emergency med 5

8/9/2019 Emergency Med 5

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Emergency Med: Lecture 5: Cardiovascular Emergencies

Dr. Agostini

8/24/2009 9:30am

First degree AV Block

Rhythm: Regular P waves: Each P followed by QRS PR

Prolonged (> 0.20 sec) Usually constant

QRS: Normal

Second degree AVB, Type I (Wenkebach)

Rate Atrial: Unaffected

Ventricular: Less than atrial the QRS is dropped eventually

Rhythm Atrial: Regular Ventricular: Irregular, progressive shortening of R R before pause

P waves: Normal PR: Progressive increase until P dropped QRS: Normal

Second degree AVB, Type II Rate

Unaffected

Ventricular: < atrial rate

Rhythm Atrial: Regular Ventricular: Usually irregular, except with constant conduction ratio

P waves: Normal PR: Normal or prolonged, but constant QRS

Normal when at Bundle of His

Wide when at bundle branch level

Second degree AVB, Type II w/ 2:1 conduction


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Second Degree AVB, Type II w/ variable conduction High grade block w/ 2 droppedQRS complexes in a row. pt will be symptomatic, prob feeling like they are going to pass out

Third degree AV block (complete AVB) atrial rate and ventricular rate are both constant but separate Rate

Atrial: Unaffected

Ventricular: < atrial rate AV nodal level block (40-60)

Infranodal block (< 40)

Rhythm Atrial: Usually regular

Ventricular: Regular

P waves: Normal

PR: Will vary varying, random lengths QRS

AV node or Bundle of His: narrow QRS Bundle branch level: Wide QRS

P to P is constant and the distances b/w QRS complexes are constantPts will be symptomatic (light headed)

Treatment for AV blocks

First degree: Symptomatic

Second degree Type I: Symptomatic

Second degree Type II: Pacemaker Third degree: Pacemaker

Atropine (max. 0.04 mg/kg) may be used (not usually for second degree type II)

PSVT (Paroxysmal supraventricular tachycardia)

Reentry mechanism, most often involving AV node alone or the AV node and an extra AV nodal bypasstract. Can affect younger people and not last long, but can also be pathologic and require treatment. Pt willcomplain of palpitations.

Rate: Usually > 150

P waves: Variable, but not discerned if they occur during QRSQRS: Usually narrow


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Cant see the P waves only T waves are shown

PSVT Treatment

Stable: Vagal stimulation, adenosine, diltiazem, beta-blockers, cardioversion Vagal stimulation lean forward and simulate bowel movement; dip head in ice water

Adenosine will put back into sinus rhythm in a few seconds

Cardioversion is used in stable pts when all other options fail Unstable: Cardioversion

Wide Complex Tachycardia

Diagnostic Considerations with Wide Complex Tachycardia

VT vs. PSVT with aberrancy

Improper treatment can complicate management

Ventricular tachycardia has a grim prognosis

**It may look like Ventricular tachycardia or PSVTif you dont know what to call it, its wide complextachycardia

Treat all wide complex tachycardia like its V-tac because it has a much worse prognosisWide Complex Tachycardia Treatment

Stable

DC cardioversion or Amiodarone Unstable

DC cardioversion

Wide Complex Tachycardia


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Sinus Tachycardia

Rate: > 100 Rhythm: Regular

P waves: Upright in 1, 2, aVF

Sinus tachycardia is VERY common from exercise, medicine, acute injury, anxiety, etc.

Symptoms & Treatment***Treat the underlying cause

Pain: Analgesics Anxiety: Sedation

Hemodynamic state: Beta blockers

Hypovolemia: Volume replacement Myocardial damage: Hemodynamic monitoring and drug therapy

Sinus bradycardia

Rate: < 60

Rhythm: Regular P waves: Upright in 1, 2, aVF

Treatment If symptomatic, treat with atropine

May need pacemaker

Pulseless Electrical Activity

PEA is the presence of some type of electrical activity (other than VT or VF), but a pulse cannot be

detected by palpation of any artery. Any rhythm or electrical activity that fails to generate a pulse is PEA.

Pt will be symptomatic close to death

Treatment

Search for and treat identified reversible causes Epinephrine 1 mg IVP, repeat q 3-5 min. Or vasopressin 40 U (1 dose to replace 1st or 2nd epi dose) Atropine 1 mg IV , repeat q 3-5 min. (3 doses)

Use atropine if you think there may be a faint pulse

Causes of Pulseless Electrical Activity = H and Ts:

Hypovolemia

Hypoxia Hydrogen ion (acidosis)

Hyper/hypokalemia Hypothermia

Tablets (drug OD, accidents)

Tamponade, cardiac Tension pneumothorax Thrombosis, coronary = MI

Thrombosis, pulmonary (embolism)


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A patient presents complaining of being lightheaded. You decide to administer an EKG. Based on the results,

which of the following would be the proper treatment?

AtropineEpinephrine

Fluid replacement

Pacemaker

Adenosine

A 60 year old female presents complaining of heart palpitations and becomes unstable. Based on the following

EKG, which treatment would you administer?

Vagal stimulation

AdenosineDiltiazem

Beta-blockers

Cardioversion

A 74 year old male presents to the ED and is unresponsive. An EKG was administered and showed a rhythm

but a pulse is unable to be palpated anywhere. You decide that the patient has pulseless electrical activity and

you are unable to identify a reversible cause. What would be your next course of treatment?

Epinephrine

Dilitazem

Vagal stimulationCardioversion

Defibrillation

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