and this afternoon we're gonna spend some time talking about dysrhythmia a tough dish with me at diagnosis and my name is Alma - I'm a faculty member at University of Maryland School of Medicine I've been there since 1996 and practice emergency medicine and I developed a very strong interest in electric car iographer a number of years ago partially related to my kids which for those of you that were in the first earlier afternoon session you understand but all it gets that's another story so anyway I'm how many of you are here from the first session so oh wow wow thanks I'm sure some of you might be feeling a little bit like this at this point so um appreciate your your efforts how many of you I'm always curious to find this out how many of you are new to Las Vegas is your first trip to Vegas anyone so Wow a few people all right how many is your second trip to Vegas alright so for a lot of us we keep coming back to vases over and over because it seems like every conference is migrated here it used to be New Orleans in San Francisco but then after Katrina everything started coming here and and San Francisco is still out there but everything seems to come to Vegas so I come over and over and over for you folks that are new to Vegas I always like to give you some warnings about Las Vegas is first of all it's not the healthiest city in the country alright in in fact you might find it ironic but there's actually a hotel called LVH unbelievably it's incredible I guess you have to have severe hypertension to be able to check into this hotel and amongst the other places in in Vegas is something called the Heart Attack Grill has any of you ever eaten there and survived so one person excellent so did you need a trip to the hospital afterwards or no no anyone else anyone know someone who ate there and died no okay there there are actually a few people that have believe it or not and what do you think happens to attendants every time something like that hits the news it skyrockets yeah actually so one of my friends and I actually went out there just to check it out I figure I'd do these lectures on emergency cardiology I've got to check this place out and it's a very interesting place this in old kind of old town Las Vegas so it's at the other end of the strip and so here are some of the folks that work these are not real nurses by the way but they dressed in nursing costumes you see the little captions bottom tastes worth dying for and they really revel in how unhealthy a lot of their food is this is a guy who was one of their unofficial spokesman who actually true story he actually died outside the restaurant and there have been a couple of other people that have eaten there and have to had to go to the hospital and I remember hearing early on after they opened up somebody developed severe chest pain after eating there and so the ambulance came in and all of the other people eating at the restaurant pulled out their their phones and we're videotaping the whole thing because they thought he was all a publicity stunt and he was really a person who was probably having ACS after eating there so you see that the menu and where is it if you weigh more than 350 pounds you eat for free so when when you go there they weigh you and put you in a hospital gown and and so these are some of the things that are on the menu the quadruple bypass burger actually holds the Guinness record for the most calorific sandwich or burger in the world any guesses on how many calories there are in this thing give me a number ten thousand nine thousand eight hundred calories and they've actually come out with at last I heard an octuple bypass burger which has I think forty three slices of bacon and eight patties and it's just a quite an incredible menu that they have there so when we went there I think I got a smoothie and some fries and and that was about it and we didn't even finish what we had there we just wanted to check it out but it was interesting here you can see this billboard deep-fried chocolate-covered butter bacon and so anyway if you want to check it out please please wait till after the course okay alright we did try to make it healthy apparently Cesar's tried to make it healthy by putting this auditorium at the end of a 1/2 mile walk so everyone's gotten a stress test and now you can relax and we'll we'll get into this so what we're gonna spend some time talking about dysrhythmia is and as I mentioned this morning I love electric cardi ography I love reading about it writing about it talking about it I'm probably one of the biggest EKG nerds that you'll come across and one of the reasons I love electrocardiography as I mentioned earlier is because this is a simple skill which can be done anytime on any patient at the bedside you don't have to ship someone down the hall to radiology or some other part of the hospital to get the test done anybody can do the test and anybody can read the test with just some practice and everybody learns I think most everybody learns basics but if you go maybe just one step not ten steps but one step beyond the basics you can save lives by knowing just a little bit more and that's what what the earlier course and what this course are really all about just teaching a little bit more than the basics and in the process of doing this I'm gonna go through a lot of cases all right so first question like we started this morning why why is this important again I'm preaching to the choir dysrhythmia management is really high risk but it's also high payoff if you get things right in other words if you make the diagnosis and you know basics of treatment patients have a really really good outcome you can take the worst possible - arrhythmia v-tach or v-fib and if you know what to do when you do it quickly usually there's a pretty darn good outcome but if you don't know what's gonna happen then there can be an awful outcome you know visa begins the classic where for every one minute that you're not defibrillating chance of survival drops 10% for every 1 minute survival drops 10% so you have to know what you're looking at and how to treat it well v-tach same thing and there's a lot of mimics of v-tach where if you don't treat them correctly your therapy can actually kill the patients and we'll we'll kind of talk about some of that as well all right the idea behind this workshop is to go a little bit beyond the basics we're not gonna talk about the absolute basics and again if there's anybody who's looking at this 12-lead and scratching their head wondering what in the world are we talking about with this EKG this is probably not the right room for you all right I'd suggest heading over to that that lenders conference is down the hall looks like they probably have some pretty good food down there but this is one of my favorite EKGs has ever been sent to me it is truly a 12-lead of the SIB hopefully not really v-fib should not be a 12-lead diagnosis all right no I hope nobody here ever gets a rhythm strip and says you know this kind of looks like v-fib but I think I want to confirm it in 11 more leads but the person that sent this to me swore that it was his partner who got the 12 lead of this patient that was in visa before they finally decided to shock him but anyway please don't get 12 leaves of v-fib if you do send it to me tell me it's someone else's EKG all right so what we're gonna do is I'm just gonna give you a little brief overview of Brady dysrhythmias and then some tacky dysrhythmias and some miscellaneous stuff and then the majority of time we're going to get into cases because I think that's really where the learning is but I just want to get everyone kind of on the same platform by going through some basics we'll try to move through the basics relatively quickly and I know that there's a lot of confusion about Brady two arrhythmias you know mobitz one mobis two third degree and I think what you'll find is that this is really easy if you simply do a very simple thing that we'll talk about and then for tachycardias he'll nail 95% of the tachycardias if you just simply remember a couple of differentials that we'll talk about so it really is easy and I think it it becomes relatively fun as we go through the cases I'm gonna I'm gonna try to throw some curveballs at you also because I want to make sure that no matter where you are in your experience and your expertise in electric cardi ography everybody will be able to learn something so whether you're maybe a little bit more at the beginner end or you're more at the advanced tender there's going to be some things that everybody can can get some good take-home points from and all of the cases I present are real cases from the emergency department either at Maryland or elsewhere so you can put yourselves in the shoes of the the acute care physician that took care of these patients as we go through this because these are cases that I'm sure you all will see alright so again let's get through the basis quickly first of all there's a few types of bradycardia there's sinus bradycardia there's junctional rhythms and then there's ventricular rhythms junctional and ventricular are usually bradycardic to start with we define zionists meaning that the impulse is coming from the sinus node as an aside how do you know if an impulse is coming from the sinus node there should be upright P waves in lis one two three and F and an L also and inverted in AVR alright if you ever have P waves that don't follow that rule so up right P waves in one two three av f AV L and inverted in AVR then it's called an ectopic atrial rhythm now is there any clinical relevance to an ectopic h over them probably not there's