Ventricular Arrhythmias :Ventricular Arrhythmias EMS Professions Temple College


Analyze the Rhythm :Analyze the Rhythm


Analyze the Rhythm :Analyze the Rhythm


Analyze the Rhythm :Analyze the Rhythm


Premature Ventricular Complexes (PVCs) :Premature Ventricular Complexes (PVCs) Definitions Early depolarization of the ventricles Occur as a result of automaticity or reentry A PVC is a characteristic of an underlying ECG rhythm PVC is not the name of a dysrhythmia


Premature Ventricular Complexes :Premature Ventricular Complexes Causes Hypoxia Myocardial Ischemia Electrolyte Imbalance Digitalis Toxicity Stimulants Chronic Heart Disease (CHF, COPD)


Premature Ventricular Complexes (PVCs) :Premature Ventricular Complexes (PVCs) Characteristics Complex is earlier than expected Wide QRS (wide is not always ventricular) OFTEN has a compensatory pause Usually irregular Not preceded by a P wave T wave opposite deflection May or may not result in perfused beat


Premature Ventricular Complexes (PVCs) :Premature Ventricular Complexes (PVCs) More Terms to Know Unifocal, Multifocal R on T Phenomenon Bigeminy, Trigeminy, Quadrigeminy, Couplet


Premature Ventricular Complexes (PVCs) :Premature Ventricular Complexes (PVCs) PVCs are not always dangerous Common for some people Consider treating PVCs if: >6/minute associated with: Severe Chest pain Hypotension, Decreased Perfusion Shortness of Breath


Premature Ventricular Complexes (PVCs) :Premature Ventricular Complexes (PVCs) Treat PVCs if consistently see any of the following with other symptoms: Multifocal Ventricular Couplets Runs of Ventricular Tachycardia R on T Phenomenon (Malignant PVCs)


Premature Ventricular Complexes (PVCs) :Premature Ventricular Complexes (PVCs) Management (Rate <60) Oxygen & Ventilation are initial treatments for ALL ectopic beats ECG Monitor, IV NS TKO assess the underlying rhythm Treat like bradycardia Atropine TCP Dopamine


Premature Ventricular Complexes (PVCs) :Premature Ventricular Complexes (PVCs) Management (Rate >60) Oxygen & Ventilation are initial treatments for ALL ectopic beats ECG Monitor, IV NS TKO assess the underlying rhythm If symptomatic (see previous):


Premature Ventricular Complexes (PVCs) :Premature Ventricular Complexes (PVCs) Management (Rate >60) Lidocaine IV Bolus, 1 - 1.5 mg/kg Infusion, 1 - 4mg/min Repeat IV push 0.5 - 0.75 mg/kg every 5 minutes to 3 mg/kg max Increase Infusion 1mg/min for every 1mg/kg IV bolus given


Premature Ventricular Complexes (PVCs) :Premature Ventricular Complexes (PVCs) Management (Rate >60) Procainamide 20 mg/min IV until: PVCs suppressed 17 mg/kg given Hypotension occurs QRS widens by 50% or more Continuous infusion at 1 - 4 mg/min


Premature Ventricular Complexes (PVCs) :Premature Ventricular Complexes (PVCs) Management (Rate >60) Bretylium IV push, 5 mg/kg slowly Infusion, 1 - 2 mg/min Used less frequently today due to supply shortage


Analyze the Rhythm :Analyze the Rhythm


Idioventricular Rhythm :Idioventricular Rhythm Causes Myocardial ischemia Hypoxia High vagal tone Drug effects


Idioventricular Rhythm :Idioventricular Rhythm Characteristics A ventricular focus takes over as an escape pacemaker site Rate 20 - 40 bpm Wide QRS complexes No P waves


Idioventricular Rhythm :Idioventricular Rhythm Management Slow rate will probably decrease cardiac output Usually a later and often pre-terminal rhythm If symptomatic, treat as unstable bradycardia Do NOT give Lidocaine or other ventricular antidysrhythmics!!!!!!!


