Tachyarrythmias

DIPEC Study Group 20.10.22

Question 1:You are given the following ecg and history. Describe
your approach to emergency management of this patient
 Question 1
• My basic appraoch to this patient will be to
assess ABCs rapidly, site a drip, get an ECG,
and then assess the patient end organ
perfusion, their rate, the width of their QRS
complexes and whether the rhythm is regular.
Based on these factors I will determine their
emergency managment
 HHH and ABCDE
• As I approach the patient I will consider if there are hazards, eg infectious
disease, I will greet the patient and if they are unresponsive at this time
call for help
• If they are not unresponsive as appears to be the case from the notes, I
will proceed to quickly assess ABCs
– Their airway is likely patent, maintained and protected if they responded
– Breathing – The patients oxygen saturation is 98% and if there is also no
increased work of breathing or other obvious findings I will not apply oxygen or
intervene further but rather move on to circulation. I will quickly auscultate the
chest for bicasal crepitations at this point
– Circulation according to the triage note the hr is 98, blood pressure is 119/66. I
will check capillary refill time and attach continuous ECG monitor, sats monitor
and other vital signs monitors. I will also briefly check for a JVP and pedal edema
– Drip – I will site an IV line and while doing this ask if the patient is currently
experiencing chest pain and assess their GCS
– about the ECG – I have looked at the ECG at at first glance it is an SVT
 Decide on stability
• I will make an assessment as to whether this
patient is unstable – his blood pressure is
normal. If he doesn’t report chest pain and I
have not found any evidence of altered mental
status, shock or acute heart failure then I will
assess this patient as stable
ECG Assessment: Narrow versus wide
complex tachycardia
• Next I will assess HR on the ECG. As this looks like a very
fast regular rhythm I would Ideally use 1500/small blocks
between QRS complexes. 1500/6 or 7 blocks is
somewhere between 200 and 250. It is difficult to see the
boxes though so I check this with a count of complexes on
the rhythm strip and I get 37 x 6 = 222. (actual rate on the
machine showed as 226)
• I therefor assess this as a tachyarythmia on rate alone
• I have already assessed the patient as stable
• My next step is to assess the QRS complex and determine
if it is wide or narrow. It is approx 2-3 small blocks and
therefore between 0.08 and 0.12sec. Thus less than
0.12seconds and thus a narrow complex tachycardia.
 Treatment: Narrow complex
tachycardia
• I now quickly screen for any sign of atrial fibrillation. RR
intervals do not appear to vary so I consider atrial
fibrillation unlikely.
• My first attempt at management will be vagal
manoevres. Modified valsalva is preferred so I will try
this first, followed by valsalva, ice water applied to
face, coughing and breathholding
• If this fails I will give adenosine 6mg by rapid IV push
after counselling the patient that they may have chest
pain or feel strange, but it will be very brief. If that is
unsuccessful I will try adenosine 12mg rapid push
• if that is unsuccessful amiodorone by slow infusion.
Case outcome
 Question 2: You have now treated the patient and this
is the new ECG. What is your assessment of the ecg and
your diagnosis
 Question 2
• ECG interpretation
– Correct patient and date
– Standard paper speed 25mm/second, standard
voltage 10mm = 1mV
– Rate = 9x6=54bpm (machine= 55bpm)
– Rhythm = sinus rhythm (P wave for every QRS)
– Axis = normal/left (I and AVF are positive)
 Question 2 cont
• ECG interpretation cont
– Complexes
•P
– normal duration (<3 small squares/120 ms)
– Looks to be <1.5mm in precordial leads and <2.5 in limb leads
therefore normal amplitude
– Morphology looks roughly normal…
 Question 2 cont
• ECG interpretation cont
– Complexes
• QRS
– Width
» Appear broad but this is actually due to the characteristic
delta wave upward stroke
– Height
» V1 + V5-6= 4 blocks = 20mm= <35mm so no hypertrophy
» V1 is low votage (<5mm and its precordial) Otherwise no
other low voltage – limb leads are >10mm and precordial
>5mm)
 Question 2 cont
• ECG interpretation cont
– Complexes
•T
– Upright in all leads except AVR. V1 is upright but should be
inverted
– Normal amplitude (Amplitude should be less than 5mm in
limb leads and <10mm in precordial leads)
– Normal morphology
•U
– Absent = normal
 Question 2 cont
• ECG interpretation cont
– Intervals
• PR
– 2 small blocks =0.08 sec = short (normal =0.12-0.2sec or 3-5 small squares
• ST Segment
– Slightest hint of ST depression in some leads but nothing exceeds 1mm so does
not meet criteria for STEMI or NSTEMI
• QT Interval
– Eyeball method…QT should be less than half of preceding RR – looks normal
– Can use various fomulas:
» Bazett = QT in milliseconds/sqr rt (RR in seconds) = 500/1.054 = 474
» Normal <440 if male and <460 if female
» Therefore prolonged
– Machine = 435 – reads as normal
 Question 2 cont
• ECG overall assessment
– Short pr
– Delta wave
– ?Prolonged QT
– Otherwise normal although v1 may be misplaced
or there may be a subtle abnormality here
• Diagnosis
– Pre-excitation syndrome :wolff parkinson white
(short PR, plus delta wave)
Case outcome
Question 3. The patient wants to know if there is
anything they can do at home if this happens
again. Teach them the modified valsalva
manoevre and explain why it works in laymans
terms
Question 3. The patient wants to know if there is
anything they can do at home if this happens
again. Teach them the modified valsalva
manoevre terms (From walter kloek book page
25)
1. Modified valsalva manoevre
– Patient in a sitting position
– PAtient to blow into tubing of BP manometer, keeping pressure at 15mmHg for at
least 15 seconds
– Then lay the patient flat on the bed
– Raise both legs to 30 degrees for 15 seconds
2. Other options/valsalva manoevre
– deep repetitive forceful coughing
– forcefully push hand on abdomen away for 15 seconds
– Hold breath and strain forcefully for 15seconds
 Question 4: You are suturing a patient in the
next bed. The intern calls you to say the ecg has
changed back to the original one and the patient
is pale, sweating and the blood pressure reading
is 80/40. You cant stop suturing now, talk the the
intern through what they must do step by step.
The patients ABC’s are unchanged
 Cardioversion indicated for unstable
tachyarythmia
• The patient now has an unstable
tachyarythmia and needs cardioversion
• If there is time the patient should get an
explanation of the procedure, sign consent
and be sedated
• Steps follow
 How to cardiovert
• From ACLS:
– Turn on defibbrilator
– Attach monitor leads and make sure the monitor is displaying the
patients rhythm
– Press sync (NB NB)
– Look for Markers on each R wave
– If Markers are not appearing adjust the gain until they do
– Select 100 joules (resus council algorithm)
– Ask everyone to stand clear of patient
– Press charge
– Make sure patient still clear
– Press shock
– Look at the monitor, if the rhythm persists increase the energy
level
Question 5: Outline the mechanism of
action of adenosine and it’s
contra-indications
 Question 5: Outline the mechanism of
action of adenosine and it’s
contra-indications
• Mechanism of action: slows conduction time through the AV node, interupting the
re-entry pathways through the AV node and thus restoring normal sinus rhythm
• Contra-indications:
– From UTD
• Hypersensitivity to adenosine
• 2nd or 3rd degree AV block
• Sick sinus syndrome
• Symptomatic bradycardia
• Asthma or bronchoconstrictive lung disease
– From ACLS
• Should not be used for pre-excited atrial fibrillation or flutter – may accelerate ventricular response
• COPD/Asthma especially if currently bronchospastic
• Lower dose for transplanted heart or if given through CVP
– unsure of source
• not with theophylline
• caution with low BP
Question 6: You have a patient with an SVT
who is stable. They have not responded to
adenosine or vagal manoevres. You have
no amiodorone. What will you use?
Question 6: You have a patient with an SVT who
is stable. They have not responded to adenosine
or vagal manoevres. You have no amiodorone.
What will you use?

