Transition into

Practice Series
(TIPS)
ARRHYTHMIC PATIENT
Approach to ECG

 Four things will tell you what the rhythm/arrhythmia is

 Fast vs Slow
 Regular vs Irregular
 Narrow vs Wide
 Association of Ps-QRS’s

 If want to do more practice of rhythm identification then useful

website is Skillstat “6 Second ECG”
Approach to Dysrhythmic Patient

 Rhythm -> Needs to PERFUSE

 i.e. if going to cause significant issues then would become a C problem

 Conscious/Uncompromised -> Conscious but symptoms -> Unconscious

 Main questions
 Perfusion
 Brain perfusion (is patient conscious/confused or not)
 Heart perfusion (ischaemic heart pain or not)
 Renal perfusion (making urine or not)
 Skin perfusion (cold/mottled or not)
 Heart Failure/Fluid status
BRADYCARDIA

 Causes (rhythm)
• Sinus bradycardia
• Atrial fibrillation with slow ventricular rate
• Heart blocks (generally 2nd Degree or 3rd Degree)
• Junctional or Ventricular escape rhythm

 Causes (problem) – Bradycardics “DIE from Time to Time”

 Drugs
 Ischaemia (cardiac or generalised hypoxia)
 Electrolytes (esp. hyperK)
 Temperature (hypo)
 Thyroid (hypo)
Approach to Bradycardic Patient

 History/Exam
 History for causes as per previous slide
 History/exam for “Serious signs/symptoms” and fluid status
 Insufficient perfusion
 Heart failure
 Temperature
 Investigations
 12 lead ECG
 Bloods (electrolytes/thyroid)
Management of Bradycardic Patient

 Assessment regarding acuity of management

 If haemodynamic concerns/heart failure -> early help!
 Things you can do as House Officer
 Medication history
 ECG
 IV access + bloods
 If concerned about haemodynamics -> resuscitation trolley nearby +/- pads
on (depending how concerned you are)
 Whats NOT expected of you
 Pacing patient
Things that can be done (NOT
expected by you)
 Chemical pacing
 Atropine
 Isoprenaline
 Adrenaline
 Transcutaneous pacing
 Often less desired as requires sedation
 Transvenous pacing
TACHYCARDIA

 Causes (rhythm)
 Sinus tachycardia
 Atrial fibrillation/flutter
 Atrial tachycardias
 “SVT”
 Ventricular tachycardia
 Ventricular fibrillation
Approach to Tachycardic Patient

 History/Exam
 History -> why are they in front of you
 Is this a primary arrhythmia or other problem driving (i.e. PE, sepsis)
 Have they had this problem before
 Lots of people have had AF/SVT -> come in with AF/SVT again

 History/exam for “Serious signs/symptoms” and fluid status

 Insufficient perfusion
 Heart failure
 Investigations
 12 lead ECG
 Bloods (FBC/electrolytes/thyroid)
 Specific investigations as to cause i.e. CTPA for ?PE etc
Management of Tachycardic Patient

 Assessment regarding acuity of management

 If haemodynamic concerns/heart failure -> early help!
 Things you can do as House Officer
 Medication history
 ECG
 IV access + bloods
 If concerned about haemodynamics -> resuscitation trolley nearby +/- pads
on (depending how concerned you are)
 Whats NOT expected of you
 Cardioverting patient (either chemically or electrically)
Haemodynamically Unstable

 Haemodynamically unstable tachycardic patient

 Indication for acute cardioversion (electrical cardioversion)
 If arrested -> defibrillation (i.e. unsynchronised)
Atrial Fibrillation/Flutter

 Benign rhythm (i.e. patient will not suddenly drop dead from THIS
rhythm) of the atria which is VERY common
 ~1/4 adults >80years old will be in AF

 Has patient had before/known to be in this rhythm

 Primary arrhythmia vs driven by something else
Approach to “Fast AF”

 ABCs
 History/Exam
 Why is patient in this rhythm
 Primary problem or due to something else
 Fluid status (VERY important)
 Medication history

 Investigations
 12 lead
 Bloods (electrolytes/renal function)
 CXR (?evidence of CHF)
Management

 Optomise fluid status/treat underlying problem

 If hypovolaemic -> fluid bolus
 If hypervolaemic -> furosemide
 Optomise electrolytes (in particular K/Mg)
 Consider if rate control required
 What to use?
 Beta blockers generally considered first line
 Digoxin useful in patients with heart failure
 Amiodarone (chat with senior) – useful for rapid control/septic patients
Summary

 Dysrhythmic Patient
 ABCs (are they haemodynamically unstable/compromised/normal)
 Medications
 Fluid status
 IV access + bloods taken
 12 lead ECG/telemetry
 Call for help early if concerns