3. Fast, irregular, broad complex tachy
WPW AF until proved otherwise
Rare but important
We can kill young people with wrong Rx
Rx?

4. WPW AF
Electricity or Procainamide
200J
Sync or unsynch?

5. Synch if they have a pulse

6. Sedation for cardioversion
Get senior help if you have time
Otherwise
 Fentanyl eg 100mcg, or 50mcg in frail elderly +
 Midazolam 1-2mg IV

8. VF
 Shock 200J un-synch
 CPR 2 min
 Check rhythm
 Repeat PRN
 Adrenaline 1mg after 2nd
shock and every 3 minutes
 Amiodarone 300mg in after 3nd
shock

9. No pulse

10. Wide complex tachy
No pulse
Treatment as forVT

11. Pulse normal BP, no CP

12. Wide complex tachy
Rx electricity
200J synched

13. Key questions?

14. Fast AF with CP and hypotension
Is there anything driving the AF?
 Sepsis, CCF, dehydration
How long has she been in AF?
 Chronic AF unlikely to cardiovert and may throw of a clot if
does cardiovert

15. Fast AF with CP and hypotension
New onset ( < 48 hours): fluid load, phenylephrine,
analgese (fentanyl) sedate and cardiovert
Chronic AF: fluid load, phenylephrine, analgese (fentanyl)
+/- treat for ACS

16. Pure alpha = vasoconstriction

17. 10mg vial in 100ml Normal Saline
= 1mg in 10ml
= 100mcg in 1ml
2ml bolus = 200mcg

18. 13 year old male with palpitation while playing play station
Hx of asthma and recent knee surgery

19. Questions?
Comments?
Suggestions?

20. Sinus tachy or SVT?

21. Sinus tachy or SVT?
Sinus tachy
 P waves
 Rate varies – watch the monitor
 Will slow with reassurance, analgesia
 Usually caused by something eg pain, illness
 Not usually the presenting complaint
 Gradual onset and offset
SVT
 Fast onset
 Constant rate – watch the monitor
 Usually presenting complaint

23. SVT
Management?

24. SVT
Vagal manoeuvres
 Valsalva
 Carotid sinus massage (age < 60)
 Face in ice water
Adenosine
 Big IV line
 Can mix with big flush
 12, 18mg
Verapamil
 5mg IV

25. Dialysis patient

26. Hyper K
Treatment?

27. Hyper K
Salbutamol 10mg neb
Calcium gluconate 1 amp = 10mmol
Arrange urgent dialysis
Then think about glucose + insulin, HCO3
Resonium probably does more harm than good

28. 40M, drowsy, BP 90/60. Hx of depression.

29. TCA overdose
HCO3 1-2mmol/kg, repeat ? Q5min till QRS < 120ms
Intubate
Hyperventilate

31. Sinus tachy with LBBB

32. 70M, CP, hypotensive

33. 70M, CP, hypotensive
Inferior MI
Do a R sided ECG – may well have a R ventricular infarct
Try atropine – unlikely to work
Avoid GTN, avoid morphine (use fentanyl for pain)
FLUID LOAD (may need litres of fluid) before trying pacing
/ inotropes
Reperfuse ASAP – PCI preferred

36. Other options for bradycardia
 Consider toxins
 Digoxin
 Beta blocker
 Calcium channel blocker
 -> specific treatments
 Otherwise
 Atropine
 Transcutaneous pacing
 Transvenous pacing
 Chronotrope eg isoprenaline/dopamine
 Bypass / ECMO

37. Narrow ComplexTachy
Narrow complex regular
 Sinus tachy: treat cause
 SVT: Vagal; adenosine; verapamil or diltiazem
Narrow complex irregular
 Treat driver eg CCF, sepsis, ischaemia, hypoxia
 If still too fast or rate contributing to ischaemia or ↓BP
 < 48 hours: cardiovert + anticoagulation
 > 48 hours: rate control + anticoagulation
↓BP: fluid, phenylephrine, diltiazem, magnesium or
amiodarone
Normal BP: diltiazem or beta blocker

38. Wide ComplexTachy
 Treat cause
Na channel blockers esp tricycylics -> bicarb and
hyperventilation
HyperK: Salbutamol, calcium gluconate etc
Prolonged QT ie Torsades: Mag
 Otherwise: electrical cardioversion

39. Bradycardia
Consider RV infarct -> fluid loading
Consider toxins -> specific treatments
Atropine
Transcutaneous then transvenous pacing
Isoprenaline / dopamine

40. References
See http://emtutorials.com/2013/05/funky-rhythms/ for
references