Atrial fibrillation emergency care algorithm. Emergency care for paroxysmal cardiac arrhythmias
Atrial fibrillation and flutter are the cause of over 80% of all "arrhythmic" SLE calls and hospitalizations of patients. Not only patients with the first or repeated attacks need help, but also those in whom, against the background of constant atrial fibrillation, AV nodal conduction suddenly improves and the heart rate increases sharply.
The volume of medical measures at the prehospital stage varies. In healthy young people, excitable, with unstable neurovegetative regulation, without atrial dilatation, short episodes of atrial fibrillation disappear spontaneously. This process can be accelerated by taking 40 mg of anaprilin (obzidan) under the tongue and repeating the same dose after 1.5-2 hours.
Undoubtedly, cases of atrial fibrillation (flutter) of alcohol-toxic genesis have become more frequent. Many of the so-called idiopathic fibrillators actually suffer from an alcoholic-toxic form of myocardial dystrophy, one of the main manifestations of which are cardiac arrhythmias, especially atrial fibrillation. In such cases, intravenous infusions of potassium chloride have high antiarrhythmic activity: 20 ml of a 4% solution of potassium chloride in 150 ml of a 5% glucose solution is administered at a rate of 30 drops / min. In 2/3 of patients, 1-3 such infusions are sufficient. Naturally, the SLE can deliver only one infusion during the call. The patient is left at home for subsequent infusions of potassium chloride or, more reliably, taken to the cardiology department. With a sharp tachycardia, they resort to a combination of potassium chloride with 0.25 mg of digoxin, which limits the number of ventricular responses and accelerates the recovery of sinus rhythm. You can add 40 mg of anaprilin (obzidan) to receive it.
In elderly patients and patients with organic heart diseases (mitral stenosis, mitral valve prolapse, cardiomyopathy, postinfarction cardiosclerosis), treatment of an attack of atrial fibrillation (flutter) begins with a slow intravenous injection of 0.25 mg of digoxin (1 ml of a 0.025% solution) or 0, 25 mg of strophanthin (0.5 ml of a 0.05% solution), unless, of course, the patients are in a state of digitalis intoxication. If there is no effect after 30 minutes, 5 to 10 ml of a 10% solution of novocainamide is slowly injected into the vein. You can enter novocainamide together with 0.3 ml of a 1% solution of mezaton. The effectiveness of novocainamide in atrial fibrillation (flutter) is beyond doubt. It is only necessary to take into account that in the damaged myocardium, novocaine-amide often causes dangerous disturbances in intraventricular conduction. With such a complication, 100 ml of a 5% sodium bicarbonate solution, which eliminates the toxic effect of novocainamide, is injected into the vein without delay (stream). The patient is taken to a specialized cardiology department.
A severe attack of atrial fibrillation or flutter with 2:1 AV nodal block (150 ventricular responses) can rapidly cause a drop in blood pressure. This reaction to a tachyarrhythmia is considered as an indication for electrical defibrillation. Of course, if circumstances permit, it is better to postpone the procedure until the cardiological hospital, where the conditions for its implementation are more favorable.
It is necessary to indicate those variants of atrial fibrillation, in which it is not necessary to resort to active treatment at the prehospital stage. These include: atrial fibrillation (flutter) with rare ventricular responses (bradycardia) and often recurrent fibrillation (flutter) in individuals with significant atrial dilatation. All these patients should be routinely placed in the cardiology department.
Paroxysms of atrial fibrillation (flutter) deserve special attention in individuals with WPW syndrome who previously suffered from attacks of reciprocal AV tachycardia. This means accession to the WPW syndrome of atrial arrhythmic disease.
The technique of treating very dangerous attacks of atrial fibrillation (flutter) in patients with WPW syndrome has its own distinctive features. Drugs that enhance AV nodal blockade are contraindicated, in particular: cardiac glycosides, verapamil (Isoptin), P-blockers. With a very fast heart rate, electrical defibrillation is immediately performed. If the number of ventricular responses does not reach extreme values (less than 200 in 1 min), then prescribe substances that predominantly block the accessory pathway or lengthen its refractory period. Among these drugs, the first place is given to aymalin (giluritmal), 2 ml of a 2.5% solution of which (50 mg) is diluted in 10 ml of isotonic sodium chloride solution and slowly (within 5 minutes) is injected into a vein. The conduction of impulses through the accessory pathway stops after a few minutes: atrial fibrillation (flutter) is recorded on the ECG with narrow QRS complexes and with a markedly reduced frequency of ventricular responses. In some cases, the dose of 50 mg of aymalin may be insufficient, then after 5-10 minutes the drug is re-introduced intravenously at the same dose. If aymalin is administered intramuscularly, then the effect should be expected in 10-20 minutes. Sometimes aymalin also eliminates an attack of atrial fibrillation or flutter.
In addition to Aymalin, the blockade of the accessory pathway is caused by disopyramide (rhythmilen): 10-15 ml (100-150 mg) of disopyramide (each 5 ml ampoule contains 50 mg of the drug) is supplemented to 20 ml with isotonic sodium chloride solution and injected into a vein for 5-10 min. The desired effect (blockade of the accessory pathway) is determined 3 to 5 minutes after the end of the infusion. In addition, disopyramide at a dose of 2 mg/kg of body weight, administered intravenously, restores sinus rhythm in 38% of patients with atrial flutter and 20% of patients with atrial fibrillation. Obviously, disopyramide can be used to treat these tachycardias in patients without WPW syndrome.
