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Bradycardia Assessment and Management
This document discusses the classification, causes, symptoms, and treatment of bradycardia. It defines different types of bradycardia based on rhythm and heart block. Common causes include medications, cardiac disease, metabolic abnormalities, and neurological or infectious etiologies. Symptoms range from dizziness to hypotension and shock. Treatment follows ACLS algorithms and may include atropine, transcutaneous pacing, or addressing underlying causes. Case examples demonstrate ECG findings and management of hyperkalemia-induced complete heart block, athlete's heart, and inferior STEMI with complete heart block.
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Introduction to bradycardia and its assessment by Callum Addison.
Detailed classification into narrow/wide complexes and types of bradydysrhythmias.
Presenting ECG readings relevant to bradycardia classification.
Detailed classification into narrow/wide complexes and types of bradydysrhythmias.
Comprehensive look at physiological, medication-related, cardiac, metabolic, neurological causes.
Discusses physiological sinus bradycardia and ECG changes during ischemia.
Details treatment medications like atropine and alternative agents for bradycardia.
Discusses physiological sinus bradycardia and ECG changes during ischemia.
Outlines symptoms like dizziness and treatment considerations under unstable conditions.
Introduces algorithms for treatment, emphasizing ACLS guidelines for bradycardia management.
Introduces algorithms for treatment, emphasizing ACLS guidelines for bradycardia management.
Discusses transcutaneous pacing indications, procedures, and contraindications.
Introduces algorithms for treatment, emphasizing ACLS guidelines for bradycardia management.
Discusses transcutaneous pacing indications, procedures, and contraindications.
Discusses transcutaneous pacing indications, procedures, and contraindications.
Detailed classification into narrow/wide complexes and types of bradydysrhythmias.
Multiple case studies illustrating assessment, causes, and management of bradycardia.
Summarizes key points on bradycardia management and emphasizes regular assessments.
Introduction to the LIFEPAK 20/20E for noninvasive pacing demonstration.
List of resources for further study on bradycardia and related clinical guidelines.
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Bradycardia Assessment and Management
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- 2. ● Narrow Complex: ●Wide Complex Classifying Bradydysrhythmias Regular Irregular Sinus bradycardia Sinus arrhythmia Complete AV Block (junctional escape) Mobitz Type I+2 Atrial flutter with high degree block Atrial flutter with variable block. Regular Irregular Sinoventricular rhythm Sinoatrial exit block with BBB Complete AV Block (ventricular escape) Mobitz Type I+2 Atrial flutter with high degree block Irregular bradycardias with BBB
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- 6. Classification (cont) ● SinusBradycardia ● Sinus node dysfunction Sinoatrial exit block Sinus arrest – pause > 3 seconds ● Sick sinus syndrome. ● AV 1st degree HB 2nd degree HB – Mobitz I + II 3rd degree HB Junctional escape ● Ventricular escape rhythm
- 7. Causes ● Physiological ● Medications– AV nodal blockade, cholinergic crisis ● Cardiac disease – Ischaemia, myocarditis, cardiomyopathies, HIS- purkinje fibre degeneration ● Metabolic/Endocrine – Anorexia, hyperkalaemia, hypothyroidism ● Neurological ● Autoimmune – SLE, sarcoidosis, amyloidosis ● Infections – Lyme disease, diptheria, typhoid fever ● Hypoxia/Hypothermia ● Surgery
- 8. Sinus Bradycardia ● Physiological Athletes RespiratorySinus Arrhythmia Sleep:
- 10. Medications ● AV nodalblocking drugs (Class II, Class IV, Digoxin, Amiodarone) ● Organophosphates ● Clonidine ● Spot Quiz – Which organophosphate was recently used to assassinate the step-brother of a well known political figure.
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- 12. Ischaemia ● Up to30% of patient with inferior STEMI will develop second or third degree AV block. ● Associated with an increased in-hospital mortality. ● Inferior myocardial wall and the SA/AV nodes are usually all supplied by the right coronary artery
- 13. Raised ICP ● Cushingresponse. ● Raised BP, Bradycardia, Irregular breathing. ● Bradycardia is due to the baroreceptor response to the sympathetic efforts to increase cerebral perfusion – or mechanical distortion of the vagus nerve
- 14. Symptomatic Dizziness, light headedness,palpitations, fatigue, exercise intolerance. Unstable ● Neuro: GCS, Syncope ● Respiratory: SOB, Pulmonary congestion ● CVS: Hypotension, shock, CHF, ACS. Symptoms
- 15. Treatment Algorithm ● ABCManagement ● IV Access/O2/Vitals/ECG ● Assess for and treat underlying causes ● As per ACLS
- 16. ACLS Algorithm ncreases firingof the SA Node by blocking the action of the vagus nerv
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- 18. Atropine ● Competitive muscarinicantagonist - Anticholinesterase inhibitor ● Increases firing of the SA Node by blocking the action of the vagus nerve. ● Onset of action ~ 1 minute ● Duration of action 30 – 60 minutes. ● The first drug of choice for symptomatic bradycardia. ● Dose in the Bradycardia ACLS algorithm is 0.5mg IV push and may repeat up to a total dose of 3mg.
- 19. Spot Quiz –Who Am I ● Invasive Pest ● Solanaceae family ● Contains Tropane alkaloids
- 20. Transcutaneous Pacing ● Non-invasivepacing is used on a temporary basis until the patient is stabilized and either an adequate intrinsic rhythm has returned or a transvenous pacemaker is inserted, whether temporary or permanent.
