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Clin-Med B2 > 7: Dysrhythmias > Flashcards

7: Dysrhythmias Flashcards

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0
Q

Arrhythmias- SA node

A

1: sunus bradycardia
2: sinus tachycardia
3: sinus dysrhythmia
4: sinus arrest

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1
Q

Normal Sinus rhythm

A
  • there must always be a P wave
  • the P wave should be a rounded shape
  • each P wave should be the same shape
  • each P wave should be followed by a QRS of normal morphology
  • the P-R interval should be 3-5 small squares and constant
  • the rhythm should be regular
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2
Q

Arrhythmias- Atria

A

1: wandering pacemaker
2: premature atrial contractions (PAC)
3: atrial tachycardia (AT)
4: Paroxysmal supraventricular tachycardia (PSVT)
- AVNRT
- AVRT
5: atrial flutter
6: atrial fibrillation

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3
Q

Arrhythmias- AV junction

A

1: junctional rhythm
2: premature junctional contractions
3: junctional ectopic tachycardia

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4
Q

Arrhythmias- Ventricles

A

1: ventricular escape complexes and rhythm
2: premature ventricular complexes
3: ventricular tachycardia
4: ventricular fibrillation

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5
Q

Arrhythmias- Conduction

A

1: AV blocks
- 1-4th degree blocks
2: Bundle branch blocks
- RBBB
- LBBB
- Hemi-blocks

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6
Q

dysrhythmia- dx

A

Holter monitor
-portable ECG recorder for 24hr recording- for arrhythmia that occur less than daily
Treadmill testing
-dysrhythmias exacerbated by stress
Electrophysiologic studies (EP)
-electrodes are placed inside the right atrium and ventricle using catheter
-dx of abnormal foci or tract, SA, AV node disorder, placement of permanent pacemaker

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7
Q

Sinus arrhythmia

A

Phasic variation of R-R interval with respiration

Heart rate increases during inspiration and decreases during expiration

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8
Q

Sinus arrest

A 
Failure of sinus node to initiate impulse- normal rhythm followed by an absent P wave and an absent ORS
causes
-sick sinus syndrome
-ischemia
-digitalis toxicity
-excess vagal tone
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9
Q

Sick sinus syndrome

A

causes: degenerative process damaging the sinus node
-Sarcoidosis
-Amyloidosis
-Chaga’s disease
-Cardiomyopathies
sx: sinus bradycardia, sinus arrest or SA block, alternating episodes of tachyarrhythmia and bradycardia
Tx: no tx for asymptomatic, permanent pacing for symptomatic pts

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10
Q

Wandering atrial pacemaker (WAP)

A

Transient shifts in location of dominant pacemaker
EKG
-continual changes in the P-wave morphology. P waves vary in size, shape, and directions
-at least 3 different P waves must be present
-varying P-R intervals
Tx: not needed

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11
Q

Multifocal atrial tachycardia (MAT)

A

WAP associated with tachycardia (>100bpm)
Narrow QRS complexes
causes
-cor pulmonale, digitalis toxicity, CAD, elderly

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12
Q

Atrial tachycardia (AT)

A 
heart rate: 120-250bpm
AV block (by adenosine) does not terminate tachycardia
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13
Q

Premature atrial complexes

A

Common and benign

Premature P wave (buried in the preceding T wave)

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14
Q

Paroxysmal supraventricular tachycardia (PSVT)

A

sudden onset, usually initiated by a premature beat and the arrhythmia stops abruptly
Could result in decreased CO, angina, hypotention, CHF
types
1: AV node reentry (AVNRT)- 90%
2: AV reentrant tachycardia (AVRT)

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15
Q

AVNRT- info

A

Slow AV nodal pathway for anterograde conduction and Fast AV nodal pathway for retrograde conduction
P-wave buried in QRS and not seen
-if P wave is seen: pseudo ‘r’ wave at the end of QRS complex in V1, V2; or pseudo ‘S’ waves maybe seen in LEAD II, III, aVF
-Tachycardia associated with prolongation of PR interval

