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Ventricular Arrhythmias. EMS Professions Temple College. Analyze the Rhythm. Analyze the Rhythm. Analyze the Rhythm. Premature Ventricular Complexes (PVCs). Definitions Early depolarization of the ventricles Occur as a result of automaticity or reentry - PowerPoint PPT Presentation
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Ventricular ArrhythmiasVentricular Arrhythmias
EMS Professions
Temple College
Analyze the RhythmAnalyze the Rhythm
Analyze the RhythmAnalyze the Rhythm
Analyze the RhythmAnalyze the Rhythm
Premature Ventricular Premature Ventricular Complexes (PVCs)Complexes (PVCs)
Definitions Early depolarization of the ventricles Occur as a result of automaticity or reentry A PVC is a characteristic of an underlying
ECG rhythm PVC is not the name of a dysrhythmia
Premature Ventricular Premature Ventricular ComplexesComplexes
Causes Hypoxia Myocardial Ischemia Electrolyte Imbalance Digitalis Toxicity Stimulants Chronic Heart Disease (CHF, COPD)
Premature Ventricular Premature Ventricular Complexes (PVCs)Complexes (PVCs)
Characteristics Complex is earlier than expected Wide QRS (wide is not always ventricular) OFTEN has a compensatory pause Usually irregular Not preceded by a P wave T wave opposite deflection May or may not result in perfused beat
Premature Ventricular Premature Ventricular Complexes (PVCs)Complexes (PVCs)
More Terms to Know Unifocal, Multifocal R on T Phenomenon Bigeminy, Trigeminy, Quadrigeminy,
Couplet
Premature Ventricular Premature Ventricular Complexes (PVCs)Complexes (PVCs)
PVCs are not always dangerous Common for some people Consider treating PVCs if:
>6/minute associated with: Severe Chest pain Hypotension, Decreased Perfusion Shortness of Breath
Premature Ventricular Premature Ventricular Complexes (PVCs)Complexes (PVCs)
Treat PVCs if consistently see any of the following with other symptoms: Multifocal Ventricular Couplets Runs of Ventricular Tachycardia R on T Phenomenon (Malignant PVCs)
Premature Ventricular Premature Ventricular Complexes (PVCs)Complexes (PVCs)
Management (Rate <60) Oxygen & Ventilation are initial treatments
for ALL ectopic beats ECG Monitor, IV NS TKO
assess the underlying rhythm
Treat like bradycardia Atropine TCP Dopamine
Premature Ventricular Premature Ventricular Complexes (PVCs)Complexes (PVCs)
Management (Rate >60) Oxygen & Ventilation are initial treatments for
ALL ectopic beats ECG Monitor, IV NS TKO
assess the underlying rhythm
If symptomatic (see previous):
Premature Ventricular Premature Ventricular Complexes (PVCs)Complexes (PVCs)
Management (Rate >60) Lidocaine
IV Bolus, 1 - 1.5 mg/kg Infusion, 1 - 4mg/min Repeat IV push 0.5 - 0.75 mg/kg every 5 minutes
to 3 mg/kg max Increase Infusion 1mg/min for every 1mg/kg IV
bolus given
Premature Ventricular Premature Ventricular Complexes (PVCs)Complexes (PVCs)
Management (Rate >60) Procainamide
20 mg/min IV until: PVCs suppressed 17 mg/kg given Hypotension occurs QRS widens by 50% or more
Continuous infusion at 1 - 4 mg/min
Premature Ventricular Premature Ventricular Complexes (PVCs)Complexes (PVCs)
Management (Rate >60) Bretylium
IV push, 5 mg/kg slowly Infusion, 1 - 2 mg/min Used less frequently today due to supply shortage
Analyze the RhythmAnalyze the Rhythm
Idioventricular RhythmIdioventricular Rhythm
Causes Myocardial ischemia Hypoxia High vagal tone Drug effects
Idioventricular RhythmIdioventricular Rhythm
Characteristics A ventricular focus takes over as an escape
pacemaker site Rate 20 - 40 bpm Wide QRS complexes No P waves
Idioventricular RhythmIdioventricular Rhythm
Management Slow rate will probably decrease cardiac
output Usually a later and often pre-terminal rhythm If symptomatic, treat as unstable bradycardia Do NOT give Lidocaine or other ventricular
antidysrhythmics!!!!!!!
