Treatment of Arrhythmias III- CardioRush

Reduced CO causes lowered cerebral, coronary, and renal perfusion, syncope, weakness, decompensation of CHF, death
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Reduced CO causes lowered cerebral, coronary, and renal perfusion, syncope, weakness, decompensation of CHF, death
What are some of the consequences of cardiac arrhythmias?
V fib, defibrillation
What is this rhythm and what is the treatment?
Image: V fib, defibrillation
Hemodynamic compromise, natural history, potential for further electrical instability or sudden death, potential for CHF or tachycardiomyopathy, risk benefit analysis
What is the decision on whether to treat a cardiac arrhythmia based on?
False (treat based on the patient, not the ECG)
True or false: you should always treat based on the rhythm on the ECG, not how the patient is feeling clinically
Cyclic variation in PP interval, slow to normal HR, varies with respiration, sometimes variable P wave height from wandering pacemaker, normal in dog and horse
What are the characteristics of sinus arrhythmia?
No treatment
Wha is the treatment for sinus arrhythmia?
Sinus arrhythmia, no treatment (cyclic variation in PP interval, P wave for every QRS)
What is this rhythm and recommended treatment?
Image: Sinus arrhythmia, no treatment (cyclic variation in PP interval, P wave for every QRS)
Sinus rhythm below low limits, typical complexes, regular rhythm
What are the characteristics of sinus bradycardia?
Normal hemodynamic status
When is it ok to NOT treat a sinus bradycardia?
Atropine, glycopyrrolate, sympathomimetics, pacing
What are some treatments for sinus bradycardia when needed, such as sinus node dysfunction?
Sinus bradycardia, treat with atropine, glycopyrrolate, sympathomimetics, or pacingWhat is this rhythm and recommended treatment (if needed)?Sinus rhythm over upper limit of HR, regular rhythm, normal complexesWhat are the characteristics of sinus tachycardia?Shock, hypovolemia, hypotension, fever, CHF, pain, hyperthyroidism, anxietyWhat are some underlying causes of sinus tachycardia?Sinus tachycardia, treat underlying causeWhat is this rhythm and recommended treatment?APC or AV junctional tissueWhat are the places that supraventricular premature depolarizations come from?Normal QRST, possible ectopic P prior, within or following QRS, non compensatory pauseWhat are the characteristics of supraventricular premature depolarizations?Frequent (no treatment if infrequent)When should we treat supraventricular premature depolarizations?APCs, no treatment if infrequent, treatment same as SVT if frequentWhat is this rhythm and recommended treatment?Beat originated lower than the SA node (AV node or lower atria)What does a negative P wave usually mean?P'What is it called if a P wave is negative?False (frequent APCs indicate more severe underlying heart disease)True or false: there is no reason to worry with APCs being present, even frequentlyRuns of beats originating in atria or AV junctional tissue >3 in number, QRST normal (possibly narrow), possible ectopic P', very regular and rapid, often abrupt start and stopWhat are the characteristics of SVT?OAVRTWhat is the most common cause of SVT in young labs or Boxers?SVTWhat is this rhythm?DiltiazemWhat is the preferred drug for treatment of SVT?Short acting, extended releaseWhat are the 2 formulations of diltiazem oral?Extended releaseWhich form of oral diltiazem is given more frequently?Open capsule, remove tablets from insideHow are the diltiazem extended release tablets given?False (good prognosis, accessory pathway can be ablated)True or false: OAVRT has a poor prognosis in most dogsDiltiazem, esmololWhat are some treatment options for rapid SVT requiring IV conversion?Diltiazem, sotalol, beta blockers, digoxin, procainamide, amiodaroneWhat are some options for oral treatment of SVT?A fibWhat is this rhythm?Chaotic, disjointed, usually rapid HR, irregularly irregular RR intervals, sometimes F waves, lack of organized P waves, variation in QRS heightWhat are the characteristics of atrial fibrillation on ECG?A fibWhat is this rhythm?Slow HR to improve cardiac fillingWhat is the goal of treatment of a fib if the patient has significant underlying heart disease?Convert to sinus rhythmWhat is the goal of treatment of a fib if the patient has no significant underlying heart disease (lone A fib)?Slow HRWhat is the goal of treatment of a fib is there is significant underlying heart disease?<140-160What HR is the goal while treating a fib in a dog?<180What HR is the goal while treating a fib in a cat?