Lecture 6

Question 1

treatment of torsade de pointes

Answer 1

magnesium sulfate

Question 2

pulseless electrical activity

Answer 2

-PEA
◼ Just like it sounds…a rhythm that should be producing a pulse but is not
▪ Normal sinus rhythm + no pulse = PEA
▪ Atrial fibrillation + no pulse = PEA
◼ V-tach and V-fib are considered separate
entities from PEA though there is often no pulse present

Question 3

cardioversion vs defibrillation

Answer 3

Cardioversion = Timed burst of electricity with hearth rhythm to avoid R on T waves
Defibrillation = When you hit the button and the patient get shocked

Question 4

stable vs unstable

Answer 4

◼ Hypotension (<90/<60 mmHg)
◼ Acute altered mental status
◼ Signs of shock   Palecooldiapharemclammy
◼ Ischemic chest discomfort
◼ Acute Heart Failure

Question 5

Hs and Ts

Answer 5

H’s
 Hypovolemia
 Hypoxia
 Hydrogen ion (acidosis)
 Hypo/hyperkalemia
 Hypothermia

T's 
 Tamponade, cardiac
 Tension pneumothorax
 Toxins
 Thrombosis, pulmonary
 Thrombosis, coronary

Question 6

adult brady with pulse

Answer 6

Differential Diagnosis
-AV block, BB, sick sinus, electrolyte imbalances

Sign or Symptom

• HR
• ECG (wideR R)
• Peripheral pulses (weak, diminished, absent)
• Capillary refill time (slow)
• Skin (clammy, pale)
• Mentation (slow)

Question 7

Adult tachy with pulse: narrow complex

Answer 7

• Sinus Tachycardia SVT
• Atrial Fibrillation
• Atrial Flutter
• Accessory pathway-mediated
• Atrial Tachycardia
• Multifocal atrial tachycardia
• Junctional tachycardia (rare)

Question 8

Adult tachy with pulse: wide complex

Answer 8

• Ventricular tachycardia/Vfib
• WPW
• Ventricular paced rhythms
• SVT with aberrancy

Question 9

adult brady with pulse steps

Answer 9

1. Do not delay tx but look for underlying causes
2. Maintain airway & monitor cardiac rhythm, BP & oxygen saturation
3. Establish IV/IO for meds
4. If stable, call for consults
5. If sx → atropine 0.5 mg bolus
   -repeat atropine q3-5 min to
   total dose of 3 mg
6. If atropine ineffective, consider transcutaneous pacing OR dopamine OR Epi infusion

Question 10

adult tachy with pulse steps

Answer 10

1. ID & tx the cause of the dysrhythmia
2. Monitor cardiac rhythm, BP & oxygenation
3. Stable or unstable
   A. unstable → immediate synchronized
   cardioversion regulareferstorhythm
   a. Narrow regular: 50-100J
   b. Narrow irregular: 120-200J e biphasic, or 200J monophasic
   Ez
   c. Wide regular: 100J
   d. Wide irregular: defibrillationB. stable → Wide or narrow QRS?

Question 11

cardiac arrest - asystole/PEA

Answer 11

When to terminate resuscitation efforts:
-Failure to respond to ACLS interventions
-Amount of time after collapse before CPR and
defibrillation began
-Length of the resuscitation effort; inc time generally
results in poor outcomes
-Any other comorbid dz or conditions
-Discovery of a “DNR” order for the victim
-Policies of the healthcare facility
-Low end-tidal carbon dioxide (ETCO2) after 20
minutes of CPR in intubated victims (e.g., <10 mm Hg by capnography) w/ other items listed above

Question 12

effusion and tamponade EKG findings

Answer 12

Effusion & Tamponade EKG Findings
◼ Pericardial effusion = low voltage of QRS
▪ Most common ECG sign
◼ Cardiac Tamponade = Electrical Alternans t.fm
▪ Virtually pathognomonic
▪ beat-to-beat shift in the QRS axis

Question 13

low voltage ECG

Answer 13

defined as peak to peak QRS amplitude of <5mm in limb leads and/or 10 mm in the precordial leads
-may be due to obesity, COPD, pericardial effusion, sever hypothyroidism, subcutaneous emphysema, massive myocardial damage/infarction, infiltrative/restrictive diseases such as amyloid cardiomyopathy

Question 14

Beck’s triad

Answer 14

For cardiag tamponade and pericardiocentesis

• hypotension
• JVD
• muffled heart sounds

Question 15

ECG triad

Answer 15

cardiac tamponade and pericardiocentesis

• sinus tachy
• low voltage
• electrical alternans

Question 16

POCUS triad

Answer 16

cardiac tamponade and pericardiocentesis

• pericardial fluid
• RV diastolic collapse
• Dilated IVC