Dysrhythmias in the ICU

This week’s core-content series lecture was given by Dr. Amal Mattu on ICU dysrhythmias.  If you think that ACLS is all you need to know for the patient with a new dysrhythmia you are dead-wrong.  In this lecture Dr. Mattu goes through a number of high-risk cases that show when standard ACLS algorithms fail, and sometimes delay appropriate, emergent treatment.

Pearls

  • Hyperkalemia commonly presents with advanced AV blocks and severe bradycardias! Going down the ACLS algorithm will be ineffective in treating many of the metabolic and toxicologic causes of unstable dysrhythmias.
  • Always assume a WCT is Vtach until proven otherwise.  If you treat a VTach like SVT, the patient is at risk for death.  Adenosine-sensitive VTACH is well described in the electrophysiology literature, so don’t be fooled!
  • Beware of the VTACH mimics!  By definition VTACH must have a rate > 120 bpm.  Any WCT < 120 is more likely to be 2/2 metabolic, tox, or other causes.
  • A post-thrombolytic WCT with a rate < 120 (for a STEMI) is a normal reperfusion rhythm.  Do NOT treat this rhythm.  Antiarrhythmics will cause ASYSTOLE.

Remember the first law of medicine, “primum… no killem.”

 

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