycemia Hypothermia
Toxins
Tamponade, cardiac
Tension pneumothorax
Thrombosis (coronary or
pulmonary)
Trauma (hypovolemia, inc ICP)
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What Is This Rhythm?
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Treatment?
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Treatment?
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Transcutaneous Pacing
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Indications for
Transcutaneous Pacing
Hemodynamically unstable bradycardias
In the setting of AMI: sinus node dysfunction,
type II 2nd-degree block, 3rd-degree heart
block
Bradycardia with symptomatic ventricular
escape beats
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Transcutaneous Pacing
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Transcutaneous Pacing
The pacing rate is set at 80 beats per minute.
In conscious bradycardic patients, pacing isbegun in the demand mode at rates slightly faster
than the native rhythm and at minimal currentoutput
The current is gradually increased by 5 to 10 mAat a time until cardiac capture is documented,
which defines the pacing threshold. The finalcurrent output should be set at the pacingthreshold or 5 to 10 mA above it.
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Transcutaneous Pacing
In the setting of a bradysystolic arrest or with
unconscious patients, it is recommended to turn
the stimulating current to maximal output (200
mA) to ensure ventricular capture
Once capture is achieved, the current may be
gradually decreased until loss of capture, whichdefines the pacing current threshold
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Transcutaneous Pacing
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Transcutaneous Pacing:
Capture vs No Capture
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Pacing below threshold:no capture
Pacing above threshold:with capture
Pacing Spike
Capture: Spike + broad QRS
QRS: opposite polarity
25 Feb 88 Lead I Size 1.0 HR=41
25 Feb 88 Lead I Size 1.0 HR=43 35 mA
25 Feb 88 Lead I Size 1.0 HR=71 60 mA
Bradycardia: No Pacing
Pacing Below Threshold (35 mA): No Capture
Pacing Above Threshold (60 mA): With Capture (Pacing-PulseMarker )
Bradycardia: no pacing
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