probably people in this room right now that lives in an ectopic atrial rhythm and it's really not a problem if you drink too much coffee in the morning you might have sick a tional ectopic rhythms as well it's not a big deal junctional rhythms there's some people that live in junctional rhythms these are often vagal and these usually are associated with rates between 40 and 60 and usually their narrow if you can't have a junctional rhythm with a bundle bundle branch block and have wide QRS but usually they're narrow rates 40 60 and ventricular rhythms are always wide and the rate is the intrinsic ventricular rhythm is in the 20 to 40 range again so in starting out with some basics here is your sinus bradycardia how do you know it's sinus well you'll see upright P waves in lead one and in two and in three where's three and then moving over upright in a VF and then go all the way up to AVR and you'll see that the P wave is inverted usually inverted in lead AVR all right so that's the sinus rhythm and normal sinus rhythm is sixty to a hundred if it's less than 60 it's called science bradycardia again this is very very basic well it will speed things up a little bit here's your junctional rhythm it's usually narrow and usually there is no P waves now the caveat here is that when you have a junctional rhythm if you look up here at me for a second the AV node is sending an impulse down to the ventricle but it often shoots an impulse up to the atrium as well so it's not that the atrium is sitting still and the the ventricles beating the atrium often contracts also but the P wave of the atrial contraction is buried inside the Kuras so you usually don't see a P wave with the junctional rhythm sometimes you can sometimes you get a little P wave right after the QRS and that's sometimes referred to as a retrograde P wave sometimes you get a P wave just before the QRS so you can get p-waves just before the QRS with the junctional rhythm but the key point here is that you'll have a short PR interval all right so if you ever see a short PR meaning the PR is less than 120 if you ever see a short PR there's two things in your differential junctional rhythm and pre-excitation WPW all right you know more about that later and then here's your ventricular rhythm it's really slow and it's fairly wide all right no big deal now we get into AV blocks and there's now we start getting into some slightly confusing territory first-degree AV block with this you see 1p way for every QRS and the PR is long that's all that first gravy block means from an acute care standpoint it has practically no relevance a lot of people will have a baseline first gravy block as we get older we tend to develop a first gravy block it's perfectly fine certain medications can produce a first gravy block but a first-degree AV block is only meaningful if there's also bradycardia if you're not bradycardic who cares if you've got a first gravy block from the acute care standpoint all right you don't need to treat a first gravy block you treat abrade of cardiac rhythm but the first two gravy block is not an issue in and of itself here is a patient with a pretty significant first gravy block and you'll notice that they just have a long PR if this person were hypotensive would you need to treat the rhythm the answer is no because the ventricular rates fine and that leads us to another important point whenever you are deciding how to treat a patient your treatment is always based on the ventricular rate not what the atrium is doing it's always about the ventricle all right so the atrium gets no respect here your question about whether somebody needs rhythm treatment right now is always based on is the ventricle too fast or as two ventricles too slow not what the atrium is doing and I'm gonna if you don't remember that point I'm gonna try to trick you a little bit later on with a case all right so it's always about the ventricle the ventricular rate here is perfectly fine so patient doesn't need rhythm management acutely alright second degree AV block there's two types of second-degree AV blocks there is second gravy block type one also known as wonky Bock also known as mobitz one and during this course I'm just going to use the move its term and then their second gravy block type 2 also known as mobitz to second degree AV block type one or mobitz one well when you look at the PR at the PR gradually increases then you've got a lonely P and then it starts over again a P way that's not conducted and starts over again second gravy block type 2 are moments to the PRS are always constant by definition the PR must be constant everywhere if you see the PR change even in one place it's not a mobitz to by definition all right the other part of the definition and again I'm going to try to trick you later with this but the other part of the definition is to before in order to call some emotes the p2p interval has to stay constant all the way across so here's your second degree AV block type 1 and what you'll notice is that there is if you look down there at the rhythm strip the PR is gradually gradually increasing its kind of gradual it's tough to notice but then when you look at the there's a p-wave right there that's that is lonely it's not conducted and if you compare the PR right before to the PR right after you clearly appreciate the difference so the and also if you mapped out the P to P interval the P to P interval all the way across stays normal there must be a constant P to P interval all right now here's mobitz 1 if I told you this patient were hypotensive and I said how do you want to treat the rhythm do you need to treat the rhythm here no why not because the ventricular rate is fine the ventricular rate here is I don't know maybe 80 or 90 so this patient doesn't need rhythm treatment it doesn't matter that they have a mobitz one it's all about the ventricle all right so it's all about the ventricle mobis ones are usually vagal usually if they're associated with an MI it's an inferior mi mobis ones usually have a good part nosis they very rarely ever need a permanent pacer right and they usually respond nicely to atropine which is an anti vagal medication all right if you if you did need to treat mobis one atropine usually works fine all right now there's a lot of people that live in mobis one and it's perfectly fine in fact I'll bet there's probably some marathon runners in here are triathletes and you might very well live in mobis one because you have high vagal tone it's perfectly fine all right mobis to p2p intervals constant and the PR interval stays the same so when you look over here you'll notice that there is a PR interval right there and there is a PR interval right there and then and there constant and these PR intervals are not changing and then there's a P wave that's lonely it's not conducted and then there's a PR and that PR is the same as that which is the same as that which is the same as that and so on so every PR interval stays the same you just have too many PS when there's too many PS I oftentimes wore fur to this as electrocardiographic poly area there's too much pee all right so if I ask you as we go through this does this patient have polyuria if you see too many Peas the answer is yes how do you tell the difference between mobitz one and MOBAs two and as we'll see third-degree heart block how do you tell the difference between the three the answer lies in looking at the PR mobis one the PR gets longer mobitz to the PRS have to stay the same and then third degree heart block the PRS are randomly changing all right that's your key the PRS are randomly changing once again you'll notice that the P to P interval has to stay constant there must be a constant P to P interval the QRS complexes are also constant because there's a an escape rhythm coming from somewhere and will look up here you've got three rhythm strips up here and I think you can appreciate let's see there's there's a PR interval right there and then there's a really long one and then a relatively normal looking one and then a super short one and then a longer one and then a really short one and so the PR interval is randomly changing so if you ever in doubt is this mobitz one or mobitz to or third degree your answer simply lies in looking at the PR and if you make it habit of looking at your PRS you're going to nail your diagnosis every time so people oftentimes are looking at 12 leads and saying is this mobis 1 or 2 or 3 degree just look at the PR all right forget the QRS complexes look at the PR and you're gonna nail your diagnosis it's all about the PR all right ok questions so far any questions all right as I mentioned earlier I like collecting signs a couple people have already sent me interesting signs so collect these signs this little mental brakes here I'm not sure where this is sent in from all right so we're done with bradycardia how easy was that you want to know the diagnosis of the AV blocks your answer lies in the PR all right excellent that's how simple it really is and we get to that when we get to the cases you'll see now tachycardias are only a little bit more complicated but actually a lot more fun all right so it's worth the little extra bit of complexity you will get your diagnosis in almost all tachycardias by asking three questions number one is it narrow or wide number two is it regular or irregular and then the key question at the end is what's the atrium doing look at what the atrium is doing look at the p-waves all right is it narrow or wide regular or irregular and then what's the atrium doing and there's a couple of differentials that are worth remembering here all right so let's start out