EMS A to Z: Tachydysrhythmias

Show Notes:

From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn

Patients with tachydysrhythmias may present in several ways: 

Palpitations

Chest pain

Dyspnea

Lightheadedness / dizziness

Altered mental status

Syncope

Weakness / fatigue

Nausea 

How do we assess / evaluate these patients? 

What are the patients characteristics and history?

Is this a healthy 24-year-old or a medically comorbid 70-year-old?

We can think about prior arrhythmias, coronary artery disease, renal disease (electrolyte abnormalities!), medications (digoxin!)

Is this patient “stable” or “unstable”?

Patient appearance (altered, pale, diaphoretic)

Vital signs (HR, BP, RR, SpO2)

ECG findings

Rate

Wide / narrow complexes

Rhythm – regular / irregular 

For the assessment, focus on evidence of cardiac / end organ dysfunction from hypoperfusion as a result of the arrhythmia!   

What is a strategy for assessing the ECG in these patients? 

Rate 

Rhythm regularity 

Complex width 

What specific rhythms can we see and how can we distinguish them?

Regular rhythm with narrow complexes:

Sinus tachycardia

SVT

Atrial flutter with RVR

Irregular rhythm with narrow complexes:

Atrial fibrillation with RVR

Wide complex tachycardia:

Ventricular tachycardia

Polymorphic ventricular tachycardia (torsades)

What therapies are available? 

Treat the underlying cause, if known

Example: a patient with obvious sepsis and sinus tachycardia or a-fib with RVR will likely benefit from treatment of the sepsis: IV fluid bolus, etc.

Example: a patient with v-tach / torsades and renal failure would benefit from magnesium and calcium with concern for hyperkalemia

Medications: consider adenosine (first line for SVT), calcium channel blockers (diltiazem, first line for atrial fibrillation with RVR), amiodarone(not typically first line)

Cardioversion: Synchronized at 120J then 200J if unsuccessful initially - if the patient is unstable!

What about patients with pacemakers? 

Pacemakers may malfunction and you may need to cardiovert patients with pacemakers in that scenario

Remember to place the external pads 10cm away from the pacemaker battery box as palpated, usually in the left upper chest wall

 

Credits:

Music: Scott Holmes Music

Sound effect: zapsplat.com