Transcript Preoperative Evaluation and Risk Assessment in the Cardiac

Telemetry / Arrythmias
Dan Crouch
Kristi Kuhn
Kate Lindley
Ben Voss
Unresponsive patient in ED
Junctional tachycardia
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Regular
Narrow complex
No P waves
Surgical consult for arrhythmia
Paroxysmal SVT (PAT)
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Benign rhythm
If sustained:
• Vagal maneuvers
• Adenosine
• DCCV
70 yo AAF with palpitations
Premature ventricular complexes
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Abnormal but usually benign
• Concerns: very frequent, history of ischemia
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Ask about symptoms (palpitations, “skipping a beat”)
• Beta-blockers for symptomatic patients
Called to see sleeping patient
NSVT
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ICM or NICM
• Usually not an indication for ICD
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Ask about symptoms
Use more beta-blockers
Patient with L-sided weakness
Atrial fibrillation
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Irregular
No coordinated atrial activity (no P waves)
Rate control
Anticoagulation
Lung transplant pt with SOB
Atrial flutter (2:1)
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Regular rhythm
Flutter circuit rate: 300 bpm
Re-entrant circuit
Diagnostic maneuvers: vagal stimulation, adenosine
Typical atrial flutter
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“Sawtooth” pattern
Atrial flutter (variable block)
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Regular flutter waves @ 300 bpm
Irregular ventricular response
• Usually seen with AV nodal blockade
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May be difficult to distinguish from coarse Afib
Nursing student asks for help
Mobitz I (Wenkebach)
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Regular P waves
Lengthening P-R interval
Shortening R-R interval
Predictably dropped beats (grouped beats)
Patient with syncope
Mobitz II
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Randomly dropped beats
Frequently progresses to 3rd degree AVB or complete
heart block
Can be indication for pacemaker
27 yo WM with syncope at work
Complete Heart Block
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Normal sinus node activity (P waves)
No ventricular response
Pt presented with syncope while driving forklift
Patient with chest pain
Ventricular tachycardia
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Wide complex tachycardias
• VT until proven otherwise for patients with ischemia
• Brugada criteria: only AV dissociation useful on tele
– GET AN EKG!!
• Non-malignant rhythm with aberrancy also possible
Pt missed dialysis
Hyperkalemia
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QRS widening
 Peaked T waves
 Treatment:
• Calcium first
• Insulin/glucose, albuterol, glucagon, NaHCO3, IVF/Lasix
• Kayexalate last
18 yo WF postpartum
Torsades de pointes
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Polymorphic ventricular tachycardia
Life-threatening with degeneration to VF
Usually precipitated by PVC in setting of long QT
Often associated with QT-prolonging drugs
Check for electrolyte disturbances (especially Mg)
Regardless of the telemetry…