with the first set so narrow regular tachycardias there's three types there's sinus tach there's SVT and there's a flutter with two to one conduction all right now going back to SVT for just a second when you talk to the electrophysiologists or read about SVT's there's a lot of different types of SVT's there's P SVT and then there's AV reentry tachycardia and AV nodal reentrant tachycardia and there's reciprocate reciprocating tachycardia and junctional tachycardia the good news here for us in acute care medicine is that we can take all of those and lump them together because they have similar ideologies and pretty much similar treatments so I'm just gonna lump them all under a term SVT all right makes it easy but electrophysiologists have a little bit more complicated time because they have to figure out all of them but that's their specialty and they can nail them we don't have to all right so narrow regular tachycardias and I'm going to ask you this differential repeatedly as we go through the next couple of hours what are the three types of narrow regular tachycardia sinus tach SVT and flutter with two-to-one how do you tell the difference between these three things what's the atrium doing with sinus tach is peak you're a speaker a speaker a speaker a speaker s with SVT there's usually no P waves or there may be little retrograde P waves P ways to come right after the chaos and then with flutter usually it's two P waves or sometimes they say F waves or flutter waves P P Q R SP P Q R SP PQRS and so on all right if you look carefully you'll see two P waves for every one QRS and usually the atrial rate is around 300 and the ventricular rates around 150 atrial flutter with two to one conduction all right now we're going to spend a little bit more time on flutter in just a little bit but atrial flutter is the most commonly misdiagnosed tackiness arrhythmia because flutter waves hide oftentimes the flutter waves hide within the T wave or within the QRS and so a lot of times people look at this and they don't see the extra P in there they just see one p wave free each Kuras or maybe they don't see any P waves and it's very easy to mistakenly call flutter sinus tach or SVT alright so whenever the the rule here is whenever you see a ventricular rate an arrow regular ventricular rate of 150 plus or minus 20 always assume it's flutter until you look really carefully look everywhere look in all 12 these don't just look at the rhythm strip look in all 12 leads if they give you where the strip look in all 13 leads because it's very commonly missed so be paranoid of missing flutter when the rate is 150 plus or minus 20 or so all right and we'll get to that here's sinus tachycardia PQRS PQRS PQRS PQRS all right simple enough it's the most common here's a patient that had this patient actually had myocarditis and was extremely tachycardic a young person and they have pica a speaker a speaker s much faster and by the way you would know how fast do you normally mount sinus tachycardia it was too fast a sinus tach that you can develop in general it's usually age dependence usually 220 minus your age all right and the cardiologist will use this during stress testing the the the fitness instructors will use this when they're trying to figure out what your your you know you should be exercising between 60 and 80 percent of maximal predicted heart rate or whatever what is the maximal predicted heart rate - twenty - or age so to a 20 year old and this was a young guy 20 year old a 20 year olds capable of having sinus tach at about 200 beats for a minute an 80 year old is only capable of having sinus tach at around 140 beats per minute alright and that can be useful sometimes because if I gave you a narrow complex tachycardia at a rate of 160 in an 80 year old well right off the bat you know it's not sinus tach all right it's a 220 - their age in general there are some rare exceptions to that okay SVT here is an SVT it's narrow it's irregular you don't see clear-cut p-waves there's no clear peak you're a speaker a speaker s on the other hand remember I mentioned sometimes you can see retrograde P waves take a look at lead 2 and you see those there's little blips right after the Kuras those are little retrograde P waves I've got a little coffee tremor sorry about that little P waves those are called retrograde P waves that's very common with SVT alright with certain types of SVT which we're just gonna call SVT so when you see those little retrograde P waves then that weighs in favor of svt's narrow it's irregular what's the atrium doing there's no clear-cut PQRS P crest in fact there's little retrograde P ways all right and then atrial flutter oftentimes you see a sawtooth type of pattern but not always this is a pretty an obvious example of that sawtooth I think if you look at the rhythm strip at the bottom it kind of looks like that sawtooth but there's inverted p-waves 2p ways for every one QRS all right with atrial flutter oftentimes atrial flutter gives you inverted P waves in the inferior leads so if you look over here at the rhythm strip alright those those are little inverted P ways there is an inverted P wave and there and there and there so those are little inverted P waves over on this side let's see there's my arrow there's a P wave right there and then there and they're in there in there and if you map those out they map out at a rate of about 300 and we'll talk about why we tend to miss flutter because when those P waves are inverted our eyes don't pick them up that easily we'll get there all right but again atrial flutter is narrow it's regular and there's two P waves for every QRS often there's a sawtooth pattern the one other point I want to make about EKGs in general but in particular flutter is if you're ever looking for P waves I know that the Machine always gives you a lead to as a rhythm strip alright and that's because the Machine wants you to miss the diagnosis but you didn't know that all right it turns out that the best lead for picking up P waves is actually lead v1 alright in general if I will say if you're in Vegas while you are in Vegas if you go to a table and it's it's gonna be a really nerdy table they're asking you about EKG leads on this table right and and they ask you to put your money down on one lead to tell you whether there's P waves yes or no put your money on v1 alright again it's a pretty nerdy table to be asking you that but nevertheless v1 often is your only lead to tell you P waves and in this case you can see nice P waves there's a P wave right there and then there's one just stuck to the beginning of the Cure and there's another one and another one stuck to the beginning of the QRS so in this case I think the in fear leaves in the sauce tooth pattern are pretty obvious but I promise you there will be times where v1 is the only lead that gives you P waves that are obvious and every other lead is tough to see and I've seen rare cases where maybe it's v2 or v5 or AVR so look everywhere in the 12-lead EKG but whenever I'm looking at a rhythm strip whenever I'm looking at the rhythm the first lead I always look at is lead v1 because if you think about it you know look up here at me for a second v1 sits right there right over the sinus node right over the the atrium so if you want to lead that's going to tell you about what the atrium is doing pick the one that sits right over top of the atrium so v1 so looking all of them but please don't just focus on lead to which a lot of people do look at v1 also scrutinize v1 sometimes v1 will give you your answer all right in any case looking everything okay so let's let's recap for just a second if you have a narrow regular tachycardia there's three possibilities what are they sinus tach SVT and flutter with two two one good all right well with narrow irregular there's only three possibilities once again there's a fib there's a flutter with variable conduction and then there's multifocal atrial tachycardia which is kind of fun we don't see it too often anymore but it still is out there in the pulmonary patients what is a flutter with variable conduction well a minute ago we talked about a flutter with two to one where there's two P waves for every one QRS and it looks very regular all the way across well what if you had atrial flutter where in the beginning of the EKG it's two to one then it becomes three to one than two to one then five to one then 4 to 1 then 2 to 1 then 5 to 1 so if the if the conduction ratio is changing your ventricular response will be irregular there's no rule that says you have to be 2 to 1 so sometimes you'll see flutter with variable conduction and it'll give you an irregular rhythm all right and then m80 again for the younger folks you may not have seen this before we used to see it a lot more often in the COPD patients on theophylline it's seen that those two things together brought out m80 more often especially theö toxicity but we still see it in pulmonary patients almost always these are pulmonary patients bad asthma I've seen in a multi lowbar pneumonia we see it more often in pulmonary hypertension patients now so almost always these are pulmonary patients and the key thing there with m-80 in terms of treatment is treat the underlying cause all right you never shock m80 there's no need to shock em 18 all right okay so we've got three things that produce narrow irregular how do you tell the difference between the three simple question what's the atrium doing with afib it's fitting all right you don't see any distinct atrial activity sometimes you see a little bumpiness that can make you think there's atrial beats but if you try to map them out they