– According to resus council algorithm – try beta

blockers or calcium channel blockers
– According to ACLS – try a beta blocker or calcium
channel blocker and consider getting an expert
opinion
– ? Reasonable to cardiovert?
 Question 7: AVRT versus AVNRT
pathophysiology and how you will
differentiate these on ECG
AVRT vs AVNRT - basic pathophysiology
 AVRT AVNRT
Regular, HR 140-280

P wave in ST segment P wave not seen or in QRS

complex

RP interval 100-120ms Pseudo R wave V1

QRS alternans Pseudo S wave II, III, AVF

Re entry via accessory pathway Re entry circuit in or around AV

= longer loop to follow node = quicker loop to follow
= P wave in ST segment = P in QRS complex
AVNRT
AVNRT
AVRT
AVRT
Question 8: Discuss your approach to the
management of stable atrial fibrillation
APPROACH TO MANAGEMENT - STABLE AFIB
 APPROACH TO MANAGEMENT - STABLE AFIB
ABCs

History- start of symptoms, stimulants, medication

Physical exam- goitre, heart failure

Investigations:
● FBC, CEU, TSH
● CXR
● POCUS

Risk stratify:
● CHA2D VASC
● HAS BLED
 APPROACH TO MANAGEMENT - STABLE AFIB

Onset < 48 hours Onset > 48 hours

● Haemodynamically stable Rate control

● no comorbidities ● BB (atenolol, metoprolol)
● age < 65 ● CCB (verapamil)
● Digoxin (in heart failure)

Rate control b blocker Rhythm control

Await spontaneous rate ● Amiodarone
conversion

Sync cardioversion Anticoagulation

● Warfarin
 DISPOSITION - STABLE AFIB
Options:

● Discharge
● Ward
● High care
● Intensive care unit
ECG Quiz
1. Dx?
Dx?
 Sinus Tachycardia
Handy tip:With very fast heart rates the p wave may be
hidden in the preceding t, producing a camel hump
appearance
2. Dx?
Dx?
3. Dx?
Dx?
4. Dx?
Flutter
5. Dx?
6. Dx?
Wolff Parkinson White – more detail on
LITFL
7. Dx?
Monomorphic Vtach
8. Dx?
 8. Dx?

PVCS, then R on T phenomenon

then torsades, degenerates into
VF
References/ Recommended Videos and
reading
• Resus council algorithm for tachycardia:
https://resus.co.za/
• Assessment of ECG :
https://litfl.com/category/ecg-library/ecg-basics/
• Valsalva manoevre – uptodate article
• Cardioversion – ACLS book
• AVRT vs AVNRT – Khan Academy
https://www.youtube.com/watch?v=tRuvXP-H164 and
google life in the fast lane articles on ecg findings
• Atrial fibrillation – Western Cape Emergency medical
guidance