Analyze the RhythmAnalyze the Rhythm
Accelerated Idioventricular Accelerated Idioventricular RhythmRhythm
Characteristics Like Idioventricular rhythm except for rate Rate, greater than 40 bpm but less than 100
bpm
Accelerated Idioventricular Accelerated Idioventricular RhythmRhythm
Management Patient may maintain adequate cardiac
output Identify underlying cause and treat!!! Monitor cardiac output and perfusion
Often a late and pre-terminal rhythm
Do NOT give Lidocaine or other antidysrhythmics!!!!!!!
Analyze the RhythmAnalyze the Rhythm
Ventricular Tachycardia Ventricular Tachycardia (VT)(VT)
Causes Myocardial ischemia Hypoxia Electrolyte imbalance Digitalis toxicity Myocardial trauma
Ventricular Tachycardia Ventricular Tachycardia (VT)(VT)
Characteristics Pacemaker site
Irritable ventricular focus takes over as pacemaker site, OR
May result from multiple ventricular foci attempting to become pacemaker site
Complexes look similar to PVCs May see P waves before complexes but uncommon Rate, usually between 100 and 250 bpm
Ventricular Tachycardia Ventricular Tachycardia (VT)(VT)
Complications Can decrease cardiac output Increases cardiac workload Decreases coronary perfusion Can quickly deteriorate into V-fib
Ventricular Tachycardia Ventricular Tachycardia (VT)(VT)
Types Monomorphic
QRS complexes all have same morphology
Polymorphic QRS complexes have more than one morphology
“Torsades de Pointes” “Twisting of the points” Usually > 200 bpm Susceptible if slow repolarization (long QT)
Ventricular Tachycardia (VT)Ventricular Tachycardia (VT)
Treatment of Stable and Unstable Oxygen, Ventilations, Assess Pulse ECG Monitor
If unstable, proceed to synchronized cardioversion
IV NS TKO Determine monomorphic vs polymorphic If wide complex of unknown origin, attempt 12
lead ECG to determine
Ventricular Tachycardia Ventricular Tachycardia Treatment: MonomorphicTreatment: Monomorphic
Treatment of Stable (limit to one antidysrhythmic) procainamide 20 mg/min IV
avoid if poor cardiac function
amiodarone 150 mg slow IV (15 mg/min) lidocaine 1.0 mg/kg IV (max 3.0 mg/kg)
Begin with 0.5 - 0.75 mg/kg poor cardiac function Follow with lidocaine infusion, 1 - 4 mg/min
synchronized cardioversion
Tachycardia: Wide Complex Tachycardia: Wide Complex (VT) Polymorphic (Torsades)(VT) Polymorphic (Torsades)
Treatment (limit to one antidysrhythmic) Normal QT
Lidocaine, 1 - 1.5 mg/kg IV (max 3.0 mg/kg), repeat @ 0.5-0.75 mg/kg q 5 min to max 3 mg/kg
Amiodarone, 150 mg slow IV (15 mg/min) Procainamide, 20 mg/min until
PVCs suppressed 17 mg/kg given Hypotension occurs QRS widens by 50% or more Then, infusion at 1 - 4 mg/min
Tachycardia: Wide Complex Tachycardia: Wide Complex (VT) Polymorphic (Torsades)(VT) Polymorphic (Torsades)
Treatment (limit to one antidysrhythmic) Long QT (including Torsades w/o arrest)
Magnesium sulfate 10%, 1-2 g slow IV over 5 mins or greater
Lidocaine, 1 - 1.5 mg/kg IV (max 3.0 mg/kg), repeat @ 0.5-0.75 mg/kg q 5 min to max 3 mg/kg
Other considerations phenytoin, isoproterenol, or overdrive pacing
Interesting QuestionsInteresting Questions
What is a capture beat?
What is a fusion beat?
How do they help or hurt you in your ECG interpretation?