In connection with the characteristics of attacks of atrial fibrillation in WPW syndrome, one cannot fail to mention the danger of atrial fibrillation turning into ventricular fibrillation as a cause of sudden death in some patients with WPW syndrome. Some of the signs point to this danger:
- very high heart rate at the time of atrial fibrillation (> 220 per 1 min);
- left-hand location of the additional path;
- the patient has several accessory pathways.
In many of these fatal cases, patients were mistakenly injected into a vein with cardiac glycosides to suppress paroxysmal atrial fibrillation.
Ed. V. Mikhailovich
"Emergency care for atrial fibrillation and flutter" and other articles from the section
Duration less than 48 hours:
amiodarone 300 mg in 5% glucose solution IV drip for 20-120 minutes. If the effect occurred during this time, then another 900 mg should be administered per day;
if there is no effect, then propafenone 1.5-2 mg/kg IV drip for 10-20 minutes. or novocainamide 10% - 10 ml in 20 ml of saline intravenously in a stream for 10 minutes.
On the first day of the paroxysm of atrial fibrillation a good effect is given by the use of novocainamide at a dose of 5-10 ml of a 10% solution in / in a stream for 4-5 minutes. Efficiency reaches 90% (on the second day only 33%).
For paroxysmal atrial fibrillation lasting more than 48 hours, it is not advisable to urgently restore the rhythm due to the high risk of normalization thromboembolism. Postpone the problem until planned therapy.
Treatment of paroxysm of atrial fibrillation you can start with the appointment of cardiac glycosides (if there is no digitalis intoxication) - digoxin 0.05 mg, or strophanthin 0.25 mg i.v. include 10-30 ml of a 25% solution of magnesium sulfate. Glycosides can be administered directly to the composition of the infusion mixture; in just 12 hours, up to 1.5 mg of digoxin can be administered. Digoxin has a dual effect: - reduces the speed of AV conduction, thereby reducing the heart rate (which in itself reduces the risk of decompensation), and can directly stop atrial fibrillation. Potassium and magnesium ions, having a stabilizing effect on the myocardium, contribute to the termination of atrial fibrillation, and also prevent the development of digitalis arrhythmias. The effect is achieved in 2/3 cases of paroxysms of atrial fibrillation.
Success is still being achieved more often with the introduction of novocainamide after 20-30 min. after the introduction of glycosides and potassium preparations. Therapy is carried out taking into account side effects (the acute toxic effect of novocainamide can be eliminated by a jet injection of 100 ml of a 5% sodium bicarbonate solution).
Isoptin It is used mainly only to slow down the heart rate, since its stopping effect does not exceed 10%).
In healthy people, excitable, with unstable neurovegetative regulation, short episodes of atrial fibrillation resolve spontaneously. It is possible to recommend taking 40 mg of anaprilin (obzidan) under the tongue and repeating the same dose after 1.5-2 hours; sedative drugs.
Intravenous infusions of potassium chloride have high antiarrhythmic activity of alcohol-toxic genesis: 20 ml of a 4% solution of potassium chloride in 150 ml of a 5% glucose solution is administered at a rate of 20-30 drops per minute; in 2/3 of patients, 1-3 such infusions are sufficient (Uzilevskaya R.A., Grishkin Yu.N., 1982). With severe tachycardia, add 0.25 mg of digoxin. Inside, you can apply 40 mg of anaprilin (obzidan).
With paroxysmal atrial fibrillation in elderly patients with organic heart disease (mitral stenosis, postinfarction cardiosclerosis), treatment begins with a slow intravenous injection of 0.5 ml of a 0.05% solution of strophanthin or 1 ml of a 0.025% solution of digoxin, unless, of course, the patients are in a state of digitalis intoxication. If there is no effect after 30 minutes. intravenously injected from 5 to 10 ml of a 10% solution of novocainamide until the effect is obtained (or until a total dose of 1 g is reached). In the absence of the effect of drug therapy, the deterioration of the patient's condition - electropulse therapy.
At a constant form of atrial fibrillation emergency care is required only if, for some reason, the refractory period of the AV node decreases and the heart rate increases. Reducing therapy with the use of cardiac glycosides, isoptin and potassium preparations is shown. The issue of restoring the rhythm is resolved in a planned manner (it must be remembered that with atrial fibrillation, blood clots often form in the atrial cavities over time, and the restoration of the rhythm can lead to fatal embolism).
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MA (atrial fibrillation, atrial fibrillation)- violation of the heart rhythm, in which throughout the entire cardiac cycle there is frequent (from 350 to 700 per minute) chaotic excitation and contraction of individual groups of atrial muscle fibers, while their coordinated whole contraction is absent and an irregular ventricular rhythm is established.
