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Published on May 22, 2009

Author: sirusmoon


VENTRICULAR DYSRHYTHMIAS : VENTRICULAR DYSRHYTHMIAS Suneesh Stephen OUTLINE : OUTLINE INTRODUCTION PREMATURE VENTRICULAR CONTRACTION VENTRICULAR TACHYCARDIA TORSADE DE POINTES VENTRICULAR FIBRILLATION IDIOVENTRICULAR RHYTHM AGONAL RHYTHM VENTRICULAR ASYSTOLE ELECTRO MECHANICAL DISSOCIATION INTRODUCTION : INTRODUCTION Ventricles produce cardiac output Ineffective ventricular output there is no cardiac output Ventricular dysrhythmia is often a precedent to life-threatening cardio respiratory arrest Categorized as ventricular or supraventricular, indicating the origin in or above the ventricles Slide 4: INTRODUCTION Slide 5: INTRODUCTION Slide 6: INTRODUCTION SVT’s include sinus tach, atrial tach, atrial flutter, atrial fib, and junctional tach SA node and AV node failure the ventricles can initiate an impulse from the Bundle branches, Purkinje fibers, or Ventricle muscle. The impulse must travel in a retrograde direction to depolarize the atria then travel forward to depolarize the Ventricles. INTRODUCTION : The p wave is usually hidden in the QRS Complex. The QRS is wide and bizzare and greater than 0.12 seconds. Usually life threatening. INTRODUCTION Slide 8: PREMATURE VENTRICULAR CONTRACTION VENTRICULAR TACHYCARDIA TORSADE DE POINTES VENTRICULAR FIBRILLATION IDIOVENTRICULAR RHYTHM AGONAL RHYTHM VENTRICULAR ASYSTOLE ELECTRO MECHANICAL DISSOCIATION TYPES OF VENTRICULAR DYSRHYTHMIAS PREMATURE VENTRICULAR CONTRACTION : PREMATURE VENTRICULAR CONTRACTION An individual complex that originates from an area below the bundle of his and occurs earlier than the next expected complex. Slide 11: PVC PREMATURE VENTRICULAR CONTRACTION PREMATURE VENTRICULAR CONTRACTION : Characteristics PVC’s are common Can occur in any underlying rhythm. P waves are absent. PR intervals are absent QRS is always wide an equal or greater than 0.12 seconds PREMATURE VENTRICULAR CONTRACTION PREMATURE VENTRICULAR CONTRACTION : Characteristics The T wave is usually deflected in the opposite of the QRS complex. A compensatory pause is found with PVC’s PVC’s are the most ominous of all ectopic Beats. PREMATURE VENTRICULAR CONTRACTION PREMATURE VENTRICULAR CONTRACTION : Characteristics Indicates increased ventricular Irritability. Since PVC’s are not rhythms, underlying rhythm must be identified. The rate and rhythm vary with the underlying Rhythm. PVC’s are counted in the total number of R waves to determine rate. PREMATURE VENTRICULAR CONTRACTION Slide 15: PREMATURE VENTRICULAR CONTRACTION CAUSES M.I. ISCHEMIA DRUG TOXICITY ACIDOSIS PAIN COPD GALL BLADDER DISEASE SYMPATHETIC NERVOUS STIMULATION ELECTROLYTE IMBALANCES Slide 16: PREMATURE VENTRICULAR CONTRACTION TYPES - SITE OF ORIGIN UNIFOCAL MULTIFOCAL Slide 17: PREMATURE VENTRICULAR CONTRACTION Unifocal PVC’s Slide 18: PREMATURE VENTRICULAR CONTRACTION Slide 19: PREMATURE VENTRICULAR CONTRACTION TYPES – RHYTHM PATTERNS BIGEMINY TRIGEMINY QUADRIGEMINY COUPLET RUN OF VT INTERPOLATED BEAT FUSION BEAT Slide 20: PREMATURE VENTRICULAR CONTRACTION Slide 21: PREMATURE VENTRICULAR CONTRACTION Slide 22: PREMATURE VENTRICULAR CONTRACTION Couplets Slide 23: PREMATURE VENTRICULAR CONTRACTION Two PVC’s in a row that are not Separated by a complex of the underlying Rhythm. Couplets Slide 24: PREMATURE VENTRICULAR CONTRACTION Couplets Additional term used to describe PVC’s. R wave of the PVC falls on the t wave of the previous complex. Very vulnerable period of ventricular repolarization Slide 25: PREMATURE VENTRICULAR CONTRACTION Three or more PVC’s exist in a row, not separated by a QRS complex of the underlying rhythm. Run of VT Slide 26: PREMATURE VENTRICULAR CONTRACTION R on T Phenomenon Slide 27: PREMATURE VENTRICULAR CONTRACTION Additional term used to describe PVC’s. R wave of the PVC falls on the t wave of the previous complex. Very vulnerable period of ventricular repolarization R on T Phenomenon Slide 28: PREMATURE VENTRICULAR CONTRACTION Interpolated Beats Slide 29: PREMATURE VENTRICULAR CONTRACTION Interpolated Beats A PVC that occurs about halfway between two normal beats. Already compensatory in the overall rhythm with no pause following it. The first regular beat after the