don't map out all right so when people first go into afib it can be very sybbie it can be very bumpy but if you try to map out those bumps they don't map out that's just fibrillation and the longer you're in afib the smaller the bumps get until you get very fine bumpiness atrial flutter with variable conduction once again you'll see atrial beats going at a rate of about 300 plus or minus a little bit and then m80 you should see at least three different morphologies for P weighs pretty much every Kuras has its own P wave but there's at least three different morphologies for the P waves all right so examples here's your afib everyone in this room has seen afib this is the most common sustained dysrhythmia tachy dysrhythmia all right and you'll see that there is no clear-cut atrial activity that maps out if you look up there in v1 yeah it looks like there's a couple bumps are those P waves well if you can't map them out they're probably not P waves and if you try to map those out they don't map out all right that's fib no big shocking information there here's flutter with variable conduction take a look at that rhythm strip on the bottom it starts out 2 to 1 then it becomes 3 to 1 then 2 to 1 then about 4 or 5 to 1 then it goes back to 2 to 1 so in the beginning of this you can see how a flutter can be irregular all right but if you look carefully once again you appreciate the inverted P waves in those inferior leads mapping out at a rate of about 300 so this is flutter with variable conduction simple enough all right and then here's your m80 multifocal atrial tachycardia I've given you three rhythm strips and if you look down there at throw the strip at the bottom you can appreciate that let this see there is one morphology for a p-wave and then there's a big P wave there and then there's that's kind of let's see a biphasic looking P wave then a giant P wave then there's another P wave right there so we've already got three and then you know what there's a fourth type of P wave right there and then these kind of show up as you go across so there's at least four different types of P waves on this strip this is your classic multifocal atrial tachycardia alright if this patient came in to your emergency department or your office and had a blood pressure of 80 how would you treat this patient anyone want to shock this patient okay you may want to but I should ask should you alright so yeah you don't shock this patient you just treat the underlying cause if this patient's hypotensive give them fluids right somebody said flows treat their sepsis figure out why they're hypotensive but ma T never causes hypotension alright if you have v-tach v-tach can cause hypotension rapid afib can cause hypotension SVT and flutter can cause hypotension ma T never causes hypotension and so you never need to treat the rhythm by using a through the mix or shock you never shock image there's two tachyarrhythmias you never shock ma T and sinus tach right what happens if you shock these patients you're pres Gainey's fall right and you don't help the patient you just piss off the patient so you don't shock them give them fluids look for a different reason for why they're hypotensive but it's not the rhythm that's producing hypotension so look for another reason for the hypotension treat the underlying cause so these are the two tachy dysrhythmias that you never shock all right and if you were to get a board review a board type of question where they give you this patient they might kind of try to bait you into shocking this patient because a CEO says if you've got an unstable tachycardia you're supposed to shock them all right with two exceptions sinus tach and MIT alright enough I've beaten that that horse enough okay so let's recap narrow regular tachycardia there's three types what are they sinus tach SVT and flutter with two to one narrow irregular tachycardia three types what are they a SIB flutter with variable conduction and m80 how do you tell the difference between all of these what's the atrium doing fantastic alright really if you remember that you're gonna nail these okay now we're on to the wide regular tachycardia so you see I've listed three up there probably it's best to just think of this as two you've got sinus tach with aberrant conduction which really means sinus tach with the bundle branch block pattern or maybe sinus attack with WPW or sinus tach with hyper K which can make your ers kind of wide you've got v-tach all right so science tech P wife's present you got v-tach with ventricular tachycardia P waves are often missing but not always sometimes you can't have P waves and the P waves should not be occurring as P chaos speaker a speaker a speaker s sometimes the P waves are just kind of thrown in there in the form of av dissociation sometimes and this is very important sometimes v-tach can give you retrograde conduction so again if you look up here at me for just a second so you here you've got your ventricle and there's some place in the ventricle it's firing impulses through the ventricle sometimes the impulses go up to his Purkinje system and activate the atrium so the ventricles firing beats here but also sometimes it shoots impulses up to the atrium and so you get a ventricular beat than in a chobe ventricle atria ventricle atrium so you get your SP ers PQRS P so you can sometimes get retrograde P waves even with v-tach all right so don't let the presence of P ways fool you be very careful about ever looking at a regular wide complex tachycardia and not calling it v-tach alright people oftentimes mix the bottom two things together alright v-tach SVT with the bundle you know what it's probably best to just pretend SVT what the bundle doesn't exist as we'll talk about all right here's your like ventricular tachycardia there's no clear-cut p-waves it's regular it's wide here's here's actually SVT with a right bundle and I'm probably doing you a disservice by even showing this to you or even acknowledging its existence all right the only way you can ever look at a attacker or wide complex tachycardia and say you know what this is just SVT with the bundle I'm gonna give them some calcium channel blockers or some beta blockers the only way that you should ever do that is if you also happen to have a baseline 12 lead and here we do the patient at baseline is sinus rhythm with the right bundle and the baseline 12 lead in all of the QRS complexes looks look looks exactly the same so every QRS complex during the tachycardic state looks exactly the same as baseline so when you compare the Charis complexes of the baseline in every one of those 12 leads looks exactly the same as during the tachycardia fine you can look at this and say you know what this is just the same right bundle that the patient has at baseline so I'm going to go ahead and call this SVT with the right bundle but if you don't have a baseline and the caresse complex is in all 12 leaves don't look exactly the same don't ever look at a wide complex tachycardia and call it SVT with the bundle because your therapy can kill all right I can't I can't I can't over it I can't under emphasize alright whatever I need to emphasize it often enough that you've got to call it v-tach I can't overemphasize the importance of this like there's been countless cases of wide complex tachycardias that I've seen or that have been sent to me where somebody says take a look at this well is this v-tach or SVT in your opinion and I always say it's v-tach I'm not gonna bother looking at it I just call it v-tach what happened and they say well we went through some algorithm and we called it SVT and we use an AV nodal blocker and the patient crashed and burned and why would you use an algorithm alright there's a lot of algorithms that have been published over the years none of them work there are brilliant electrophysiologist who for the past 50 years have been studying electro physic studying electric choreography and no one has ever ever been able to come up with an algorithm that reliably distinguishes between SVT versus v-tach so just call it all v-tach and you save every life that's what we should be all about all right all right so wide regular tachycardia what's your differential number one v-tach number two maybe v-tach or maybe v-tach or v-tach maybe sinus tach with the bundle if you clearly see peak arrest P cross P cross P caress but SVT with the bundle I would just say don't bother alright be extremely careful about ever looking at a wide complex tachycardia with about wide irregular tachycardia there's really two major things to think about with wide irregular there's a fib with a bundle branch block pattern and there's a fib with WPW how do you tell the difference between the two in this scenario you need to look at the kiosk morphologies a fib with and also look at the rate masive with the bundle well let me back up for a second how many of you in the past month of working clinically have seen a patient with new onset rapid afib raise your hand yeah so almost everybody how fast was your patients ventricle beating new onset rapid afib give me a number how fast was your patients ventricle beating 120 140 160 maybe 180 anyone say 200 a kid was 200 theory' rare very rare to get up to 200 I'm hearing a lot of you know 150 s plus or minus 20 or 30 all right that's your classic afib with a bundle all right here's a tip with the right bundle notice that the rate is about 150 and the other thing to notice take a look at the QRS complexes they're pretty much the same all the way across here's a fib with the left bundle notice the rate is about a hundred fifty hundred sixty plus or minus whatever and also notice