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16
Q

AVNRT- management

A 
Initial maneuvers
-carotid sinus massage
-gagging
-valsalva maneuver
If fails
-Adenosine (DOC)**
If hemodynamic compromise (hypotension)
-DC cardioversion**
Chronic 
-Beta blocker
-Ca channel blockers
-Class IC antiarrhythmics
-Radiofrequency catheter ablation of slow tract
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17
Q

AVRT- info

A

AV node and 1 or more bypass tracts
Orthodromic tachycardia (narrow qrs complex tachycardia)
-anterograde via AV node and retrograde via accessory pathway
Antidromic tachycardia (wide qrs complex tachycardia)
-anterograde via accessory pathway and retrograde via bundle of His and AV node

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18
Q

Antidromic AVRT

Study These Flashcards
A 
Wolff-Parkinson-White syndrome (WPW)
associated with Ebstein's anomaly
The bundle of Kent* (accessory pathway)
- results in delta waves**
EKG
-Short P-R interval (0.12sec)
-Slurring of upstroke (delta waves) of QRS complex
-Secondary ST-T wave change
19
Q

AVRT- tx

Study These Flashcards
A

Catheter ablation (choice)
DC cardioversion
Orthodromic: Adenosine or verapamil*
Antidromic: Procainamide or cardioversion
-contraindicated: AV node blockers** (digitalis, adenosine, diltiazem, verapamil, Ca channel blocker, beta-blocker)

20
Q

Atrial flutter- info

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A

Rhythm disturbance of the atria
Sawtooth flutter waves (P waves) in LEAD II, III, aVF**
-reentrant atrial tachycardia
-rate of ventricular response increases above 140/m-> CO drops and cardiac sx appear*
Complication- CHF, embolization

21
Q

Atrial flutter- causes

Study These Flashcards
A
  • long standing HTN
  • Valvular heart disease (rheumatic)
  • Coronary artery disease
  • Acute pulmonary embolism*
22
Q

Atrial flutter- tx

Study These Flashcards
A 
symptomatic
Cardiversion
-when spontaneous reversion doesnt occur
-when there is hemodynamic instability
-acute myocardial ischemia
Rate control
-verapamil, beta-blockers
-catheter ablation (if no response to drugs)
23
Q

Atrial fibrillation

Study These Flashcards
A

dysrhythmia due to multiple areas of reentry within the atria
complete disorganization of atrial electrical activity
Atrial rate: 350-600/m-> P waves are replaced by fine, undulating fibrillatory waves (“F” waves)**
R-R interval is irregular
Peripheral emboli**- 15% risk of stroke

