Arrhythmias

Question 1

Sick sinus syndrome/Tachy-Brady

Answer 1

Hospitalize
Unstable-ACLS, Atropine, Dopamine, Epi
Stop CCB/BB
Transcutaneous/Transvenous pacing
Ultimately=Permanent pacemaker

Question 2

Sinus arrest (>2 seconds)

Answer 2

If >6 seconds- Permanent pacemaker

Question 3

First degree AV block

Answer 3

No tx

PR int over 200msec

Question 4

Second degree AV block, Mobitz I

Answer 4

No tx

AKA Wekenbach, lengthening PR interval

Question 5

Second degree AV block, Mobitz II

Answer 5

Emergency, need pacemaker.
Consistent PR interval. Dropped QRS, sometimes 2:1.
Block=below HIS (NOT AV)

Question 6

Complete heart block

Answer 6

Emergency, need pacemaker.
Sx: SOB, Syncope, HF
Independent/Unassoc P & QRS

Question 7

Bundle branch block

Answer 7

No tx.
QRS >0.12 
RBBB= bunny-ears, may be normal
LBBB= negative V1 & positive V6. Never normal. Can't r/o MI EKG changes. 
ST/T waves in opposite direction.

Question 8

Tachycardia

Answer 8

Unstable–SHOCK

DONT use Adenosine with WPW/AFib

Question 9

PAC

Answer 9

Usually asx
Tx: BB or CCB for palpitations
P waves early & may be different morphology

Question 10

SVT types

Answer 10

1. AVRT- path within AV node

2. AVNRT - path outside the AV node. WPW.

Question 11

SVT tx

Answer 11

Unstable-cardioversion
Stable-Adenosine or Vasovagal maneuver will terminate.
1st line: Catheter ablation
Other options: BB, CCB, anti-arrhythmics

Question 12

SVT sx/EKG

Answer 12

P waves usually hidden, if seen will be different morphology.
Regular narrow QRS at 140-240 bpm.
Sx: palpitations & syncope

Question 13

WPW EKG

Answer 13

Delta wave on resting/sinus (pre-excitation of ventricles)

Syndrome: Delta + SVT + Sx

Question 14

WPW with AFib

Answer 14

NO Adenosine, if you block AV node conduction will only go through alternative pathway.
Adenosine will send into VFib
OK tx: Cardioversion, BB, CCB, acute anti-arrhythmics
Need cath ablation

Question 15

Atrial fibrillation EKG

Answer 15

Irregularly irregular, no discernable P waves (300-600 if measurable).
Ventricular rates-100, but may be slow/normal. QRS same morphology but variable at intervals.
QT interval difficult to measure.
Most common chronic arrhythmia

Question 16

AF risk factors/presentation

Answer 16

Age, Sleep apnea, Valve disease, Obesity, CAD, HTN
May present with embolic event.
Other sx same as others.

Question 17

AF classifications

Answer 17

1. Paroxysmal-terminates spontaneously/w/in 7 days
2. Persistent-fails to terminates w/in 7 days of tx
3. Longstanding persistent-continuous for >12mo.
4. Permanent-constant & agreed on no rhythm meds.

Question 18

Valvular AF

Answer 18

AF with MS/Rheumatic valve ds
Requires Warfarin (higher stroke risk)

Question 19

CHADSVASC

Answer 19

C ongestive heart failure
H TN
A ge (65 1, >75 2)
D M 
S troke (2)
V
A scular ds 
S ex (F)
C haracteristic

2 or more=Anticoag
1=grey area
0=aspirin is an option

Question 20

AFib tx (anticoag vs procedure)

Answer 20

WATCHMAN/left atrial ligation procedure for CI to anti-coag.
1st line=NOAC
2nd line= Warfarin

Question 21

NOACs & CI

Answer 21

Adjust for renal fxn
2 hours effective.
Direct=Dabigitran/Pradaxa
Xa inhibitor=Apixiban/Eliquis (best safety)
CI: Bleeding, thrombocytopenia, Severe uncontrolled HTn

Question 22

Warfarin

Answer 22

Vitamin K antagonist (Vit K reverses)
Narrow therapeutic window-INR checks
Effective in 2-3 days

Question 23

Afib acute tx

Answer 23

1. Rate: Metoprolol/Diltiazem (Digoxin if difficult)
2. Cardioversion: Electric or with Amiodarone (Class III)
   W/o anticoag, OK 24-48hrs IF no MS or enlarged LA
   Unsure-TEE to look for LAA thrombus
   Anit-coag 4 wks before & after cardioversion.