that the cure s morphologies are the same all the way across all right if you have a fib with the right bundle or a fib with the left bundle you can treat them just like any other a-fib patient you've ever seen you want to use calcium channel blockers fine beta blockers fine ditch if you're not in a hurry ditch sure amiodarone fine you want to shock them that's fun it works fast you can shock them also almost anything that you want to do everything you do for a normal narrow afib you can do for a fib with the bundle no problem alright a-fib with WPW is a completely different animal this is a fib with WPW notice in some places in some places you've got rates of 250 or 300 a fib with the bundle never goes that fast notice also the morphologies are changing some are wide some are narrow some where everywhere in between that's your a fib with WPW here's your afib with WPW notice how fast it can get you can get rates of 250 300 beats per minute it's irregularly irregular morphologies are changing some are really wide some are narrow and notice in some places race approach 250 or 300 afib what the bundle never does that when you see this this is a fib with pre-excitation and the only acceptable therapy is either procainamide or etomidate followed by 200 joules all right you can shock them or whatever sedation you want all right but what happens if you give this patient am you a calcium channel blocker or beta blocker or ditch or amiodarone they die and they die really fast except for didge which dies slowly all right not even joking you give somebody a dose of didge the case reports say that two or three hours later they die alright we'll talk about why a little bit later on so it's real and we're gonna spend about a good 20 minutes on WPW later on so if you've never understood BPW I promise you you will after today all right you have to because otherwise your therapy can kill these patients if you fail to distinguish a fib WPW versus a fib with the bundle all right all right everyone okay so far all right polymorphic ventricular tachycardia it's regular it's why the morphologies are changing there's a specific type of polymorphic v-tach called tor Saad dip wha right people oftentimes use these terms interchangeably tor Assad de plant versus polymorph attack so tor Assad is polymorphic v-tach associated with the prolong QT alright and it's important to understand the distinction there you've got generic polymorphic v-tach and then you've got the torus odd type of polymorphic v-tach so why is it important to understand that there's a difference well let's say you've got a patient who shows up with polymorphic v-tach you don't know whether this is generic or polymorphic so what are you gonna do with this patient you're probably gonna have to shock them alright so let's say you shock this patient you get them back to sinus rhythm now you look at their 12-lead and say oh the QT is normal what does that mean it means this was generic polymorphic v-tach well now you probably ought to put them on something to prevent them from going back into it what do you put a generic polymorphic v-tach person on after you've shocked him out of it whatever you want lidocaine a meal procainamide and then look for an underlying cause usually ACS alright treat that all right no problem what if you shock this patient out of it you get your 12 lead now that they're back in sinus rhythm and you say oh they've got a long QT QT C's greater than 500 they've got a long QT that means this was the torus odd type of polymorphic v-tach all right well now that you've got them back in sinus rhythm you should probably put them on something to prevent them from going back into it and then look for and treat the underlying cause what are you going to put them on to prevent them from going back into it magnesium magnesium is the only acceptable therapy if it's the tor sod patient because what happens if you've got the torso patient in other words the long QT patient and you put that patient on lidocaine a me or procainamide what do they do to the Qt they lengthen it again lidocaine a plus minus but a me and park an amide will just lengthen it right back out and put them right back into tor Assad all right so that's why it's so important to understand that there is a not so subtle difference between generic polymorphic v-tach versus the tour Saad type when you get them out of it look at the QT or maybe you see a long QT right before they went into it sometimes you see a long QT on their baseline 12 lead or maybe they were demonstrating a long QT before the arrhythmia started all right now tour Saad literally translated me is twisting around the points and so a lot of times people will say well when you see the Charis get bigger than smaller than bigger than smaller than bigger than smaller that's Taurus odd wrong generic polymorph attack can do that as well so you cannot distinguish generic polymorphic v-tach versus Taurus odd by simply looking at this morphology of big or small or big or smaller they both will do that the only way to tell the difference is take a look at the cutie on the EKG right before they went into it or on the EKG after you get them out of it all right and if the cuties normal use whatever you want look for ACS if the Qt is prolonged only use magnesium and then search for the underlying cause of the long QT which we'll talk more about later all right actually we talked about that tomorrow long causes of long QT all right everyone okay with that distinction all right good okay and then approaching the end of this intro section cell rated idioventricular rhythm also known as a IVR let me only block this out for just a second okay we talked about ventricular rhythms when somebody has a ventricular rhythm of 20 to 40 that's called a ventricular escape rhythm simple enough all right if somebody has a ventricular rhythm of a hundred thirty or faster that's called v-tach simple enough right well if you have a ventricular rhythm between 40 and a hundred thirty what's that called that's called an accelerated ventricular escape rhythm because remember normal venture Coast caper that's 20 to 40 between 40 to 130 it's called accelerated ventricular escape rhythm also known as accelerated idioventricular rhythm or a IVR all right and this is what it looks like it's a ventricular rhythm that is somewhere between 40 and 130 if it was faster than 130 what would we call it v-tach if it was less than 40 what would we call it ventricular escape rhythm right between 40 and 130 is called accelerated ventricular them or accelerated idioventricular rhythm or a IVR why is this important the reason you need to know about this is that a IVR typically occurs in the setting of acute coronary occlusion acs when they reaper fuse so in other words let's say you've got a patient who comes in with an included coronary artery an acute occlusion they've got acs they've got a STEMI and you give them thrombolytics you break apart the clot at the moment the clot breaks apart patients oftentimes will develop this rhythm they'll develop this now lots of times it lasts for about 10 or 15 seconds and goes what usually it lasts for about 10 or 15 seconds and goes away all right every now and then it lasts for four or five minutes which is long enough for somebody to check a 12-lead and panic your computer will call it v-tach because your computer is trying to fool you all right as I said earlier today computers are programmed by plaintiff attorneys they're trying to get you to do the wrong thing all right your computer doesn't know what this is your computer calls it v-tach it's not v-tach this is what's referred to as a reperfusion arrhythmia when your artery reaper fuses they suddenly have a little bit of this and then they go back to normal this doesn't cause destabilization it doesn't even cause symptoms the patient's just sitting there chillin they're doing fine they suddenly develop this rythm everybody panics they think oh my god it's v-tach we need to give them a medication to suppress it we need to give them lidocaine or a meal or procainamide and if you give lidocaine or a meal or procainamide to this rhythm what happens it's a present it turns it to asystole it suppresses everything except death all right it kills them it will put the patient into asystole and they will die all right and that's what happened in this case this patient had a big anterior wall STEMI got TPA they reap refused about 45 minutes after the TPA the patient's sitting there doing fine their pains gone away I don't know reading the newspaper doing perfectly fine suddenly they developed this rhythm all right this is as classic as stories you're gonna get they suddenly developed a strengthened 45 minutes later which is a typical time frame during which tea TPA will work so the nurse sees this rhythm grabs the quick twelve leg gives it to the doc the doc calls it v-tach because it's regular it's wide the rate is 105 which technically is tack and then computers calling it v-tach the patient patient got lidocaine and went right into asystole all right when you see this rhythm there are two things that you can do you can either give the patient a high-five because it means your TPA is working their arteries opening up or you can put your hands in your pockets and step away from the patient and you you wait a minute or two and it goes away nobody gets unstable from this rhythm it goes away all right the cardiologists see this all the time we send people up to the cath lab they open the balloon boom the patient goes into this rhythm what do they do nothing they're happy to see it it goes away after a few seconds sometimes a few minutes