interpolated beat usually has a prolonged PR interval. Slide 30: PREMATURE VENTRICULAR CONTRACTION Occurs when the atria are depolarizing at the same time a ventricular contraction occurs. The resulting beat is a fusion of the normal beat that should have occurred and the PVC. A kind of rare PVC. Fusion beat Slide 31: PREMATURE VENTRICULAR CONTRACTION CRITERIA FOR TREATMENT OF PVC’S : CRITERIA FOR TREATMENT OF PVC’S MORE THAN 6 IN A ONE MINUTE STRIP MULTIFOCAL COUPLETS RUN OF VT R ON T MEDICALLY UNSTABLE Slide 33: DIFFERENTIATION OF PVC P wave – absent QRS interval – wide and bizarre (>0.12seconds) Pause – compensatory T wave – opposite to the QRS complex Frequency – most common in pathology Cause – cardiac irritability VENTRICULAR TACHYCARDIA : VENTRICULAR TACHYCARDIA VENTRICULAR TACHYCARDIA : VENTRICULAR TACHYCARDIA Originates from a single site in the ventricles. 100 to 250 impulses per minute. No normal-looking QRS complexes. Absent P wave or obscured or retrograde QRS: duration > 0.12 sec, bizarre and increased amplitude Run of three or more consecutive PVC’s. Commonly persists for an extended period of time. Life-threatening. VENTRICULAR TACHYCARDIA : VENTRICULAR TACHYCARDIA VENTRICULAR TACHYCARDIA : VENTRICULAR TACHYCARDIA May occur with or without pulses. A patient with a pulse is usually hypotensive VT is ominous because of its tendency to degenerate to ventricular fibrillation without a pulse. VENTRICULAR TACHYCARDIA : VENTRICULAR TACHYCARDIA The pulseless cardiac arrest patient is apenic and/or pulseless will require basic or Advanced life support. P waves may exist between ventricular Complexes if there is an a-v block. P waves will have no regular relationship to the QRS complexes. Usual regular rhythm. VENTRICULAR TACHYCARDIA : VENTRICULAR TACHYCARDIA SYMPTOMS Run of VT – may only feel slightly weak or complain occasional palpitation. Sustained VT – may be unstable leading to unresponsiveness, loss of pulse VENTRICULAR TACHYCARDIA : VENTRICULAR TACHYCARDIA ALGORHYTHM OF TREATMENT Assess the patient if stable Provide oxygen Start IV, reassess LIDOCAINE, reassess If VT is controlled,IV of LIDOCAINE VENTRICULAR TACHYCARDIA : VENTRICULAR TACHYCARDIA ALGORHYTHM OF TREATMENT If not successful with LIDOCAINE Administer PROCAINAMIDE until one of the following: Total of 17mg/kg has been given PVC’s have stopped Patient hypotensive QRS becomes 50% wider than before VENTRICULAR TACHYCARDIA : VENTRICULAR TACHYCARDIA Reassess the patient, if the VT is not controlled with LIDOCAINE or PROCAINAMIDE,administer BRETYLIUM. If BRETYLIUM controls the VT start a BRETYLIUM IV. monitor the patient If VT controlled, iv of PROCAINAMIDE VENTRICULAR TACHYCARDIA : VENTRICULAR TACHYCARDIA If the patient has a pulse but poor cardiac output Perform synchronized cardioversion if the heart rate is >150 LIDOCAINE if max dose has not been given Continue cardioversion LIDOCAINE 5-10 min. until 3 mg/kg given PULSELESS CPR TORSADE DE POINTES : TORSADE DE POINTES Translated it means “twisting of the points”. Looks similar to VT. Unknown if it is from single or multiple sites. Begins close to the baseline gradually increasing and decreasing in a repeating pattern. Slide 45: TORSADE DE POINTES Slide 46: TORSADE DE POINTES Slide 47: TORSADE DE POINTES This occurs in a period of 5 to 20 beats. The rhythm resembles a twisting and turning motion along the baseline. Torsade usually has a rate of 200 to 250 beats per minute. Amplitude continually changes from complex to complex. Slide 48: TORSADE DE POINTES WARNING SIGNS Prolongation of QT interval Prominent U waves Very large T waves Ventricular bigeminy with R on T Slide 49: TORSADE DE POINTES CAUSES Hypokalemia Quinidine therapy. Severe bradycardia as a major predisposing factor. Slide 50: TORSADE DE POINTES MANAGEMENT Eliminate drug toxicites Eliminate electrolyte imbalances. Quinidine is the primary culprit of drug toxicity. This is a life-threatening dysrhythmia. Cardiac output is not maintained, and adequate oxygen is not circulated. Slide 51: TORSADE DE POINTES TREATMENT Vagal stimulation Intravenous lidocaine Mechanical pacemakers Cautiously administered iv isoproterenol. Unsynchronized cardioversion CPR if no pulse VENTRICULAR FIBRILLATION : VENTRICULAR