Etiology of MA paroxysm:
a) cardiac factors. MI in the acute period, acute myocarditis, acute pericarditis, cardiomyopathy, mitral valve prolapse, hypertensive crisis, the presence of additional pathways (more often with WPW syndrome), cardiac surgery (especially CABG and prosthetic heart valves)
b) extracardiac factors. intake of large doses of alcohol, pulmonary embolism, thyrotoxicosis syndrome, acute psycho-emotional and physical stress, electrical injury, hypokalemia
Clinic and diagnosis of MA paroxysm:
- complaints of palpitations, dizziness, shortness of breath (especially in patients with mitral stenosis and HCM), general weakness, fatigue, sometimes chest pain, fainting
- signs of CHF may increase (up to the development of cardiac asthma), episodes of thromboembolism are characteristic (especially at the time of rhythm recovery)
- when examining the pulse, it is characteristic: erratic appearance of pulse waves (pulse arrhythmia), constantly changing amplitude of pulse waves (all pulse waves of different filling), pulse deficit (HR is greater than the number of pulse waves on the radial artery due to a significant decrease in VR during contractions of the left ventricle after short diastole), changing heart rate even at complete rest
- characterized by continuous fluctuations in blood pressure values
- percussion - expansion of the left border of relative dullness of the heart (with mitral stenosis - and upper)
- auscultatory: absolutely erratic, arrhythmic activity of the heart (delirium cordis), constantly changing volume of the first tone (due to the changing duration of diastole and different filling of the ventricles, after a short diastole, the volume of the first tone increases)
- ECG: P wave is absent in all leads; there are frequent waves of atrial fibrillation f in leads II, III, aVF, V1, V2 (up to 350-700/min); R-R intervals are different in duration (the difference is more than 0.16 sec); depending on the frequency of ventricular contraction, there may be a tachy-, normo-, and bradyarrhythmic form of MA
Pathogenetic variants of MA paroxysm:
a) hyperadrenergic variant- based on high tone of the sympathetic division of the ANS
b) vagal variant- based on high vagal tone
c) hypokalemic variant- based on hypokalemia, most often after forced diuresis or alcohol intake
d) cardiodystrophic alcoholic variant- based on the damaging effect of alcohol and its metabolite acetaldehyde on the atrial myocardium, excitation of the SNS, increased synthesis and release of KA, release of potassium, magnesium, phosphorus from cardiomyocytes and their overload with calcium, etc.
d) stagnant option- based on the formation of many local disturbances of excitability and conduction due to remodeling of the LA walls in congestive heart failure
e) thyrotoxic varinate- at the core - an increase in SNS activity, an increase in the density and sensitivity of myocardial beta-adrenergic receptors to CA, an increase in myocardial oxygen demand, a decrease in potassium concentration in myocardiocytes and their potassium overload, and other pathogenetic mechanisms underlying thyrotoxicosis.
Urgent measures for PT in an outpatient setting.
Indications for rhythm restoration at the prehospital stage:
1. Paroxysmal form of atrial fibrillation lasting less than 48 hours, regardless of the presence of hemodynamic disorders
2. Paroxysmal form of atrial fibrillation lasting more than 48, accompanied by severe ventricular tachysystole (HR 150 / min and >) and serious hemodynamic disorders (hypotension< 90 мм рт.ст. альвеолярный отёк лёгких, тяжёлый ангинозный приступ, ЭКГ-картина ОКС как с подъёмом, так и без подъёма сегмента ST, loss of consciousness)
In all other forms of AF (including paroxysms of unknown duration) requiring emergency treatment, one should not seek to restore sinus rhythm in the prehospital
Ways to restore the rhythm at the prehospital stage. medical and electrical cardioversion:
- in the presence of severe hemodynamic disorders, an emergency electrical cardioversion should be performed (initial shock of 200 J)
— for quick medical elimination of MA, you can use
a) procainamide (novocainamide) IV slowly 100 mg every 5 minutes to a total dose of 1000 mg under the control of heart rate, blood pressure and ECG (10 ml of 10% solution diluted with 0.9% sodium chloride solution to 20 ml, drug concentration 50 mg/ml); at the time of restoration of the rhythm, the administration of the drug is stopped; contraindications: arterial hypotension, cardiogenic shock, severe heart failure, prolongation of the QT interval; because novocainamide can cause the transformation of MA into atrial flutter with a high coefficient of conduction to the stomach and the development of arrhythmogenic collapse, it is recommended to introduce verapamil / isoptin IV 2.5-5.0 mg before stopping MA
b) amiodorone: IV infusion of 150 mg (3 ml) in 40 ml of 5% glucose solution for 10-20 minutes, followed by maintenance infusion in the hospital (in 50%, a single infusion does not work)
In order to avoid thromboembolic complications, a single intravenous injection of sodium heparin 5000 IU is indicated before the start of rhythm recovery (in the absence of contraindications).
Treatment of MA in the hospital:
Relief of an attack:
1. With atrial flutter with hemodynamic disturbance - EIT (electrical cardioversion)
2. In the absence of hemodynamic disturbances, it is not necessary to resolve the issue of the need to restore the rhythm, it is not carried out in cases of: 1) severe organic damage to the heart, 2) frequent paroxysms of AF (more than 3 per year or the restored rhythm lasts less than 4-6 months), AF duration is more than 3-5 years, 3) concomitant pathology that determines an unfavorable prognosis for life, 4) the patient's age is more than 70 years, 5) bradysystolic form of AF or Frederick's syndrome (combination of AF and complete AV blockade)
3. To restore the rhythm, it is possible to use the following drugs (but not more than 2 at once):
1) verapamil 0.25% - 4 ml IV (caution with WPW)
2) procainamide 10% - 5-10 ml IV (careful - causes significant hypotension)
3) quinidine sulfate orally 200 mg every 2-3 hours up to a total dose of 1000 mg or until the relief of paroxysm (only with persistent MA for at least 3 days)
4) amiodarone 1200 mg/day, of which 600 mg IV for several hours, the rest of the IV dose at a rate of 0.5 mg/min for the rest of the day
If the paroxysm lasted more than 48-72 hours, at least 6 hours before the rhythm is restored, anticoagulant therapy is performed.