it's a sign that the artery has opened up all right so it looks like the v-tach but it's not fast enough to call v-tach v-tach by definition has to have a rate of at least 120 to 130 on the rates less than 120 to 130 don't call it v-tach all right and will will hammer the home with more cases later on so this is a classic reperfusion arrythmia it makes for a great board questions and unfortunately this is a real life scenario that happens and this is an opportunity for us to kill patients if we're not knowing if we don't know about this all right all right and then lastly v-fib we kind of mentioned v-fib don't get 12 leads on v-fib all right check for a pulse check for pulse whenever you think you're looking at v-fib check for a pulse by definitions there should be no pulse the reason I'm harping on that remember when I was an intern working in the CCU we had a post STEMI patient who got Linux he was doing fine up in the up in the the CCU and suddenly his monitor has started alarming going off v-fib v-fib so my senior resident grabbed the paddles we went running over and he shocked this poor guy who is simply taking a nap and one of his leads had come loose and was kind of flapping around a little bit if we had simply checked for a pulse Wheeler said hey he's got a pulse it can't be v-fib so we never got any Christmas cards from him no all right so check for a pulse in um all right there's your visa should be a rhythm strip diagnosis all right so summary bradycardia bradycardia czar a piece of cake your answer lies in the PR just look at the PR mobis one PR is gradually increasing and then you've got a non-conductive p-wave mobis two PRS are staying the same and third-degree heart block the PRS are randomly changing there's no pattern to it and with all of these the PA to P interval should be constant the P to P interval is not constant then we're looking at something else we'll get there all right tachycardias simple differentials questions is it narrow or wide is it regular or irregular and then your key question is what's the atrium doing and we'll go through those differentials again as we go through this all right questions yeah stable v-tach huh stable v-tach you can use medications you can sedate in cardiovert either way is perfectly fine in fact we'll we'll get to I think we've got a v-tach case coming up but in terms of therapy the the current guidelines give amiodarone a class to be rating procainamide is a class to a rating porque no mites a bit better anyone know what class one is in the international guidelines us guidelines class one lidocaine it's kind of indeterminate class one light them up shock them cardioversion is class one there are no medications that are class one it's the best fastest safest thing we can do for patients all right now I think a lot of people feel a little hesitant to shock patients you always wanted to date them of course but a lot of times people feel a little uncomfortable about it so if you're going to use a medication you can use a medication but at the first hint of instability instability just shock them and one of the drawbacks of the Meo and procainamide is that they can drop your blood pressure and a mio is also associated with developing some bradycardia as well if if they get a little too much so in lidocaine lidocaine's lidocaine is a nice lidocaine is nice because when it works it works really fast and when it doesn't work you know really fast and it doesn't cause hypotension and it doesn't synergize with your subsequent medications to produce hypotension the problem with lidocaine is that it only works in about 20% of cases so I would never argue with somebody who wants to try lidocaine as long as there's someone else who's drawing up their second medication because it usually won't work but if it works that's fantastic so alright other questions before we move forward into the cases a lot of times people will so let's say let's say you started with lidocaine and that's not working lidocaine is not going to make them hypotensive if they get hypotensive it's from the arrhythmia if they get hypotensive at any point just stop what you're doing in shotgun all right so if lidocaine doesn't work and they're still stable then you'd certainly be justified in switching over to a me or procainamide if you started with amiodarone and it didn't work after you've waited half an hour or so and they're still stable and the patient's wide-awake in saying get away from me with those paddles then you can go with procainamide the problem with when you give a m-- you and then procainamide or procainamide than a mio they can synergize and produce a bit more hypotension so so I think I think ideally if you don't start with sedate and cardiovert then probably you want to think about sedation cardioversion after your first medication hasn't worked but there are some people that will try a second medication before cardioversion yep sure so so I mentioned etomidate but whatever sedative you want if you want to use propofol that's fine if you want to use ketamine that's fine a lot of people like ketamine because usually your cardioverted people because they're a bit hypotensive so ketamine is great because it maintains blood pressure people might question propofol because propofol can drop your blood pressure a bit so though I think you'll be appropriate to use ketamine there if you don't have at Amadei yeah yeah I'm I'm not gonna I'm definitely not gonna stand here and say that one drug is better than the other whatever you're comfortable with I think it's fine yep so if if you think somebody has flutter with two to one but the computer is calling it sinus tach I I would always go with what you think and not what the computer thinks so if you think it's flutter and you want to give something to slow it down I think that's a great option I think I would never suggest use a computer over your clinical judgment yeah it if it turns out that it was sinus tach and you gave them a little diltiazem or beta blocker it's probably no harm at all yeah all right so let's go ahead and let's get into the cases we are going to take a break we'll take a good 15 minute break 5 3 maybe how about in half an hour let's do a few cases and then we'll take a break everyone okay with that all right all right so we'll start with some warm-up ones some pretty easy ones 48 year-old man starts the new blood pressure medicine now he's got lightheadedness he's got a blood pressure of 80 I showed this to you earlier already diagnosis here good so this is just your sinus with first-degree AV block no big surprise here sinus rhythm first-degree AV blocks ventricular rate of 95 with a ventricular rate of 95 we don't need to treat the rhythm that's a no that's a good ventricular rate and and so I what are you gonna do to treat his blood pressure of 80 give him some fluids right that's probably about it all right simple enough we were just getting started 57 year old man took too much of his blood pressure medicine and he's got a pressure of 80 also so it's narrow it's regular it's slow and the rate is me I don't know maybe about 40 or so so I'm hearing people say junctional good this is this is a junctional rhythm it's just a junctional escape rhythm so junior junctional rhythm ventricular rate of about 40 and actually this is a nice example if you look way over at the end actually it's starting over here see no P waves but every now and then a P waves can sneak out look right over there I see that P wave it came out before and it's a short PR that's typical of a junctional rhythm short PR so remember two things produced a short PR junctional rhythm and pre-excitation alright so this is just a junction rhythm the story with this patient he he was on lopressor and his blood pressure was still kind of high so his doc started him on a new medication called metoprolol and the patient didn't realize they were the same thing so he was he was actually compliant he was taking both medications in fact he didn't stop the first one to take the the higher dose of the metoprolol so he was a little bit too beta blocked so with that story how would you treat the patient treatment of beta blocker excess you could use glucagon right click on and whenever you give looking on what do you do step away from the stretcher right because they tend to vomit all right so you can't actually pre medicate them with some some antiemetics if you want but click on would be your treatment of choice here but if it wasn't a medication related issue this guy has an unstable bradycardia because his blood pressure's low and he's definitely bradycardic this would be a reasonable opportunity to use some atropine because it's narrow junctional rhythms are often vagal try some atropine if that doesn't work then you can move up to pacing and the rest of your ACLs algorithm alright so after his heart rate came up those T waves flipped back up right also all right number three 70 year old woman with four days of nausea vomiting malaise and she's got a blood pressure of 80 also and you've got three rhythm strips alright so first question do you see polyuria yes there's too much pee all right so you've got a question is this mobitz one or mobitz - or a complete heart block how do you tell the difference your answer lies in the peer so that's all you've got to look at all right don't let anything else distract you the only thing you've got to look at is the PR interval so look at your PR intervals let's take the rhythm strip at the top all right does it look like your PRS let's see well gradually we'll start out over where it's - there we go PRS aren't they gradually increasing staying the