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Tachycardias or slow down, you move too fast Susan P. Torrey, M.D., FACEP, FAAEM Associate Professor of Emergency Medicine Tufts University School of Medicine Baystate Medical Center, Springfield, Mass

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Objectives Review diagnostic criteria of tachycardias Consider the diagnostic grid Answer several interesting questions Whats the scariest atrial fib youll ever see? Lets use adenosine its safe, isnt it? How DO you know if its v. tach? Review more sneaky rhythm strips

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Rate Rate = 300 # big boxes between R-R 300 150 100 75 60 50

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Rate?

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1. Between 150 - 300 2. 75 x 3 = 225

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Normal conduction

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Wolff-Parkinson-White x x - short PR - delta wave - increase QRS width

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Sinus tachycardia normal P before every QRS upright P in lead II Max. heart rate = 220/minute age in years

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Sinus tachycardia Common causes: compensation for shock - dehydration, hemorrhage, sepsis fever drugs (cocaine) acute pulmonary embolism thyrotoxicosis anxiety - needs to be dx of exclusion

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19 yo male with multi-drug OD

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Atrial fibrillation no discernible P waves - atrial activity is fibrillatory waves (f) - fibrillatory waves II and V 1 ventricular rhythm is irregularly irregular - untreated ventricular rate 100 180/min

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Atrial fibrillation

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Atrial flutter atrial activity regular deflections (F waves) - F waves usually 300/minute rate and regularity of QRS variable - in purest form, multiple of 300

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Atrial flutter untreated, flutter usually has 2:1 AV block regular rhythm at 150/minute

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Rate of 150 when the rate is 150/minute always consider 2:1 atrial flutter

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Multifocal atrial tachycardia P waves of varying morphology ( 3 foci) - absence of single dominant P wave Variable PP, RR, PR intervals - the other irregularly irregular rhythm Seen with COPD, elderly, seriously ill

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Supraventricular tachycardia Regular, narrow tachycardia 2 re-entry AV nodal re-entry vs. AV re-entry (bypass) Onset and termination is abrupt Heart rate 140-220/minute Differential: sinus tach, 2:1 flutter, ? a fib

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Reentry mechanism fast pathway - rapid conduction time - long refractory period - slow pathway - slow conduction - short refractory

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SVT

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Pseudo-S waves with AVNRT Pseudo-S waves disappear with sinus rhythm

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another SVT

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AV reentry tachycardia? QRS alternans Prolonged RP interval

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AV Reentry Tachycardia (WPW?)

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after cardioversion!

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Ventricular tachycardia Abnormal wide QRS Regular rhythm dead regular Rate usually 140-200/minute

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Wide-complex tachycardia 70% of WCT is ventricular tachycardia differential includes SVT with aberrancy SVT with pre-existing bundle branch block SVT with bypass tract

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RegularIrregular Narro w Wide Diagnostic grid - tachycardias

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RegularIrregular Narro w Sinus tach SVT 2:1 flutter Wide Diagnostic grid - tachycardias

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RegularIrregular Narro w Sinus tach SVT 2:1 flutter Atrial fib MAT Wide Diagnostic grid - tachycardias

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RegularIrregular Narro w Sinus tach SVT 2:1 flutter Atrial fib MAT Wide V. tach SVT with Diagnostic grid - tachycardias

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RegularIrregular Narro w Sinus tach SVT 2:1 flutter Atrial fib MAT Wide V. tach SVT with Atrial fib with Diagnostic grid - tachycardias

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What is the scariest atrial fibrillation you will ever see? 38-year-old man with history of palpitations

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Or this

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Scary atrial fib Atrial fib with - aberrancy - pre-existing bundle, or - bypass tract with Wolff-Parkinson-White ! - changing QRS shape and rapid conduction

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Atrial fib with WPW most AV node blockers bypass conduction must avoid A B C D A adenosine B beta-blockers C calcium-channel blockers D digoxin treat with electricity or procainamide

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What about amiodarone? 2005 ACLS rec: amiodarone 2010 ACLS returns to procainamide Simonian S Inter Emerg Med 2010 Literature review challenges superiority and safety of amiodarone for atrial fib with WPW Complex drug with effects on Na +, K +, and Ca ++ channels, as well as - and -blocking effects