Question 24

AFib long term tx

Answer 24

1. Rhythm: (early) Anti-arrhythmics, Cath ablation, MAZE
2. Rate: (older) BB, CCB, Digoxin
3. AV ablation + pacemaker: if unable to get on BB, etc (low blood pressure)

Question 25

AFlutter EKG

Answer 25

Saw tooth P waves in inferior leads (II, III, aVF) RA re-entry circuit, 300bpm Ventricular response typically regular (2:1/3:1) 2:1 can show up as HR of 150, be suspicious

Question 26

AFlutter tx

Answer 26

1. CHADSVASC anticoag. 2. Same acute tx as AFib 3. Chronic=catheter ablation is primary tx Antiarrhythmics if cannot undergo ablation. (not as good)

Question 27

Atrial tachycardia EKG

Answer 27

From atria, not SA node. P waves hidden, 140-220. Versus SVT (Adenosine does not terminate atrial tachy)

Question 28

Atrial tachycardia Tx

Answer 28

Normal self-limited, will terminate on its own. BB, CCB, Ic & III for sx. Rarely need cardioversion.

Question 29

PVC EKG/Sx

Answer 29

Wide premature QRS w/o preceding P wave Sx=Palpitation Need a holter monitor to assess Tx need

Question 30

Effective bradycardia

Answer 30

When PVC does not perfuse blood to extremities. | No pulse on that beat.

Question 31

PVC Indication for tx

Answer 31

>20% burden of QRS are PVC | & Underlyig structural heart issues

Question 32

PVC Tx

Answer 32

Sotalol (antiarrhythmic) | Ablation (for uncontrolled sx or PVC causing CM)

Question 33

Ventricular Tachycardia EKG

Answer 33

``` 3 or more PVC in a row Rate 160-200 Nonsustained= less than 30 sec Sustained= more than 30 sec Cause: Previous MI scar/LVOTO ```

Question 34

V tach Acute Tx

Answer 34

1. Unstable: Shock 2. Stable: IV Amioradone & BB Lidocaine/Procanimide if Am doesn't work If still SV not restored--Cardiovert Full Cardiac workup including cath Always treat as VT (may be aberrant SVT)

Question 35

Monomorphic vs. Polymorphic VT

Answer 35

1. Monomorphic: Re-entry circuit via MI scar | 2. Polymorphic: More unstable, AMI

Question 36

Chronic VT Tx

Answer 36

1. ICD 2. Sotalol/Amiodarone 3. Ablation 4. BB (improves survival)

Question 37

Torsades & Acute Tx

Answer 37

Polymorphic VT due to long QTc/Complete hrt block Tx: Mg & Cardioversion & IV BB Temporary pace @ 100bpm (decreases QTc)

Question 38

Torsade chronic Tx

Answer 38

1. Stop offending QTc agents | 2. Congenital-- BB long term

Question 39

Common QTc meds

Answer 39

1. Antiarrhythmics 2. Antihistamines 3. Antimicrobials (Macrolide, Fluoroquinolones, Fungal) 4. Antipsychotics 5. Gastric motility agents

Question 40

VFib

Answer 40

No discernable activity, 200-300 if you could count Need to shock ASAP Death, pulseless. MCC= CAD (Other CHF, Primary arrhythmia)

Question 41

VFib Tx

Answer 41

``` ACLS: Emergent DFib Epinephrine Chest compressions Secure airway ``` Hypothermia minimizes brain injury. ICD needed if not caused by MI.