constant or are they randomly changing the other gradually increasing so what does that mean this is mobitz one exactly so this is mobitz one with the blood pressure of 80 how are we gonna treat this patient how many people want to use atropine anybody want to paste this patient not a single one I couldn't full a single one and why do you not want to treat this patient with your ACLs drugs because the ventricular rate is fine 94 this is the first time I've given this conference many times this is a first time nobody raised their hand for atropine so I should get you to see if you'll raise your hand for other things that are correct just needs to be sure all right good excellent so the ventricular rate is fine so you don't need to treat the rhythm all right so give fluence I heard somebody say Q fluids perfect treat their sepsis I don't know figure out what's causing the hypotension but it's not the rhythm all right 62 year old man with shortness of breath and chest pain blood pressure is 80 I think our triage blood pressure monitor is stuck at 80 but here we are so again is there polyuria yes so mobis one versus mobis two versus third degree your answer lies in looking at the PRS all you got to do so look at the PRS and what's going on with the pr intervals gradually increasing staying constant or randomly changing randomly changing so that means this is third-degree or a complete heart block and what do you want to do let's see his science tact their degree AV block junctional escape rhythm ventricular rate is 48 how do you want to treat this yeah for pacing I think I would just go right to a pacer so in general we're not really talking much about treatment but we'll throw this in in general if you have unstable sinus Brady or unstable mobitz one try your atropine if you have unstable mobis 2 or unstable third degree just go right to pace all right and that's yeah basic ACLs just general sometimes people ask me about the interpretation up here so the interpretive formal interpretation sinus tach why am i calling the sinus tach it's because if you look at the P waves the P waves are faster than 100 so call this sinus tachycardia all right and then I'm going to describe the AV block as third gravy block now if there's a complete heart block none of these QRS complexes are coming from the from atrial impulses where are these QRS complexes coming from if there's a complete heart block they're coming from the AV node so think of the AV node all right not as a little dot in the heart think of the AV node as a region of the heart and when there's a complete heart block there's a block at the top of that AV node but you still have the rest of the AV node to shoot impulses down to the ventricle all right so you've got a complete heart block in the AV node below the block is shooting out impulses to the ventricle the result is you've got narrow QRS complexes at a typical junctional rate between 40 and 60 all right so this is a junctional escape rhythm with the ventricular rate of 40 48 all right everyone okay with that it's a science tact there's an AV block and then okay all right good enough okay number five 85 year-old woman comes in with syncope now she is feeling okay laying the stretcher not moving around she's got no pulmonary edema or chest pain but when she gets up and starts walking around she feels a little light-headed so we're just keeping her in the stretcher and the stretcher blood pressure is okay 120 finally 120 and this is the EKG now it's not a great baseline but that's what we've got that's what we deal with all the time right and once again do you see evidence of poly Aereo is there are there too many P ways here all right good so all you've got to do so your question is the mobis one mobitz ii or mobis three or thirty degrees sorry third-degree heart block all you've got to do is look at the pr intervals so what do you think the PRS are doing gradually increasing staying the same or randomly changing how many people say mobis one mobis two third degree so some third degree okay so which is fine is it's not a great rhythm strip there but let's take a look alright so again remember with mobitz one the PRS have to be increasing with MOBAs to every PR is the same with third-degree randomly changing alright so we'll start over here way on the Left there's a PR there alright so put that into your brain how big that PR is that and there's another PR and there's another PR they're looking pretty similar and there's a non-conductive that's really wavy so let's skip that there's another PR and there's where's the next PR there's a bunch of P waves there there's another PR and then another so the PRS are pretty much all the same so that means that this is mobitz - alright and mobis too often gives you a wide QRS in fact this this patient has a mobitz to with the left bundle type of pattern that's very typical mobis to pretty much always gives you a cure s that's a little bit wide or very wide alright mobis - is unlikely to give you a narrow QRS alright but again the key thing all you've got to do is ask what's the PR doing look at all of your PRS you'll see all the PRS here are staying the same so this is just a mobitz - alright everyone okay with that questions so again all you've got to do is look at the PR yep would you be able to call that sorry no complete again all you're worried about is the PR intervals it doesn't matter how many P waves you've got you can you can have five P waves for every one Kuras five P waves ers 5py scares and all you do is look at the PR with every caress and if those are staying the same that's considered a second degree or it's considered a MOBAs - alright it's a special type of mobis - sometimes people will call that MOBAs too advanced AV block but whatever it's the mobis - and they all get treated the same way all right so it's not about how many pieces there are that are not conducted it's not how bad the poly area is it's only about the PR all right all the questions all right so texting while driving kills but for more driving tips text us at safety to zone 9 one on somebody sent this from somewhere in California so great all right let's do let's do one more case and then we'll take our break 44 year old man complaining of weakness blood pressure of 60 he's got a really slow wide rhythm the rate here is I don't know 30s I suppose blood pressure is 60 so it's it's wide there's no clear-cut p-waves what would this rhythm be considered venture well it's wide all right junctional usually is narrow at 40 to 60 ventricular is wide usually at 20 to 40 and this is probably in that 20 to 40 range so this would probably be a ventricular escape rhythm alright that's what we would call it what do you want to do for this patient pace so what if I told you we tried pacing in the Pacers not capturing what's next what's the next thing that we do when a trance contain trans cattiness trans contains Pacers not capturing what's next epi or dopamine all right those are kind of equivalent in ACLs take your pick what if I told you that the EPI and dopamine aren't helping what's next transvenous pacing alright what if I told you the transvenous is not capturing when somebody said back there check your potassium why is that because hyper kaeleen is exactly right this was hyperkalemia alright so this is one of the curveballs oh let's take a little digression and talk about hyperkalemia which is a very common cause of bradycardia and for some ungodly unknown reason it's just not well taught all right if you look in Tintin Alley and Rosen and the major textbooks in e/m and an I am even a lot of Cardiology textbooks nobody talks about bradycardia from hyperkalemia and yet if any of you work with I can't imagine you do but non-compliant dialysis patients if are they outside of Baltimore do you all see them so I guarantee you guys have seen this or gonna see this this is another one of those conditions where I guarantee if you came back next year everyone in this room will come back next year and say I saw it I saw the hyper K Brady case alright and it's strange thing about whenever I go to medical conferences somebody talks about something I've never heard it before and then I go back to work amen boom suddenly I start seeing it pop up everywhere and I'm thinking my god I did missing this you're gonna have the same experience alright because it's really really out there so let's talk about hyperkalemia so everybody learns about peaked t-waves everybody learns about widening of the QRS alright and everyone learns about sine wave which is gonna be at the bottom of the slide but there's a lot of things in between the PT wave wide QRS and the sine wave you get a prolonged PR and then the P wave goes flat and you lose your P wave by the way if you just take a look at this prolonged PR I'm sorry wide QRS plus loss of the P wave that kind of starts sounding like a ventricular rhythm doesn't it or v-tach wide QRS no P wife we can start looking like v-tach alright what else tacky dysrhythmias brady this rhythm is advanced a vblocks strange type of rhythms you can have st-elevation ST depression new bundle branch blocks new fascicular blocks the sine wave or you may prefer cosine wave right hyperkalemia can do anything to the 12-lead EKG I always refer to hyperkalemia as the great imitator or the syphilis of electric cardi ography because it can it can imitate everything I work in Baltimore so I have to bring syphilis into the discussion right it can imitate everything and yet this advanced AV blocks and sinus pauses is really common that I want to emphasize here because it is so common everybody's the customs the T waves but you are going to