4. Prevention of paroxysms:
a) if there is CHF - cardiac glycosides (digoxin orally or intravenously 0.25-0.5 mg once, then 0.25 mg every 6 hours to a total dose of 1.0-1.5 mg, then a maintenance dose orally 0.125-0.375 mg 1 time / day for a long time with periodic ECG control)
b) if there is no CHF, beta-blockers (propranolol 30-120 mg/day) or amiodarone (100-600 mg/day, once a year - chest x-ray and thyroid control)
c) if one drug is not effective: beta-blocker + cardiac glycoside or beta-blocker + amiodarone
d) for the prevention of thromboembolic complications permanently acetylsalicylic acid 150 mg/day orally
154. Urticaria and angioedema: emergency care, medical tactics– see question 165.
The main forms of tachycardia, features of ECG diagnostics, emergency medical care, tactical solutions
1. Paroxysms of fibrillation (flicker) and atrial flutter are summarized by the term "atrial fibrillation". Clinical manifestations of atrial fibrillation are associated with changes in ventricular complexes; pathology of atrial teeth and QRS complexes is recorded on the ECG. With a paroxysm of atrial flutter, instead of P waves, sawtooth F-waves of fibrillation are recorded with a frequency of up to 200 per 1 min or more, and the F-F intervals are equal to each other. In this case, the following variants of changes in the ventricular complex are usually observed:
- the correct ventricular rhythm is preserved, each QRS is preceded by the same number of F waves. The QRS complex is evenly narrowed, but not deformed. R-R intervals are reduced, but equal to each other, the frequency of R-R is 120 in 1 min or more;
- the QRS complex is deformed. The R-R intervals are uneven due to the deformation of the QRS complex, the R-R frequency is slightly less than 120 per 1 min, but can reach 300 if there is 1 QRS complex for 2 or 1 F fibrillation wave. A high heart rate is not hemodynamically productive and leads to coronary blood flow disorders resulting in ventricular fibrillation.
In paroxysmal atrial fibrillation, the P, F waves and F-F intervals are not defined, and irregular atrial fibrillation is usually observed as an uneven line. In this case, the following variants of changes in the ventricular complex are usually detected:
- R-R intervals are different in length, i.e. there is no correct ventricular rhythm, although the QRS complex is not changed;
- R-R intervals are the same, i.e., the rhythm of ventricular contractions is correct (due to ventricular automatism with complete blockade of AV conduction).
Thus, atrial fibrillation is clinically characterized by a change in the frequency and rhythm of the peripheral pulse.
Diagnosis is put on the basis of clinical, anamnestic and ECG data in the approximate wording "Atrial fibrillation, attack." When recognizing the underlying disease, complicated by atrial fibrillation, its diagnosis precedes the formulation of a diagnostic conclusion (for example: “Cardiosclerosis, chronic heart failure, atrial fibrillation” or “Acute myocardial infarction, atrial fibrillation”). The diagnosis is supplemented by the characteristics of the form of atrial fibrillation - in the form of an attack, for the first time, a repeated attack or a permanent form.
Emergency(before the patient is transferred to the medical, cardiology or intensive care emergency care team):
- in case of sudden cardiac arrest - cardiopulmonary resuscitation;
- in cardiogenic shock and cardiogenic pulmonary edema - emergency treatment of these emergency conditions (see the articles Cardiogenic shock, Cardiogenic pulmonary edema);
- with paroxysmal atrial fibrillation, no indications for cardioresuscitation, no signs of cardiogenic shock and pulmonary edema, and in the presence of clinically significant disorders (tachycardia, anginal pain, an increase in cardiac and neurological symptoms), as well as with reliable knowledge of the known method of suppressing paroxysm, paramedical team before the arrival of the medical team, according to indications, the following emergency medical measures are carried out:
a) in the absence of arterial hypertension:
- potassium chloride 4% 20 ml mixed with magnesium sulfate 25% 5 ml in 100 ml of 5% glucose solution intravenously at a rate of 40-60 drops per minute or with syringes intravenously slowly;
- novocainamide 10% solution 10 ml mixed with mezaton 1% 0.2 (0.5) ml intravenously at an injection rate of 0.5-1 ml per 1 min;
b) with arterial hypotension:
- digoxin 0.05 (0.025)% solution or strophanthin, or corglicoi 0.06% solution - 1 ml per 10 ml of 0.9% sodium chloride solution or water for injection;
- verapamil (finoptin) 0.025% solution - 2 ml intravenously slowly. Verapamil can be used orally at a dose of 40-80 mg.
It should be remembered that the use of cardiac glycosides, verapamil and other calcium channel blockers is contraindicated in WPW syndrome. The ECG sign of WPW syndrome is an extended QRS complex with a delta wave. In this case, it should be limited to the introduction of novocainamide (procainamide) 10% -10 ml intravenously slowly at an injection rate of 0.5-1 ml per minute under the obligatory monitoring of ECG and blood pressure levels. It should be remembered that procainamide (procainamide) is contraindicated in the permanent form of atrial fibrillation and in the first paroxysm of atrial fibrillation. If a complication of novocainamide therapy (acute arterial hypotension) occurs, use:
- sodium chloride 0.9% solution intravenously under the control of blood pressure until it stabilizes at the transport level (100-110 mm Hg), and if there is no effect, add to the infusion solution:
- norepinephrine 0.2% solution - 1 ml or mezaton 1% solution - 1 ml and carry out infusion under the control of blood pressure.
