Summary
Emergency medicine and critical care are fields that often require rapid diagnosis and intervention for specific emergent arrhythmias. Wide QRS tachycardia is a cardiac rhythm with a rate faster than 100/min and a QRS duration ≥0.12 s. Causes of wide QRS tachycardia (W-QRS-T) are supraventricular tachycardia with preexisting or functional bundle branch block, orthodromic circus movement tachycardia (CMT) using the AV node in the anterograde direction, antidromic CMT, AV reentry tachycardia using a Mahaim fiber, ventricular tachycardia (VT), ventricular flutter (VFlut) or ventricular fibrillation (VF). A systematic ECG approach with evaluation of AV dissociation, QRS width, QRS axis and QRS configuration permits correct identification of more than 90% of the underlying arrhythmia mechanisms and the site or arrhythmia origin. In hemodynamically unstable W-QRS-T, electrical DC cardioversion should be performed immediately. If the hemodynamic situation is stable, antiarrhythmic drugs are indicated. In monomorphic VT ajmaline (50–100 mg i.v.) or procainamide (10 mg/ kg i.v.) are drugs of first choice; in patients (pts) with VT and acute myocardial ischemia, lidocaine (100– 150 mg i.v.) is successful. In polymorphic VT, the most important aspect is the identification of reversible etiologic factors (withdrawal of the offending agents). DC cardioversion is acutely successful, but recurrences of polymorphic VT are prevented only by accelerating the heart rate with isoprenaline (1–4 μg/kg/min i.v.), atropine (0.5–1.0 mg i.v.) or temporary right atrial pacing. Magnesium sulfate is the drug of first choice in torsade de pointes tachycardia with a dosage of 2 g over 5 min, repeated with an additional 2 g over the next 15 min, if necessary. VFlu and VF are life-threatening arrhythmias that require immediate DC cardioversion with or without mechanical resuscitation. Amiodarone can be given (300 mg i.v.) for life-threatening VT refractory to other conventional treatment.
Zusammenfassung
In der Intensivund Notfalltherapie sind bei lebensbedrohlichen Rhythmusstörungen schnelle diagnostische und therapeutische Maßnahmen notwendig, um nicht das Leben eines Patienten (Pt) zu gefährden. Tachykardien mit breitem QRS-Komplex (B-QRS-T) sind durch eine Herzfrequenz > 100/ min und eine QRS-Breite ≥0,12 s definiert. B-QRS-T sind typisch für supraventrikuläre Tachykardien mit vorbestehendem oder funktionellem Schenkelblock, orthodromen „circus movement“-Tachykardien (CMT) und anterograder Leitung über eine akzessorische Bypassbahn, antidromer CMT, AV-Reentry-Tachykardie bei Mahaim-Faser, Kammertachykardien (KT), Kammerflattern (KFlat) und Kammerflimmern (KF). Eine systematische EKG-Analyse mit Beurteilung von AV-Dissoziation, QRS-Breite, QRS-Achse und QRS-Konfiguration erlaubt eine sichere Beurteilung von Arrhythmie-Mechanismus und Ursprungsort >90%. Bei hämodynamisch instabiler B-QRS-T sollte unverzüglich eine DC-Kardioversion erfolgen. Antiarrhythmika (AA) sind bei stabiler Hämodynamik therapeutische Alternativen. Bei monomorpher KT sind Ajmalin (50–100 mg i.v.) oder Procainamid (10 mg/kg i.v.) AA der ersten Wahl. Bei Pt mit akuter myokardialer Ischämie ist Lidocain (100– 150 mg i.v.) erfolgreich. Die Identifikation reversibler Ursachen (Absetzen entsprechender AA) ist bei polymorphen KT wichtigste Maßnahme. Die DC-Kardioversion ist bei polymorphen KT akut erfolgreich, KT-Rezidive lassen sich aber nur durch Isoprenalin (1–4 μg/kg/min i.v.), Atropin (0,5–1,0 mg i.v.) oder temporäre rechtsatriale Stimulation verhindern. Magnesiumsulfat (2 g i.v. als Bolus, bei Bedarf erneut 2 g nach 15 min i.v.) ist das Medikament der Wahl bei Torsade de pointes-Tachykardien. KFlat und KF sind lebensgefährliche Arrhythmien, die eine sofortige DC-Kardioversion, mit oder ohne Reanimationsmaßnahmen, erfordern. Amiodaron (300 mg i.v.) ist bei anderweitig therapierefraktären lebensbedrohlichen KT als therapeutische Alternative anzusehen.
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Trappe, HJ., Weismüller, P., Rodriguez, L.M., Smeets, J.L.R.M. (2001). Diagnostik und Therapie von Tachykardien mit breitem QRS-Komplex. In: Trappe, HJ., Schuster, HP. (eds) Die Notfalltherapie bei akuten Herzrhythmusstörungen. Steinkopff, Heidelberg. https://doi.org/10.1007/978-3-642-57631-7_4
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