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rapid atrial fib with wide complex after cardioversion after ablation of bypass tract

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Lets use adenosineits safe isnt it? Adenosine (Adenocard) an 1 receptor agonist rapid onset and brief duration frequent side-effects: facial flushing, chest pressure, dyspnea

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SVT conversion with adenosine

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Adenosine

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Beware proarrhythmias ! Torsade de pointe Precipitates atrial fib and flutter Protracted bradycardia and asystole 2:1 flutter 1:1 conduction Mallet Emerg Med J 2004

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SVT at 140 ? Adenosine 6 mg IV 1:1 atrial flutter at 280/minute

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Adenosine as diagnostic tool SVT Atrial flutter Sinus tach Ventricular tach converts to sinus reveals flutter waves reveals P waves nothing !

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pediatric tachycardia 8-month-ago child with hx cardiac surgery as infant; parents say child is fussy HR 300/minute Adenosine

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Pre-hospital tachycardia

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How do you know if its V. tach?

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EKG criteria favoring V. Tach AV dissociation

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AV dissociation

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How do you know if its V. tach? EKG criteria favoring V. Tach AV dissociation QRS concordance all chest leads (V 1-6 ) predominantly negative

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QRS concordance

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How do you know if its V. tach? algorithms Brugadas four-step algorithm 98% sens / 96% spec Circ 1991 Vereckeis new simplified algorithm Euro Heart J 2007

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How do you know if its V. tach? clinical predictors association with heart disease or MI 98% positive predictive value Aktar Ann Intern Med 1988

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Its v. tach!

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1. 68-year-old woman with COPD complains of palpitations and nausea. Irregularly irregular a. fib vs. MAT

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2. 38-year-old woman complains of palpitations and weight loss. Regular, narrow SVT vs sinus tach

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3. 70-year-old woman with weakness. PMH: Parkinsons Disease Regularbut fibrillatory waves?

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4. 72-year-old man with palpitations, weakness, and chest discomfort.

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after adenosine F

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5. 65-year-old man with palpitations and shortness of breath.

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wide-complex, irregularly irregular yikes after Amiodarone then spontaneously converted to sinus

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6. 56-year-old man with lung cancer from oncology clinic with SOB.

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Irregularly irregular at 185/min Now 145/minute, and

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7. 75-year-old man from nursing home with altered mental status.

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Appropriate DDD pacer function essentially sinus tach

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8. 65-year-old woman with dyspnea and chest pain.

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Emergency Department EKG

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After diltiazem

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9. 70-year-old man with palpitations and SOB

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Close-up of III and aVF

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After adenosineoops!

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10. 65-year-old woman after syncope.

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After spontaneous conversion

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Pseudo-S waves of AVNRT

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11. 70-year-old man with chest pain 90/60, 200, 28, 92%

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After electrical cardioversion

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12. 72-year-old woman heart racing EMS gave Amiodarone

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ED 12-lead 15 minutes later

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15 min laterspontaneous conversion

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In conclusion Remember, tachycardias are easy Narrow or wide complex? Regular or irregular?

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RegularIrregular Narro w Sinus tach SVT 2:1 flutter Atrial fib MAT Wide V. tach SVT with Atrial fib with Diagnostic grid - tachycardias

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In conclusion Remember, tachycardias are easy Narrow or wide complex? Regular or irregular? If the rate is around 150 think 2:1 flutter.

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In conclusion Remember, tachycardias are easy Narrow or wide complex? Regular or irregular? If the rate is around 150 think 2:1 flutter. Use Adenosine, but respect it.

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In conclusion Remember, tachycardias are easy Narrow or wide complex? Regular or irregular? If the rate is around 150 think 2:1 flutter. Use Adenosine, but respect it. Rapid wide-complex atrial fib think WPW Avoid A B C D (and amiodarone)

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In conclusion Remember, tachycardias are easy Narrow or wide complex? Regular or irregular? If the rate is around 150 think 2:1 flutter. Use Adenosine, but respect it. Rapid wide-complex atrial fib think WPW Treat wide-complex tachycardia per ACLS