With atrial flutter while waiting for the medical team and possible electrical impulse therapy:
- strophanthin (korglikon) 0.06% solution - 1 ml per 10 ml of 0.9% sodium chloride solution (water for injection);
- or novocainamide (procainamide) 10% solution intravenously slowly 0.5-1 ml per 1 minute under the control of ECG and blood pressure. The drug is contraindicated in WPW syndrome, as well as with an increase in tachycardia.
tactical activities.
1. Call for help from a medical team with an indispensable face-to-face transfer of the patient to ensure the continuity and succession of medical events. It is acceptable to start transportation to the hospital by the paramedic team with the transfer of the patient under medical supervision along the way, and the medical team goes to the ambulance of the paramedic team. Transportation on a stretcher, lying down. Delivery to the cardioreanimation department, bypassing the emergency department, is required to transfer the patient to the on-duty doctor of the hospital.
2. Indications for emergency delivery to the hospital:
- an attack of atrial fibrillation, which arose for the first time;
- an attack complicating acute coronary insufficiency or complicated by it;
- complications of antiarrhythmic therapy, even stopped;
- repeated paroxysms of atrial fibrillation:
- non-stopping attack of atrial fibrillation, even without clinical manifestations of circulatory failure.
By the decision of the doctor of the ambulance team called for help, the patient may be left for home treatment if the paroxysm of atrial fibrillation with ECG control has been eliminated and in the absence of clinical manifestations of acute coronary insufficiency, as well as peripheral circulatory insufficiency. In this case, a call is transmitted for an active visit by a therapist or family doctor to the polyclinic on the day the patient contacts "03". During non-working hours for the polyclinic, the ambulance medical team actively performs a second call on the same day.
2. Supraventricular tachycardia. The cause of supraventricular tachycardia is usually alcohol, narcotic, barbituric and other drug intoxication, as well as dysuretic hypokalemia as a result of uncontrolled use and overdose of potassium-sparing diuretics (for example, furosemide or hypothiazide in order to reduce weight or lower blood pressure). The pulse rate at the same time reaches 160 beats / min, with a higher frequency, the pulse becomes intangible. On the ECG, a regular, strictly correct rhythm with uniform R-R intervals is determined.
Diagnosis is put on the basis of clinical, anamnestic and ECG data in the approximate wording "Attack of supraventricular tachycardia" indicating (if possible) the nosological form of the disease complicated by this attack (alcohol intoxication, diuretic hypokalemia, etc.), or complicating the attack (for example, acute coronary insufficiency, arterial hypotension, etc.).
Emergency. Unilateral (!) massage of the carotid sinus zone. Pressure on the eyeballs can lead to severe complications and is therefore not recommended for the practice of an ambulance paramedic.
In the absence of effect and with normal blood pressure:
- verapamil 0.25% solution - 2 ml (5 mg) intravenously diluted with 10 ml of 0.9% sodium chloride solution or water for injection, administered slowly. Verapamil is contraindicated in arterial hypotension and WPW syndrome. If there is no effect from the initial administration of verapamil, it is repeated at the same dose twice more with an interval of 5 minutes with a total amount of the drug administered 15 mg, or 6 ml, or 3 ampoules of 2 ml of a 0.25% solution. Hypotension and (or) bradycardia, which complicated the use of verapamil, is stopped by intravenous administration of calcium chloride 10% solution - 10 ml.
With the ineffectiveness of verapamil:
- novocainamide 10% solution 10 ml mixed with 10 ml isotonic sodium chloride solution intravenously slowly (injection rate 0.5-1 ml per 1 min), only in the horizontal position of the patient under the control of continuous ECG monitoring. At the time of restoration of the rhythm, the infusion should be stopped immediately! If the infusion is complicated by collapse - mezaton 1% solution of 0.3-0.5 ml mixed with 2-5 ml of isotonic sodium chloride solution intravenously.
With hypotension and the absence of the effect of the introduction of verapamil, as well as when the ECG reveals the absence of a P wave and the presence of a wide deformed ventricular complex:
- novocainamide according to the scheme:
- ATP 1% solution 1 - 2 ml (10 - 20 mg) intravenously, quickly for 3 - 5 s in a dilution of 5-10 ml of isotonic sodium chloride solution (water for injection). ATP (sodium adenosine triphosphate, triphosadenine), metabolic, has an antiarrhythmic effect. It is not included in the list of medicines in Appendix No. 13 of the Order of the Ministry of Health of the Russian Federation of 1999, but it can supplement it. Registered in the Russian Federation No. 71/2. ATP is recommended by M. S. Kushakovsky (2001). A. L. Vertkin (2001) and others. ATP is contraindicated in acute myocardial infarction, AV blockade, arterial hypotension, inflammatory lung diseases, bronchial asthma.
Tactical activities:
1. Call for help from a medical team (specialized, cardiological or intensive care) with an indispensable face-to-face transfer of the patient to ensure the continuity of medical events. It is possible to transfer the patient to the medical team along the way. But without transferring the patient from car to car. On a stretcher, lying down, and transferring the patient in the hospital to the doctor on duty of the cardio intensive care unit, bypassing the emergency department.
2. Indications for emergency delivery to the hospital:
- unresolved ventricular arrhythmia;
- complications of antiarrhythmic therapy, including stopped;
- first-time paroxysm of ventricular arrhythmia.
The decision to leave the patient at home, i.e. refusal to be delivered to the hospital, can only be taken by an ambulance doctor called “for help”. Patients can be left on the spot after the elimination of signs of paroxysmal supraventricular tachycardia with ECG confirmation, in the absence of clinical decompensation of cardiac activity, as well as indications for emergency hospitalization associated with the cause of ventricular tachycardia. Patients are transferred under the supervision of a local therapist or family doctor for a visit on the same day. During non-working hours for the clinic, it is obligatory to visit the patient on the same day by the SMP medical team.
