Antiarrhythmic Therapy In The Emergency DepartmentYou must be a full Eusem member to view this file Go backProf. Dr. med. Ellen HoffmannDepartment of Cardiology and Intensive Care UnitKlinikum BogenhausenANTIARRHYTHMIC THERAPY IN THE EMERGENCY DEPARTMENTANTIARRHYTHMIC THERAPY IN THE EDElectrolyte imbalanceIschemiaHeart failureMyocarditisValve diseaseHypertensionHypoxiaHyperthyreoidismDrugsAlcoholIdiopathicPsychogenicBradycardiaSupraventricular tachycardia/atrial fibrillationVentriculartachyarrhythmiatreatment of underlying diseaseELECTRICAL ANTIARRHYTHMIC THERAPYCARDIAC DISEASELV dysfunctioncardiac ischemiasymptomatic hypotension / pre-/syncopecardiac Decompensation / cardiac arrest- repetitive- sustained- incessant- bradycardia- ventricular tachycardia- supraventricular tachycardiaCLINICAL SYMPTOMSDEFIBRILLATION CARDIOVERSION - PACINGHEMODYNAMIC INSTABILITYARRHYTHMIAType / Heart Rate / Duration CARDIAC ARREST IN THE EMERGENCY DEPARTMENT:NATIONAL REGISTRY OF CARDIOPULMONARY RESUSCITATIONKayser RG et al., Resuscitation 2008n = 430 US/Can. hospitals, data collection 2000 -2005n = 60 852 in-hospital cardiac arrestsLocation ofinitial arrest1st pulseless rhythmEDn=7435General floorn=9806% witnessed% survived to discharge88.547.722.810.833%37%822%53%10%434%AsystolePEAVFVTINDEPENDENT PREDICTORS OF SURVIVAL witnessed event, location, age, 1st pulseless rhythm, ECG monitor, comorbidityVFVTPEAAsystoleADVERSE SIGNS syst. BP < 90 mmHg, HR < 40 bpm, heart failure, ventricular arrhythmiasYesNo0.5 mg atropine i.v.Risk of asystole ? recent asystole AV-Block II Mobitz complete heart block pause > 3 sNoMonitoring / admissionNoNolan JP, ERC Guidelines 2005Yes Transvenous pacingRepeat atropine i.v. to max. 3 mgadrenaline 0.02-0.1 mg i.v.isoprenaline, dopamineORtranscutaneous pacingMANAGEMENT OF ACUTE BRADYCARDIASatisfactory response ?oxygen, vein cannulation, 12-lead ECGBASIC LIFE SUPPORT (CPR 30:2)Assess Rhythm1 x defibrillation 150-200J bi-/ 360J monophCPR 30:2 2 minafter 3 defibrillations amiodarone 300 mg i.v.immediately resumeNolan J, Resuscitation 2005ShockableVF/Pulseless VTNon-shockablePEA/AsystoleDuring CPR: Check reversible causes: hypoxia, toxins, hypother., hypo/hyperkal. Adrenaline every 3-5 min Consider amiodarone, atropine, magnesiumimmediately resumeCPR 30:22 min PEA - primary : acute ischemic events, electr. resuscitation after cardiac arrest - secondary: massive pulmonary embolism, acute malfunc. of prosthetic valves, exsanguination, cardiac tamponadeM.G. , m., 46 yrscardiac arrest during business meeting immediate PCI RCX occlusion ? reopening und stent emergency physician: ventr. fibrillationfirst responder resuscitation (15-20 min)urgent transport to hospital=> 2x defibrillation: sinus rhythmafter extubation: normal neurological status47 yr old female, lone atrial fibrillation, sotalol for recurrence preventionTORSADE DES POINTES TACHYCARDIATreatment options: drug withdrawal / correction of electrolyte magnesium sulfate 2 g anti-bradycardia pacingDrug-induced TdP: antiarrhythmics antibiotics anti-psychotics etc.DIFFERENTIAL DIAGNOSIS OF BROAD COMPLEX TACHYCARDIAS Torsade des pointes VT: monomorph/polymorph SVT with BBB (preexisting, tachy-related) SVT with antegr. conduc. over access. pathway Ventricular pacing ECG artifactNAVT-Trials (NotArzt und Ventrikulre Tachykardie)n = 64 emergency physicians, n = 8 12-lead ECGsOverall 55 61Internist53 56Anesthesiologist 50 60Cardiologist 68 73Surgeon 59 63Emergency physician >5yr58 64CORRECT DIAGNOSIS [%]by ECG only+ additional infoOhlow et al., Dtsch Med Wochenschr 2005ABSENCE OF DIAGNOSTIC RELIABILITY MANAGEMENT OF BROAD COMPLEX TACHYCARDIAAdverse Sign syst. BP<90 mmHg, reduced level of consciousness, chest |