if you haven't already seen these bradycardic rhythms this is classic hyper K alright nobody would miss this your computer will probably pick this up this is the type of thing that's in the textbooks and on the board exams you've got nice peaked t-waves and the wide QRS out there you'll also notice that there's already a prolonged PR interval out there here's also classic hyper K by the way the computer called this anterior stemmy didn't say anything about hyper can see there's st-elevation there's a new axis change or rightward axis out there but I think most everybody here is gonna pick this up there's a wide QRS there's huge peaked t-waves notice the P waves are gone there's no more P waves alright and so if this were your rhythm strip or maybe if this were your rhythm strip you this could start looking like v-tach right although it's a little bit too slow but anyway classic hyper K this is also classic hyper K now things are starting to stretch out a little bit as you start heading towards sine wave alright and asking stretch out your T waves are not that peaked anymore they're starting to get nice and rounded but these are all classic hyper K these are your textbook cases nobody's gonna miss this I think this is also classic hyper K take a look at this strange sinus pauses yeah there's there's some peaked t-waves out there and I've shown this to a lot of people who don't even notice the peaked t-waves because they're so focused on trying to figure out what the rhythm is and it's just a strange bizarre rhythm here's another pearl if you ever look at a rhythm strip and the first word that pops in your head is the word bizarre bizarre in emergency medicine equals hyper K bizarre equals calcium a bicarb all right don't think too much about it if you see somebody who simply looks bizarre given calcium by car but the egg right you just might save a life and what's the harm what happens if you give somebody a couple amps of bicarb and they weren't hypokalemic what happens to him what if I gave everybody in this room two amps of sodium bicarb IV what would happen to you nothing it gets metabolized and it's gone from your system in about 15 minutes and might make your beer or soda tastes kind of funny for a little while alright what what happens in a CLS is really down on bicarb but I don't know for not a great reason bicarb usually doesn't help people in cardiac arrest but that doesn't mean that it's dangerous it's not dangerous what about calcium what happens if you give 2 grams of calcium to somebody who's not hyper K what happens their bones get stronger no nothing right it's no harm at all give calcium to everybody right people always say well what if they're on ditch well the best studies that we have on patients on didge who get calcium for Hyper kay show no increase in adverse outcome now you know let me take a step back from that if you know somebody is is a digit oxic then give them digibind of course that's going to be the best treatment give them digibind but if you're worried about giving calcium just because somebody happens to be on didge give them the calcium that's life-saving if they're having a terrible rhythm like that alright so give it there's no harm there here's another take a look classic hyper K I'm going to show you a bunch more look at the T waves aside from v4 and v5 there's really not much in terms of peaked t-waves I mean the rest of the T waves are probably not even noticeable here you've got some narrow QRS you got some wide Kerris complexes what's the rhythm I don't know forget it to people look at this also and you know gosh a lot of people don't even notice these T waves out here because they're so focused on the rhythm you know there's there's a P well kind of shaking here there was a PQRS and then another P and another QRS and people think it says move as one or move it to you don't forget it don't think about it just given calcium bicarbonate it you know here's another great one this this was an interesting case this is a 45 year old guy who had recently been diagnosed with hypertension and got started on a potassium sparing diuretic now unknown to his primary care doc he had also started some wacky new diet that had him eating seven bananas a day alright true story so the guy one day is feeling really weak no surprise he's got a rate in the 30s so he calls paramedics paramedics arrive and they see his heart rate like this his blood pressure's low he can barely get up in walk as he's feeling so weak so the paramedics give him a half milligram of atropine it does nothing alright by the way why does atropine not work for this because it's right exactly this is not a vagal bradycardia atropine's for vagal causes so in general with tox and metabolic problems ACLs fails miserably ACLs was never intended to be used for toxin metabolic ACLs was written for the 65 year old cheese take eating diabetic hypertensive patient who's walking down the street coming out of a Vegas casino who one day clutches his chest and falls to the ground that is who a COS was written for it was never intended to be used for toxin metabolic and it fails miserably with toxin metabolic so anyway back to the case he gets a half a milligram of atropine atropine from the paramedics it does nothing so they quickly bring him to the emergency department in our emergency department our our doctors think it well our atropine is better so we're gonna give him atropine also right so against another 1/2 milligram atropine it doesn't work of course so then let's see what's next on the ACS algorithm transcutaneous pacing so they tried transcutaneous pacing and it doesn't capture and this has been reported in the literature transcutaneous and transvenous pacing often won't work in hyperkalemia because there's some changes within the intracellular milieu the pacing just doesn't work maybe related to the acidosis that they have also because most hyper k patients are also asked to Datuk from renal failure all right so trans contains pace is not working what's next dopamine or epi he got started on the EPI drip it's not working pressors often don't work when patients are severely acidotic all right so what's next transvenous pacing well it turned out that there is no transvenous pastry's in the IDI for some reason so they call upstairs to the cardiology fellow cardiology fellow says all right I'll grab a transvenous pacing the EP lab I'll be down shortly in the meantime put a cordis catheter in this guy and we'll float we'll float the pacer together so the residents are high-fiving each other they're like guess we're gonna give it transvenous paster out of this so they put a cordis catheter a right IJ cordis catheter this guy's now got a hole in his neck from a cordis catheter right cardiology fellow arrives and they open up the kit to get ready to float this and then the lab calls the lab says we've got a potassium of like seven point two seven point three so cardiology fellow and the residents are like well we've already opened up the kit let's just float it anyway right okay so they float the Pacer it doesn't work and then they give the guys some calcium and bam just like that heart rate comes right back up problem solved I've seen at least two patients get cordis catheters four for transvenous pacing more than just hyperkalemia and I've heard about a third also all right and this the literature has shown that Pacers don't capture with hyperkalemia so when in doubt just think outside the ACLS box when your first step or two of a cell it's not working think maybe this is not an ACLs case maybe this is toxin metabolic which is a lot of what we see in acute care medicine right all right so again this was after treatment take a look what happened all right a couple grams of calcium and an amp of bicarb am comes right back up all right here's the second case almost identical story this guy got a cordis transvenous floated didn't capture and then they gave him some calcium and bicarb problem solved here's another one this patient has a new right bundle from hyper K a rightward axis and an irregular rhythm the computer is reading this essentially is new onset a fib and this is simply hyperkalemia with the very very slow rhythm take a look at these sinus pauses alright and the the T waves are not even all that prominent I wouldn't look at these T waves and say all this is hyperkalemia but just simply that it's a bizarre bradycardia you try some atropine on this patient doesn't work think outside the a Celeste box take a look at this one huge huge sinus pauses in there and again aside from v4 there T waves are not even all that peaked everywhere else in here so just big sinus pauses in there so again very very important to remember hyperkalemia is a common cause of bradycardia strange bradycardia CIN emergency medicine so you have to think outside the ACLS box when you're taking care of these patients and when your first step or two of ACE less aren't working or if you have any suspicions of renal problems whether it's the dialysis patient that missed dialysis or a person who maybe has chronic kidney disease and it's just a lot sicker or out of what we see patients that are just not regular getting regular medical care and come in and this is often there in first onset diagnosis of renal failure when they come in hyper K with these strange Brady rhythms I guarantee everybody here is gonna see this probably within the next year or so alright questions about hyper K or bradycardia all right okay well why don't we take our break is 555 let's come back at 610 and we will resume at that point so 15 minutes and if there's any questions I'll be up here for questions right