<50What HR is the goal while treating a fib in a horse?Amiodarone, Beta blocker, Ca channel blocker (Diltiazem), DigoxinWhat are the 4 most common medications used to slow AV conduction?Digoxin and diltiazemWhat is the most common combination of drugs used to treat a fib with underlying heart disease?TrueTrue or false: combining digoxin and diltiazem is more effective in lowering the HR than either drug used aloneConvert to sinus rhythmWhat is the goal of treating a fib if there is NO significant underlying heart disease, such as in horses or large breed dogs?QuinidineWhat is the drug of choice when trying to convert horses to sinus rhythm?DigoxinWhat drug is used before quinidine to reduce the HR in horses?False (Only used in a hospital environment due to high side effect profile)True or false: Quinidine can be used in any environment in horses, it is a safe drug with a low side effect profileDiltiazem, sotalol, class I drugsWhat drugs have there been anecdotal reports of converting horses from a fib to sinus rhythm?AmiodaroneWhat drug other than quinidine is more commonly used in horses with a fib to convert to sinus rhythm?ECG synchronized cardioversionIf drugs fail to convert horses to sinus rhythm from a fib, what is another option for treatment?ARVCWhat is the most likely cause of R on T ventricular tachycardia in a Boxer?Run of premature ectopic impulses from the ventricle >3, wide and bizarre, Large T wave in opposite direction of QRS, ST segment slurringWhat are the characteristics of ventricular tachycardia on ECG?Developing v fibWhat is the risk of R on T v tach?Lidocaine bolus, CRIWhat is the first choice therapy for V tach on emergency presentation?Procainamide, esmolol, sotalol, amiodarone, synchronized cardioversionWhat are some options for emergency treatment of V tach if lidocaine doesn't control arrhythmia?Sotalol, sotalol and mexiletine, mexiletine and atenolol, amiodaroneWhat are some options for chronic management of V tach?Acid base status, electrolytes, hypoxemia, anemia, blood volume, pain, drug toxWhat are some systemic diseases that may result in ventricular arrhythmias if there is no found underlying cardiac disease?IndefinitelyHow long do you treat for management of ventricular arrhythmias if the cause is underlying heart disease?While in hospital, wean when sending homeHow long do you treat for management of ventricular arrhythmias if the cause is underlying systemic disease?False (very difficult to totally control arrhythmia, other metrics are used for success)True or false: treatment of ventricular arrhythmia is only considered effective if the patient is converted to normal sinus rhythmElimination of sustained V tach, scary arrhythmias, and clinical signsWhat is the goal of management of ventricular arrhythmias?Sustained V tach, R on T, rapid ventricular arrhythmiasWhat are some examples of scary ventricular arrhythmias?Accelerated idioventricular rhythmWhat is this rhythm?Accelerated idioventricular rhythmWhat is the term for runs of VPCs at a normal or slightly elevated HR?No treatmentWhat is the therapy for accelerated idioventricular rhythm?Chaotic, disorganized activation of ventricles, irregular undulations in baseline, CO drops to 0What characterizes ventricular fibrillation on ECG?V fibWhat is this rhythm?Electrical DC countershock (defibrillation)What is the only reliable way to convert ventricular fibrillation?Current must traverse heart, all cells depolarize at once, repeated shocks if needed, CPR, epi, amiodarone, MgWhat must occur during defibrillation for successful conversion to a more normal rhythm?Sick Sinus SyndromeWhat is this rhythm?Periods of sinus arrest followed by paroxysm on SVTWhat characterizes sick sinus syndrome on ECG?False (syncope may be caused by either periods of brady or tachycardia)True or false: in sick sinus syndrome, only periods of bradycardia will result in syncopeOlder female Schnauzers, Westies, PugsWhat animals are predisposed to sick sinus syndrome?False (not usually life threatening unless under anesthesia)True or false: the arrhythmia in sick sinus syndrome is always life threateningExternal cardiac pacingWhat should you ALWAYS do for dogs with sick sinus syndrome under anesthesia?Atropine response testWhat test can be used in sick sinus syndrome to see if they are amenable to treatment?Propantheline bromide, theophylline, terbutalineWhat are some options for medical management of sick sinus syndrome if they are positive on an atropine response test?TerbutalineWhat medication used to manage sick sinus syndrome has a higher risk of side effects?Permanent pacemakerWhat is the treatment for sick sinus syndrome is they are negative on the atropine response test?Absolute absence of atrial activity, P wavesWhat characterizes atrial standstill on ECG?Atrial