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- 22. Alternative Agents ● Adrenaline(second line agent). Non-selective A/B agonist. 2-10mcg/min Titrated to maintain a satisfactory HR. ● Dopamine – 2-10mcg/kg/min ● Isoprenaline – 2.5mcg/min
- 23. Transcutaneous Pacing ● Indications Patientwith symptomatic bradycardia and a palpable pulse who has not responded to pharmacological therapy (or no IV access able to be established). High-grade AV blockade (3rd degree heart block or unstable mobitz type II. Cardiac arrest with ventricular standstill, but atrial activity present. ● Recent asystole. ● Contraindication Asystolic cardiac arrest
- 24. Transcutaneous Pacing ● Forpacing readiness (i.e. standby mode) in the setting of acute myocardial infarction (AMI) with the following: Symptomatic sinus bradycardia Mobitz type II second-degree AV block Third-degree AV block New left, right or alternating bundle branch block or bifascicular block
- 25. Transcutaneous Pacing -Procedure ● O2 and IV Access. ● Sedation unless contraindicated. ● Placement of pads on clean, dry, shaven skin. ● Pacing mode with rate 60-80 bpm. ● Begin pacing at 5mA amp, increase amperage in 5mA increments until visible electrical capture- (QRS-T complexes after each pacing spike). ● Check pulse for mechanical capture. ● Increase by a further 5mA after capture.
- 26. Classification of Bradycardia ●Absolute or Relative ● Functional or relative bradycardia occurs when a patient may have a heart rate within normal sinus range, but the heart rate is insufficient for the patients condition. An example would be a patient with an heart rate of 80 bpm when they are experiencing septic shock. ● Narrow or Wide Complex ● Regular or irregular ● Sinus vs Sick Sinus vs AV nodal vs Ventricular
- 27. Case 1 ● 68year old female. ● Presents with an episode of syncope on a background of 1 week of vomiting and poor oral intake. ● GCS 14 on arrival, HR 34, BP 80/53 ● PMHx: HTN, CHF ● Medx: Spironolactone, Bisoprolol.
- 28. Case 1 (cont) ●K+ of 7.8 ● Responded to IV calcium gluconate, IV insulin dextrose and inhaled salbutamol. ● Always consider the diagnosis of hyperkalaemia in patients presenting with bradycardia or complete heart block. ).
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- 30. Case 1 (cont) ●Severe bradycardia (HR ~ 30 bpm) ● Symmetrically peaked T waves in V2-5 ● Flattening, broadening and near-disappearance of P waves (still barely visible in V1-3) ● Prolongation of the PR interval ● Broad QRS complexes (~120 ms)
- 31. Case 2 ● 48year old presents with sharp pleuritic chest pain after playing a game of squash today. ● PMHx: BPH, Meningioma. ● Fhx: CAD. ● No recent immobilization or surgical history. ● O/E Haemodynamically stable WNL. 3rd heart sound heard.
- 32. Athlete's Heart ● Regularphysical activity leads to physiological adaptions in cardiac dimensions. Primarily LV wall thickness and cavity size. ● Enhanced diastolic filling with increased stroke volume and cardiac output. ● Subsequent bradycardia, repolarization abnormalities and voltage criteria for chamber enlargement. ● Accentuated antagonism.
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- 34. Athlete's heart. ● Electrocardiographicfindings that are common, training-related, normalize with exercise and that do not require additional evaluation are: ● Sinus bradycardia ● 1° atrioventricular block or mobitz 1 are common. ● Incomplete right bundle branch block (BBB) ● Early repolarization. ● Isolated voltage criteria for left ventricular hypertrophy (LVH).
- 35. Athlete's Heart (cont) ●With voltage criteria for LVH, pathological hypertrophy should be suspected in any of the following: ● Left atrial enlargement, ● Left-axis deviation, ● Repolarization abnormalities, ● Pathological Q waves. ● T-wave inversion ≥2 mm in ≥2 adjacent leads.
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- 37. Case 3 ● 74year old lady with sudden onset 30 minute episode of crushing central chest pain, radiating to neck and associated with diaphoresis and palpitations. ● Previous similar episodes for the last 6 months on exertion however only mild in severity. ● PMHx: Diabetic, HTN, Hypercholesterolaemia. ● Shx: Smoker ● O/E – HR 42, BP 102/60, Sats 97% on RA.
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- 39. Case 3 (cont) ●Regular, narrow complex bradycardia. ● Ventricular rate of 43 BPM. ● Complete AV block. ● Likely junctional escape rhythm. ● Significant ST elevation in leads II, III, and AVF, with reciprocal ST depression in leads I and AVL, all suggestive of an inferior STEMI.
- 40. Case 3 (cont) ●Inferior STEMI with RV infarction was diagnosed. ● IV fluids were given. ● Aspirin, Ticagrelor and Heparin were given ● Patient taken to cath lab: ● Coronary angiography revealed an acute thrombus with 100% occlusion of the proximal Right Coronary Artery (proximal to the right ventricular marginal branch), successfully stented and reduced.
- 41. Summary ● Remember ABC'ss ●Assess and treat underlying causes ● Reassess regularly for changes in rhythm. ● Decision to treat largely based on haemodynamic stability and risk of asystole. ● Clear algorithms provided by APLS/ACLS available for treatment.
- 42. LIFEPAK 20/20E Defibrillator/Monitor Noninvasive(Transcutaneous) Pacing Demonstration video (4 minutes). ● https://www.youtube.com/watch? v=Nb0fDABC6UY
- 43. References/Further Reading ● ACLS/APLSAustralia ● Australian Resuscitation Council ● Textbook of Cardiology.org ● Family Practice Notebook ● LITFL ● Dr Smith's ECG Blog ● Dr Venkatesan.com ● Department of Agriculture and Food.