3. Ventricular tachycardia. Fibrillation and flutter of the ventricles.
Left ventricular tachycardia occurs in the vast majority of cases in the acute phase of myocardial infarction, with unstable angina pectoris, in patients with postinfarction cardiosclerosis, especially with postinfarction left ventricular aneurysm and hypertension (the latter diseases are established anamnestically using medical certificates). In addition, left ventricular tachycardia can be caused by overdoses of antiarrhythmic drugs, cardiac glycosides, as well as poisoning with household FOS insecticides and household and atmospheric electricity. The classic ECG sign of left ventricular tachycardia is the presence of widened (more than 0.12 s) QRS complexes, as well as atrioventricular dissociation, that is, the mutually independent rhythm of P waves and QRS complexes, with tachycardia detected clinically and on the ECG. Left ventricular ischemic tachycardia is especially unfavorable due to the risk of transition to ventricular fibrillation with cardiac arrest.
Right ventricular tachycardia is a manifestation of hypertrophy and overload of the right heart in chronic respiratory failure, which complicates tuberculosis, pneumosclerosis, bronchiectasis and other chronic lung diseases. Right ventricular tachycardia can also occur in acute respiratory failure, complicating pulmonary embolism (PE), status asthmaticus or a prolonged attack of bronchial asthma, spontaneous pneumothorax, exudative pleurisy with a massive lunge, confluent pneumonia, postoperative period during surgical interventions on the chest organs (according to discharge hospital patient). ECG signs of right ventricular tachycardia, in addition to increased heart rate, are the splitting of the ventricular complex in III, V1, V2, V3 leads, and in lead aVF - signs of blockade of the right leg of the His bundle.
Diagnosis is put on the basis of clinical data, anamnesis and the results of ECG studies with the obligatory determination of the underlying disease that caused an attack of ventricular tachycardia, fibrillation and ventricular flutter and the reflection of these pathological syndromes in the diagnosis formula.
Emergency carried out in accordance with the underlying disease, which was complicated by left ventricular tachycardia, flutter and ventricular fibrillation. In acute myocardial infarction, unstable angina pectoris, worsening of the course of hypertension with ventricular tachycardia, but with stable hemodynamics at the beginning, apply:
- lidocaine 2% solution - 2-2.5 ml (80-100 mg) or 1-2 mg per 1 kg of body weight, i.e. 0.5 ml in isotonic sodium chloride solution 5-10 ml intravenously slowly in for 3-5 minutes per injection until a clinical effect appears or up to a total dose of 3 mg per 1 kg of body weight (total 120 mg or 3 ml of 2% lidocaine solution). With no effect:
- novocainamide according to the above scheme:
- EIT (medical event):
- in acute cardiac arrest - cardiopulmonary resuscitation.
Right ventricular tachycardia usually resolves quickly with
proper emergency medical care for a patient with bronchial asthma or spontaneous pneumothorax.
Tactical activities:
1. Call for help from a medical or specialized cardiological, cardio-resuscitation team.
2. Emergency delivery to a specialized department of a multidisciplinary hospital or to a cardiac intensive care unit, on a stretcher, lying down or in a functionally advantageous semi-sitting position in case of acute respiratory failure. It is possible to transfer the patient to the medical team along the route without transferring him to another car. Control of life support functions in transit. Readiness for emergency cardioresuscitation in the ambulance.
3. Transfer of the patient in the hospital to the emergency doctor on duty, bypassing the emergency department.
Criteria: Rhythm is irregular, R-R intervals are different, P waves are absent. Waves f (waves of atrial fibrillation) are detected - large or small-wave fluctuations with a frequency of 350-600 / min.
In this example, the waves of fibrillation are barely noticeable - this is small-wave atrial fibrillation.
Atrial fibrillation (the term accepted in Russia), or atrial fibrillation (international terminology) is a rhythm disturbance characterized by chaotic excitation and irregular contraction of groups of atrial cardiomyocytes at a frequency of 350-600 per minute, leading to the absence of a coordinated systole atria.
Depending on the duration of existence and the ability to terminate (spontaneously or under the influence of antiarrhythmic drugs or cardioversion), the following forms of atrial fibrillation are distinguished.
■ Paroxysmal form of atrial fibrillation. The most important distinguishing feature of this form is the ability to spontaneous termination. At the same time, in most patients, the duration of the arrhythmia is less than 7 days (most often less than 24 hours).
□ From a practical point of view, a paroxysmal form is distinguished on the SMPatrial fibrillation up to 48 hours and more than 48 hours.
■ Stable (persistent) form of atrial fibrillation.
The most important distinguishing feature of this form is the inability to spontaneously stop, but this can be eliminated with the help of medical or electrical cardioversion. In addition, the stable form of atrial fibrillation is characterized by a much longer duration of existence than the paroxysmal form. A temporary criterion for a stable form of atrial fibrillation is its duration for more than 7 days (up to a year or more).
■ Permanent form of atrial fibrillation. The permanent form includes those cases of atrial fibrillation when it cannot be eliminated with the help of medical or electrical cardioversion, regardless of the duration of the arrhythmia.
According to the frequency of contractions of the ventricles, the following forms of atrial fibrillation are distinguished:
■ tachysystolic (more than 90 per minute);
■ normosystolic (60-90 per minute);
■ bradysystolic (less than 60 per minute).