standstillWhat is this rhythm?Atrial muscle dystrophy, hyperkalemia, hypothermia, terminal eventWhat are some causes of atrial standstill?Labs, springer spanielsWhat breeds are predisposed to atrial muscular dystrophy?Only pacemaker in AMD, correct underlying factors in othersWhat is the treatment for atrial standstill?NaCL IVF, Ca gluconate, Na bicarbonate, dextroseWhat is the treatment for hypokalemia that results in atrial standstill?Minor delay in AV conduction, prolonged PR intervalWhat characterizes first degree AV block?More advanced conduction disturbances, some P waves not conducted to ventriclesWhat characterizes second degree AV block?Complete block, no P waves conducted, atria and ventricles beat independentlyWhat characterizes third degree AV block?Second degree AV blockWhat is this rhythm?Second degree AV blockWhat is this rhythm?No treatment, avoid drugs that worsen AV blockWhat is the treatment for first degree AV block?High grade second degree AV block (some P waves still conducted)What is this rhythm?High grade second degree AV block (some P waves still conducted)What is this rhythm?Third degree AV blockWhat is this rhythm?No therapy required, should respond to atropineWhat is the treatment for Mobitz type I (Wenckeback) second degree AV block?PacemakerWhat is the treatment for Mobitz type II second degree AV block?Permanent pacemakerWhat is the treatment for third degree AV block?Sudden death, syncope, bradycardia induced CHFWhat is the risk in third degree AV block?Suppresses escape rhythmsWhy can't we treat dogs with ventricular arrhythmias that have atrial standstill before a pacemaker is placed?False (Dog has 3rd degree AV block with ventricular arrhythmia, treating with lidocaine would suppress the ventricular escape rhythm and no pulse would be left)True or false: It is appropriate to treat this dog with lidocaine upon presentation in the ERSome SSS dogs, minimally symptomatic animalsWhen is medical management indicated for patients with bradycardias?Sympathomimetics, vagolyticsWhat are some examples of drugs that can be used in management of bradycardias?Theophylline, terbutaline, isoproterenolWhat are some examples of sympathomimetics that can be used in medical management of bradycardias?Hypotension, v tach, v fibWhat are some side effects of isoproterenol?Atropine, glycopyrrolate, propantheline bromideWhat are some examples of vagolytics that can be used in medical management of bradycardias?Temporary transvenous pacing lead, transthoracic pacing, permanent pacemaker implantationWhat are the options for pacing in bradycardias?False (requires heavy sedation or general anesthesia)True or false: transthoracic pacing can be performed on an awake animalPermanent pacemakerWhat is the only definitive therapy for AV block?Pulse generator, leadwireWhat are the components of a cardiac pacemaker?Transvenous, transthoracicWhat are the options for temporary cardiac pacing?Transvenous, epicardialWhat are the options for permanent cardiac pacing?DogsIn what species is transvenous cardiac pacing more commonly used?CatsIn what species is epicardial cardiac pacing more commonly used?Clots in CVC, chylous effusionWhat happens when a transvenous pacemaker is used in cats?Animal sedated, minimum HR set on machine, shock delivered if HR falls below set limitWhat happens in transthoracic temporary pacing?Perforation and pericardial effusion (esp in small dogs), in contact with diaphragm and paces itWhat is the risk of screwing the pace leadwire into the myocardium?Ventricular origin beatsWhat is the normal ECG for animals with a pacemaker?Check placement, baseline for comparison to check for movement in futureWhy should you always get a radiograph immediately after placing a pacemaker?AV synchrony, more physiologicWhat is the benefit of a dual chamber lead pacemaker?Can't be fixed in place, higher risk of dislodgingWhat is the risk of using a dual chamber lead pacemaker?>19 months (many live over 3 years)What is the mean survival of a dog after pacemaker placement?20%What is the complication rate in animals with pacemakers?Leadwire dislodgement/fracture, infection, battery failure, progression of cardiac diseaseWhat are some complications from pacemakers that can occur in dogs?Twiddlers syndromeWhat is the term for when the leadwire can be twisted, causing the lead to back out of the ventricle?False (often well tolerated in cats)True or false: third degree AV block is often fatal in cats without pacemaker placement100What is typically the mean escape beat HR in cats with third degree AV block?Transdiaphragmatic epicardial pacemakerWhat type of pacemaker is placed in cats with symptomatic third degree AV block?