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Arrhythmia CBL
Arrhythmia CBL
Learning Objectives
By the end of the session, you should be able to:
1. List the primary risk factors for ischemic heart disease.
2. Explain the rational for the use of aspirin and beta-blockers in the treatment of patients with a previous
MI.
3. Identify several basic rhythm disturbances based upon a patient's ECG.
4. Discuss the possible etiologies of different rhythm disturbances in patients with a history of heart
disease.
5. Describe the major therapeutic goals in treating patients with atrial fibrillation.
6. Identify drugs of choice for treatment of hemodynamically significant ventricular arrhythmias in and out
of the ICU.
7. Discuss the common clinical symptoms associated with an acute MI.
8. Describe clinically significant side effects of amiodarone and lidocaine.
DRUG LIST: lidocaine, amiodarone, aspirin, warfarin, metoprolol, hydrochlorothiazide, ACE inhibitors, statins
2
Upon arrival in the Emergency Department Mr. Hart is given a chewable aspirin tablet,
and a nitroglycerin tablet sublingually. A blood sample for measuring cardiac enzyme
levels is obtained. ECG leads, O2 saturation monitor, and a blood pressure cuff were
applied. His ECG (leads I & V1) is shown below. His initial blood pressure readings vary
between 170/110 and 150/85 mm Hg. His pO2 is 93%. Mr. Hart stated that after his MI
six months ago, he developed a chronic irregular heart rhythm for which he has also
been taking both metoprolol and warfarin po qd. Mr Hart added that he missed
taking his daily dose of these two medications this morning due to all the confusion
related to his chest pain.
V1
__
0.2 sec
Mr. Hart is a well-developed man who weighs 90 kg. He is 5’6” tall. While in the
Emergency Department his B.P. suddenly falls to 104/60 mm Hg. His radial pulse is
fast and irregular in rate, rhythm and amplitude. His ECG indicates a similar rhythm
disturbance, but now his ventricular rate has increased to 160-180 min-1 . His
respirations are 20/min, and his body temperature is 99.6oF. His skin is moist and
cold. His neck veins are distended. The E.R. physician starts an I.V. Blood samples for
PT/PTT, INR and arterial gases are obtained.
The patient's blood gases, BUN, creatinine and electrolyte levels are found to be
normal. The INR is within the therapeutic range. The patient’s status is closely
monitored and an initial i.v. bolus of low dose metoprolol (2.5 mg over two minutes)
is administered.
Within 5 minutes, Mr. Hart’s B.P. begins to stabilize at ~130/90 mm Hg, with a
ventricular rate of 90-100 bpm. Approximately 10 minutes later, Mr. Hart comments
on feeling dizzy before suddenly losing consciousness. His blood pressure monitor
indicates an arterial pressure of less than 40/20 mm Hg. His multi-lead ECG is shown
below:
Q14: What is the rhythm and rate in his ECG? Vtach, 300bpm
Q16: What is the indication for the use of amiodarone (or lidocaine) in this setting?
amiodarone cause its a antiarrhythmic
Q17: Should treatment with an i.v. antiarrhythmic have been given prior to DC Cardioversion?
no
Q18: What are the primary antiarrhythmic mechanisms of action of lidocaine and amiodarone?
1b III
Q19: If lidocaine were used, what are the primary warning signs of lidocaine toxicity that you should
watch out for ?
hypotension apparently
Q20: What are some of the clinically significant side effects of long term treatment with amiodarone?
HEART BLOCK!!!!
gray-blue skin
lung fibrosis
neurologic side effects
gray corneal microdeposits
7
Two days later Mr. Hart has an irregular heart rhythm of 90-110/min and B.P. of
110/80 mm Hg. His neck veins are no longer distended, and he has occasional runs of
ventricular premature beats. The analysis of his serum enzyme profile determined
from blood samples taken at the time of admission, and 6 hours after admission to the
hospital are made available, and are shown below.
Serial Changes in Cardiac Enzymes.
Enzymes Patient Values Patient Values Normal Range
(at admission) (after 6 hrs)
Myoglobin 220 ng/ml 620 ng/ml 0 - 100 ng/ml
Troponin-I 1.1 ng/ml 7.1 ng/ml 0 - 1 ng/ml
Total CPK 220 U/L 320 U/L 20-200 U/L
CPK-MB 5.8 ng/ml 15.8 ng/ml <5 ng/ml
CPK- creatinine phosphokinase; CPK-MB - cardiac specific isoform
yes
The End