Treatment
The decision on the need to restore sinus rhythm at the prehospital stage primarily depends on a combination of two factors:
■ forms of atrial fibrillation;
■ the presence and severity of hemodynamic disorders: acute left ventricular failure (arterial hypotension, pulmonary edema), coronary insufficiency (anginal attack, signs of myocardial ischemia on the ECG), disorders of consciousness.
Restoration of sinus rhythm
Indications for the elimination of atrial fibrillation at the prehospital stage:
■ Paroxysmal form of atrial fibrillation lasting less than 48 hours, regardless of the presence of hemodynamic disorders.
■ Paroxysmal form of atrial fibrillation lasting more than 48 hours anda stable form of atrial fibrillation, accompanied by severe ventricular tachysystole (heart rate of 150 or more per minute) and serious hemodynamic disturbances (hypotension<90 мм рт.ст., альвеолярный отёк лёгких, тяжёлый ангинозный приступ, ЭКГ-картина острого коронарного синдрома как с подъёмом, так и без подъёма сегмента ST, loss of consciousness).
For all other forms of atrial fibrillation (including paroxysm of unknown duration) requiring emergency treatment, one should not seek to restore sinus rhythm at the prehospital stage.
There are two ways to restore sinus rhythm in atrial fibrillation in the prehospital stage: medical and electrical cardioversion.
■ In the presence of severe hemodynamic disorders (hypotension<90 мм рт.ст., альвеолярный отёк лёгких, тяжёлый ангинозный приступ, ЭКГ-картина острого коронарного синдрома как с подъёмом, так и без подъёма сегмента ST, loss of consciousness), an emergency electrical cardioversion (initial shock of 200 J) should be performed.
■ To quickly eliminate atrial fibrillation at the prehospital stage, use an antiarrhythmic class I A procainamide(novocainamide *), which is used under the control of heart rate, blood pressure and ECG. Procainamide is administered intravenously at a dose of 100 mg every 5 minutes to a total dose of 1000 mg (up to 17 mg / kg of body weight), while 10 ml of a 10% solution is diluted with 0.9% sodium chloride solution to 20 ml ( concentration 50 mg/ml). At the time of restoration of sinus rhythm, the administration of the drug is stopped. To prevent a decrease in blood pressure, the introduction is carried out in a horizontal position sick.
Side effects often occur with rapid intravenous administration: collapse, impaired atrial or intraventricular conduction, ventricular arrhythmias, dizziness, weakness. Contraindications: arterial hypotension, cardiogenic shock, severe heart failure, interval prolongation Qt. One of the potential dangers of using procainamide for the relief of atrial fibrillation is the possibility of transforming atrial fibrillation into atrial flutter with a high conduction coefficient to the ventricles of the heart and the development of arrhythmogenic collapse. This is due to the fact that procainamide blocks sodium channels, causing a slowdown in the conduction rate.excitation in the atria and at the same time increases their effective refractory period. As a result, the number of circulating excitation waves in the atria begins to gradually decrease and, immediately before the restoration of sinus rhythm, can be reduced to one, which corresponds to the transition of atrial fibrillation to atrial flutter. In order to avoid such a complication, it is recommended to introduce before the start of stopping atrial fibrillation with procainamide verapamil(for example, isoptin *) in / in 2.5-5.0 mg.
On the one hand, this makes it possible to slow down the rate of conduction of excitations along the AV junction and, thus, even in the case of transformation of atrial fibrillation into atrial flutter, to avoid severe ventricular tachysystole. On the other hand, in a small number of patients, the administration of verapamil may be sufficient to stop the paroxysm of atrial fibrillation. In Russia, when procainamide is administered to correct hypotension, it is practiced to use phenylephrine(mezaton * 1% 0.1-0.3 ml). However, it should be remembered that the drug is poorly understood, can cause ventricular fibrillation, angina, dyspnea. Phenylephrine is contraindicated in children under 15 years of age, pregnant women, ventricular fibrillation, acute myocardial infarction, hypovolemia. With caution whenatrial fibrillation, hypertension in the pulmonary circulation, severe aortic stenosis, angle-closure glaucoma, tachyarrhythmia; occlusive vascular diseases (including history), atherosclerosis, thyrotoxicosis, in the elderly.
■ To eliminate atrial fibrillation, you can use an antiarrhythmic III class amiodarone. However, given the peculiarities of its pharmacodynamics, amiodarone cannot be recommended for the rapid restoration of sinus rhythm, because the onset of antiarrhythmic action (even when using intravenous "loading" doses) develops after 8-12 hours. subsequent hospitalization of the patient with the continuation of the infusion of the drug in the hospital. Amiodarone (more than 50% single injection without effect) - intravenous infusion of 150 mg (3 ml) in 40 ml of 5% dextrose solution for 10-20 minutes.
Amiodarone is not compatible in solution with other drugs. Side effects often occur with rapid intravenous administration: hypotension and bradycardia. It should be remembered that with intravenous administration there is a risk of developing polymorphic ventricular tachycardia. Contraindications: hypersensitivity (including to iodine), cardiogenic shock, arterial hypotension, hypothyroidism, thyrotoxicosis, interstitial lung disease, pregnancy.
■ Before the restoration of sinus rhythm, it is advisable to introduce an IV heparin sodium 5000 ME. Main contraindications: hypersensitivity to heparin, bleeding, erosive and ulcerative lesions of the gastrointestinal tract, diseases with increased bleeding (hemophilia, thrombocytopenia, etc.), severe arterial hypertension, hemorrhagic stroke, recentsurgical interventions on the eyes, brain, prostate gland, liver and biliary tract, pregnancy.