24
Atrial fibrillation- physical exam
Variation in intensity of first heart sound (S1)** Heart rate is irregular Absence of 'a' wave in Jugular venous pulsation** (no atrial contraction)
25
Atrial fibrillation- tx
Rate control- beta blocker, Ca channel blocker, digoxin Anticoagulant therapy -Heparin and Warfarin if A-fib > 2days old** Restoration of rhythm- cardioversion -hemodynamically instable: IV heparin-> immediate cardioversion** -hemodynamically stable: --48hrs of A-fib: continue cate control and anticoagulation for 3 weeks before attempting cardioversion** Rhythm control -Type IA, IC, III -Amiodarone (Class III): DOC following cardioversion**
26
Junctional escape rhythm
SA node fails to discharge-> AV node becomes the dominant pacemaker causes -Inferior MI, cardiac surgery, digoxin toxicity EKG -inverted or absent P-wave before QRS complex or P after QRS -narrow QRS
27
Premature ventricular complexes (PVC)
MC ventricular rhythm disturbance Two successive PVCs are called "couplet" -Monomorphic VT: 3 or more PVC >100bp with similar morphology -Multifocal or polymorphic VT: morphology varies* -Bigeminy VT: PVCs successively alternate with a sinus beat Discordant ST segment and T wave changes (T wave is opposite the major deflection of the QRS) Full compensatory pause- double the preceding R-R interval following PVC
28
PVC- causes, tx
- excess caffeine, alcohol, tobacco - emotional stress - sympathomimetics - hypoxia, hyperkalemia, hypokalemia no tx w/o significant sx Beta blocker can be used in MI
29
Ventral tachycardia- sx
``` Sustained VT: -lasts >30 sec -associated with hemodynamic instability -syncope, dizziness, palpitations Nonsustained VT: -lasts <30 sec -not associated with hymodynamic compromise -Asx or transient palpitations ```
30
VT- dx
Intermittent canon 'a' waves in Jugular veins and Variable first heart sound (S1)**
31
VT- tx
Hemodynamic instability: DC cardioversion** Stable pts -Lidocaine (DOC)** -Procainamide Recurrent sustained or sx non-sustained VT: -Implanted cardioverter/defibrillator (ICD)
32
Torsades de Pointes- info
VT characterized by polymorphic QRS* associated with prolonged QT* (often >0.6sec) Risk of sudden death**
33
Torsades de Pointes- causes
Congenital anomaly: familial long QT syndrome Drugs: Quinidine, Disopyramide, Phenothiazine, Tricyclic antidepressants** Electrolyte imbalance: hypokalemia, hypomagnesemia**
34
Torsades de Pointes- tx
Acute -IV magnesium** (slows down the heart-> watch out for cardiac arrest) -Beta blocker, Mexiltine, Phenytoin Chronic -Beta blocker -if recurs --Left-sided cervicothoracic sympathetic ganglionectomy --Dual chamber permanent pacing --Cardioverter/Defibrillator (ICD) for congenital forms
35
Ventricular escape beats- Idioventricular rhythm
there is a lack of impulses from SA or AV nodes
36
Ventricular fibrillation- info
chaotic ventricular rhythm-> no ventricular contraction no P wave no QRS complex LETHAL!! in 3-5 mins
37
V fib- tx
Immediate cardioversion and CPR
38
First degree AV block
delay in conduction from sinus node to the ventricle all impulses are conducted P-R interval >0.2sec
39
Second degree AV block
``` intermittent failure of AV conduction Type I (Mobitz type I or Wenkebach): MC: AV node (qrs narrow) -Progressive lengthening of the P-R interval-> failure of a P wave to conduct and an absent QRS Type II (Mobitz type II) -Abrupt failure of AV conduction -no preceding gradual P-R prolongation ```
40
Second degree AV block type I- tx
``` Most case dont require tx Electrophysiologic mapping if -no identifiable acute cause -elderly pt -Severe coronary artery disease -calcified aortic disease Permanent pacing if -Block within the bundle of His (qrs wide)* -History of dizziness or syncope ```
41
Third degree heart block-info
Complete heart block - total dissociation btw P wave and QRS complex - Giant cannon wave in jugular vein may be seen when atria contracts against closed AV valve**
42
Third degree heart block- AV node
Narrow QRS complex Asx Heart rate >50bmp Tx: pacemaker, Atropine
43
Third degree heart block- Bundle of His
Wide QRS complex Ventricular rate 30-40bpm Unresponsive to ANS influence* Tx: permanent pacing**
44
Right bundle branch block
S2 is widely split due to delayed closure of pulmonic valve Secondary R wave (R') in right precordial LEADs: V1, V2 Wide S wave: V5, V6
45
Left bundle branch block
Paradoxical splitting of S2 due to delayed closure of aortic valve** (during inspiration, splitting gets smaller) Broad R wave: V5, V6 Deep S wave: V1, V2
46
What to focus on..
Ddx- sinus tachycardia (p-qrst), paroxysmal supraventral tachycardia (pseudo R wave, sudden onset) Sinus arrest (no p and qrs) WAP (at least 3 p wave morphology, with tachycardia-> MAT) PAC (narrow qrs) PVC (wide qrs)- both with premature p wave PSVT- know tx: AVNRT (adenosine) Antidromic AVRT: delta waves. contraindication Atrial flutter/ fibrillation- dx, complication, PE, tx schedule. premature ventricular complexes- dx V-tach: management, sx Torsades de pointes: ekg V-fib: ekg, tx AV block: just know all blocks RBBB, LBBB

Clin-Med B2 (14 decks)

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