Analyze the Rhythm :Analyze the Rhythm


Accelerated Idioventricular Rhythm :Accelerated Idioventricular Rhythm Characteristics Like Idioventricular rhythm except for rate Rate, greater than 40 bpm but less than 100 bpm


Accelerated Idioventricular Rhythm :Accelerated Idioventricular Rhythm Management Patient may maintain adequate cardiac output Identify underlying cause and treat!!! Monitor cardiac output and perfusion Often a late and pre-terminal rhythm Do NOT give Lidocaine or other antidysrhythmics!!!!!!!


Analyze the Rhythm :Analyze the Rhythm


Ventricular Tachycardia (VT) :Ventricular Tachycardia (VT) Causes Myocardial ischemia Hypoxia Electrolyte imbalance Digitalis toxicity Myocardial trauma


Ventricular Tachycardia (VT) :Ventricular Tachycardia (VT) Characteristics Pacemaker site Irritable ventricular focus takes over as pacemaker site, OR May result from multiple ventricular foci attempting to become pacemaker site Complexes look similar to PVCs May see P waves before complexes but uncommon Rate, usually between 100 and 250 bpm


Ventricular Tachycardia (VT) :Ventricular Tachycardia (VT) Complications Can decrease cardiac output Increases cardiac workload Decreases coronary perfusion Can quickly deteriorate into V-fib


Ventricular Tachycardia (VT) :Ventricular Tachycardia (VT) Types Monomorphic QRS complexes all have same morphology Polymorphic QRS complexes have more than one morphology “Torsades de Pointes” “Twisting of the points” Usually > 200 bpm Susceptible if slow repolarization (long QT)


Ventricular Tachycardia (VT) :Ventricular Tachycardia (VT) Treatment of Stable and Unstable Oxygen, Ventilations, Assess Pulse ECG Monitor If unstable, proceed to synchronized cardioversion IV NS TKO Determine monomorphic vs polymorphic If wide complex of unknown origin, attempt 12 lead ECG to determine


Ventricular Tachycardia Treatment: Monomorphic :Ventricular Tachycardia Treatment: Monomorphic Treatment of Stable (limit to one antidysrhythmic) procainamide 20 mg/min IV avoid if poor cardiac function amiodarone 150 mg slow IV (15 mg/min) lidocaine 1.0 mg/kg IV (max 3.0 mg/kg) Begin with 0.5 - 0.75 mg/kg poor cardiac function Follow with lidocaine infusion, 1 - 4 mg/min synchronized cardioversion


Tachycardia: Wide Complex (VT) Polymorphic (Torsades) :Tachycardia: Wide Complex (VT) Polymorphic (Torsades) Treatment (limit to one antidysrhythmic) Normal QT Lidocaine, 1 - 1.5 mg/kg IV (max 3.0 mg/kg), repeat @ 0.5-0.75 mg/kg q 5 min to max 3 mg/kg Amiodarone, 150 mg slow IV (15 mg/min) Procainamide, 20 mg/min until PVCs suppressed 17 mg/kg given Hypotension occurs QRS widens by 50% or more Then, infusion at 1 - 4 mg/min


Tachycardia: Wide Complex (VT) Polymorphic (Torsades) :Tachycardia: Wide Complex (VT) Polymorphic (Torsades) Treatment (limit to one antidysrhythmic) Long QT (including Torsades w/o arrest) Magnesium sulfate 10%, 1-2 g slow IV over 5 mins or greater Lidocaine, 1 - 1.5 mg/kg IV (max 3.0 mg/kg), repeat @ 0.5-0.75 mg/kg q 5 min to max 3 mg/kg Other considerations phenytoin, isoproterenol, or overdrive pacing


Interesting Questions :Interesting Questions What is a capture beat? What is a fusion beat? How do they help or hurt you in your ECG interpretation?