Failure to restore sinus rhythm
You should not restore sinus rhythm at the prehospital stage with the following variants of atrial fibrillation.
■ Paroxysmal form lasting more than 48 hours, accompanied by moderateventricular tachysystole (less than 150 per minute) and a clinical picture of moderately severe hemodynamic disorders: acute left ventricular failure (congestive moist rales only in the lower parts of the lungs, SBP> 90 mm Hg), coronary insufficiency (anginal pain lasting less than 15 minutes and without signs of myocardial ischemia on the ECG).
■ A stable (persistent) form, accompanied by moderate ventricular tachysystole (less than 150 per minute) and a clinical picture of moderate hemodynamic disturbances (see above).
■ Permanent form, accompanied by ventricular tachysystole and a clinical picture of acute left ventricular disease of any severity or coronary insufficiencyany degree of expression.
Carry out drug therapy aimed at slowing the heart rate to 60-90 beats per minute, reducing the signs of acute left ventricular failure (adjustment of blood pressure, relief of pulmonary edema) and relief of pain, followed by hospitalization of the patient.
To control the heart rate, use one of the following drugs (it is recommended to choose according to the order of presentation).
■ Digoxin(preferable in the presence of manifestations of heart failure, including in patients taking β-blockers) - in / in a stream of 0.25 mg in 10 -20 ml of 0.9% sodium chloride solution.Converts atrial flutter to heart rate controlled fibrillation. Contraindicated in WPW syndrome, acute myocardial infarction, unstable angina, myocardial infarction.
■ Verapamil(in the absence of signs of heart failure in the patient) - IV bolus at a dose of 5 mg over 2-4 minutes (to avoid the development of collapse or severe bradycardia) with a possible repeated administration of 5-10 mg after 15-30 minutes while maintaining tachycardia and no hypotension.
Contraindicated in WPW syndrome, arterial hypotension (SBP less than 90 mmHg), cardiogenic shock, chronic and acute heart failure, as well as in patients taking β-blockers due to the high risk of developing complete AV block or asystole.
ATRIAL FLUTTER
Atrial flutter at a ratio of 4:1 Criteria: P-waves are absent, "sawtooth" F waves are recorded instead - atrial flutter waves with a frequency of 250-350/min (type I) or 350-430/min (type II).
In this example, the R-R intervals are the same (every fourth F wave is conducted to the ventricles).
Criteria: P-waves are absent, "sawtooth" F waves are recorded instead - atrial flutter waves with a frequency of 250-350/min (type I) or 350-430/min (type II).
In this example, the R-R intervals are different due to the varying degree of AV block - every second or third F wave is delivered to the ventricles.
Atrial flutter - a significant increase in atrial contractions (up to 250-450 per minute, usually in the range of 280-320) while maintaining the correct atrial rhythm. The ventricular rate depends on conduction in the AV node and in most cases only every second (2:1) or third ectopic impulse (3:1) is conducted to the ventricles.
Treatment
The algorithm of actions at the prehospital stage with atrial flutter does not differ from that with atrial fibrillation and depends on the form of atrial flutter, the nature of the heart disease, against which the rhythm disturbance occurred, as well as the presence and severity of hemodynamic disturbances and coronary circulation.
Atrial flutter with a high ratio of atrioventricular conduction (3:1, 4:1) without severe ventricular tachysystole and the absence of complications does not require emergency therapy. In case of atrial flutter with a high frequency of ventricular contraction, depending on the severity of hemodynamic disorders and myocardial ischemia, either the restoration of sinus rhythm with the help of medical or electrical cardioversion, or drug therapy aimed at slowing the heart rate and correcting hemodynamic disorders (see Fig. 3) -23).
Uncomplicated atrial flutter with a high ventricular rate at the prehospital stage requires only a decrease in heart rate, for which cardiac glycosides (digoxin) or calcium channel blockers (verapamil, diltiazem) are used; the use for this purpose (β-blockers (propranolol) is the least advisable, although possible.
With unstable hemodynamics, the development of complications against the background of atrial flutter with high ventricular contractions (AV conduction 1: 1), emergency electropulse therapy is indicated, synchronized with R tooth (initial discharge 100 J). With a discharge inefficiency of 100 J, the discharge energy is increased up to 200 J.
Indications for hospitalization. The same as for atrial fibrillation.
Clinical examplesWoman 70 years old. Complains of interruptions in the work of the heart, weakness, pressing pain behind the sternum for an hour. Suffering from coronary artery disease, atrial fibrillation. Takes sotahexal. Last night (8 hours ago) the rhythm of the heart was disturbed. I took 2 tablets of cordarone 200 mg each. Attacks of arrhythmia are usually stopped by cordarone (taking pills or intravenous administration of the drug).
Objectively: the state is satisfactory, consciousness is clear. Skin of normal color. Respiration is vesicular. Heart rate 115 per minute, palpation: the pulse is arrhythmic, heart sounds are erratic, non-rhythmic. BP = 160/90 mm Hg The abdomen is soft and painless.
ECG shows atrial fibrillation.
D.S. . ischemic heart disease. Paroxysm of atrial fibrillation.(I48)
Sol. Cordaroni 5% - 6 ml
Sol. Natrii chloridi 0.9% - 10 ml
The medicine was not administered because the patient felt better. The rhythm of the heart recovered on its own. On the repeated ECG - sinus rhythm, heart rate - 78 per minute. There are no data for acute coronary pathology.