FIBRILLATION One of four forms of cardiac arrest: asystole, pulseless ventricular tachycardia, electromechanical dissociation (emd). Easiest to recognize. V fib is a lethal dysrhythmia. VENTRICULAR FIBRILLATION : VENTRICULAR FIBRILLATION VENTRICULAR FIBRILLATION : VENTRICULAR FIBRILLATION VENTRICULAR FIBRILLATION : VENTRICULAR FIBRILLATION It originates from many different sites within the ventricles. The cardiac cells do not have time to completely depolarize and repolarize. The myocardium lacks effective muscular contraction. VENTRICULAR FIBRILLATION : VENTRICULAR FIBRILLATION The myocardium has a quivering muscular activity. Fib reveals an irregular wavy baseline Coarse ventricular fibrillation the waves have a higher amplitude Course Ventricular Fibrillation : Course Ventricular Fibrillation Fine Ventricular Fibrillation : Fine Ventricular Fibrillation VENTRICULAR FIBRILLATION : VENTRICULAR FIBRILLATION Ventricular rhythm: no pattern or regularity. P wave, QRS complex, PR interval, T wave : can’t be determined Fine ventricular fibrillation have less amplitude, indicating fewer cardiac cells are able to respond to electrical impulse. Fine V fib responds less easily to treatment Coarse fibrillatory wave: greater chance of successful electrical cardioversion than small amplitude VENTRICULAR FIBRILLATION : VENTRICULAR FIBRILLATION Defibrillation Defibrillation produces a stimulus much stronger than the normal cardiac stimuli. The stimulus depolarizes all cells that are in a repolarized refractory state. The intent is to produce a uniform state of polarization. THERAPY WARNING DYSRHYTHMIAS : WARNING DYSRHYTHMIAS VENTRICULAR TACHYCARDIA 5 OR MORE PVC’S PER MINUTE MULTIFOCAL PVC’S COUPLETS R ON T PHENOMENON IDIOVENTRICULAR RHYTHM : IDIOVENTRICULAR RHYTHM Any rhythm originating in the ventricles. Regular, slow rhythm with wide ventricular complexes without p waves. 15 to 40 beats per minute. IDIOVENTRICULAR RHYTHM : IDIOVENTRICULAR RHYTHM AGONAL RHYTHM : AGONAL RHYTHM Dying heart Usually originates from a single site in the ventricles. The atria, AV junction, bundle of his, and bundle branches can no longer function as pacemakers. <20 beats per minute. AGONAL RHYTHM : AGONAL RHYTHM Pulseless Electrical Activity (PEA) : Pulseless Electrical Activity (PEA) Note that PEA can look like any rhythm (any organized electrical activity), but if no pulse it is PEA VENTRICULAR ASYSTOLE : VENTRICULAR ASYSTOLE Asystole literally means without contractions. No waves, no complexes Rhythm is flat line on the EKG. Patient is pulseless and apneic. Management includes chemotherapies and basic life support. VENTRICULAR ASYSTOLE : VENTRICULAR ASYSTOLE ELECTRO MECHANICAL DISSOCIATION : ELECTRO MECHANICAL DISSOCIATION The failure of the myocardium to mechanically respond to normal electrical depolarization is EMD. Not generally a dysrhythmia, rather a condition. The electrical rhythm is frequently NSR. Slide 70: Management includes immediate basic life Support with advanced life support. Pericardial tamponade can mimic emd. Occurs when the heart chambers or vessels Bleed into the pericardial sac. ELECTRO MECHANICAL DISSOCIATION Slide 71: Blood accumulates and eventually Compresses the heart. Marked progressive cardiac output, Narrowing pulse pressure, distended neck Veins, and shock symptoms. Diminished heart sounds. ELECTRO MECHANICAL DISSOCIATION MANAGEMENT : MANAGEMENT Requires the removal of the blood in the pericardial sac. Pericardiocentesis usually results in dramatic improvement. Cardiac tamponade must be considered in any patient presenting with EMD. ELECTRO MECHANICAL DISSOCIATION CONCLUSION : CONCLUSION PVC’s are not rhythms PVC’s are counted in the total number of R waves to determine rate. VT is ominous because of its tendency to degenerate to ventricular fibrillation without a pulse. Prolongation of QT interval in Torsades Pointes CONCLUSION : CONCLUSION Ventricular rhythm: no pattern or regularity in VF Regular, slow rhythm with wide ventricular complexes without p waves in idioventricular rhythm <20 beats per minute in agonal rhythm No waves, no complexes in asystole EMD is not generally a dysrhythmia, rather a condition. Slide 75: MERCI BEAUCOUP

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