Cardiac arrhythmia management

Question 1

What is pulseless electrical activity (PEA)

Answer 1

1. no pulse found -> Cardiac arrest 2. ECG shows electrical activity

Question 2

Management of PEA

Answer 2

1. e.g. Asystole / normal electrical activity on ECG w/o pulse - No shock - CPR only - Adrenaline

Question 3

Ventricular tachycardia

Answer 3

1. Fine VF - small amplitude, gets weaker and weaker 2. Coarse VF - greater amplitude 3. Originates from ventricles -> Broad complex tachycardia 4. Ventricular tachycardia - no P waves, broad and regular

Question 4

Cardiac causes of bradycardia

Answer 4

1. Cardiac conduction blocks

2, no cardiac - drugs, toxins, metabolic ( beta blockers)

3. electrolytes - K and Mg
4. Hypothyroidism

Question 5

initial management of adult bradycardia

Answer 5

1. Heart rate < 50 bpm
2. A, B , C ( airway, breathing and circulation)
3. Blood pressure and IV access
4. ECG

Question 6

Which redflags identified in bradycardia management

Answer 6

1. Hypotension 2, Altered mental state 3. Signs of shock 4. Ischaemic discomfort 5. Acute heart failure If no - MONITOR + OBSERVE

Question 7

Redflags have been identified in bradycardia

Answer 7

1. Give atropine if ineffective ; 2. Transcutaneous pacing 3. Dopamine or epinephrine infusion

Question 8

atropine - use - MoA - contraindication

Answer 8

1. used in the treatment of bradycardia 2, an ACh receptor antagonist to decrease Parasympathetic nervous system and increase sympathetic nervous system 3, Contraindic - patient is predisposed to narrow-angle glaucoma

Question 9

First degree heartblock

Answer 9

1. PR interval is longer than expected 2. slower conduction mabe due to beta blocker use

Question 10

Second degree heart block ( Mobitz type I)

Answer 10

1. PR interval gets longer and longer –> until QRS suddenly disappears

Question 11

Second degree heart block (Mobitz type II)

Answer 11

1. QRS suddenly drops - no PR prolonging 2. Risk of deteriorating int o asystole

Question 12

Third degree heart block

Answer 12

1. regular P waves and QRS but they do not talk to each other 2. SAN creates own rythm - atria contract but not contact via AV noe 3. No AVN firing - escape beats only 4. risk of asystole is high and pacemaker is needed

Question 13

Managment of atrial tachycardia

Answer 13

1. Heart rate > 150 bpm 2. A, B , C 3. IV access and ECG 4. Check for red flags 1. Vagal manoeuvres - increase activity of Vagus nerve 2, Adenosine - to chemically cardiovert the heart

Question 14

Redflag in supraventricular tachycardia

Answer 14

1. hypotension 2. acutely altered mental status 3. signs of shock 4. chest pain 5. heart failure –> NO 6. is QRS wider than > 0.12 secs? —>NO 1. Vagal maneuvers 2. Adenosine 3. Beta blocker/Calcium channel blockers

Question 15

management of Ventricular tachycardia

Answer 15

1. Shock + CPR 2. Amiadorone

Question 16

What’s the purpose of CPR?

Answer 16

CPR = pressing on the chest -> heart is artificially pumped (blood around the

coronary arteries -> perfusion of myocardium is increased; possibly back flow back to the heart -> hope to restart the heart working)

Question 17

Do we shock the patients with PEA?

Answer 17

Patients who have electrical activity (PEA, asystole) -> no need to shock, as it’s not going to help them

• cardiac compressions will help them more
• adrenaline

Question 18

Where does the electrical impulse start in:

A. broad complex

B. narrow complex

Answer 18

If the impulse start from VENTRICLE = it is BROAD

If the impulse start in the ATRIA -> it is NARROW complex

Question 19

ALgorithm for the management of bradycardia

Answer 19

Question 20

What’s 1st line drug treatment for bradycardia?

Answer 20

Atropine

*Atropine will speed up HR, make it to pump quicker and generate better BP)

*before giving atropine, leads to pace the heart needed to be put on in case if we need to pacethe patient

Question 21

Management of bradycardia, after atropine was given and it was ineffective

Answer 21

electricity to pace -> transcutaneous pacing (to ‚take over’ patient’s heart activity, we need to pace at higher HR than normally for patient is)

*this is notcomfortable for patient - minor sedation needed

Question 22

What types of bradycardia have a higher risk of becoming asystole?

Answer 22

• recent asystole
• Mobitz II
• Complete Heart Block with wide QRS
• Ventricular Pause > 3s
• these patients should be monitored closely
• pacemaker needs to be placed in (to avoid asystole)

Question 23

Atropine

• uses
• MoA
• contraindication

Answer 23

Uses:

• treatment of pesticide and nerve agents poisoning
• to decrease salivation during surgery
• treatment of bradycardia

Mode of action: anti-muscarinic (anti-cholinergic) -> inhibits PNS

Contraindication: patients predisposed to narrow- angle glaucoma

Question 24

Atropine in cardiac treatment

• MoA

Answer 24

In cardiac treatment:

• it acts as muscarinic ACh receptor antagonist -> increased firing of SA and

conduction via AV nodes (as it decreases PNS input so more SNS like picture)

• it also opposes the action of Vagus, blocks ACh receptor sites

Question 25

Possible causes of narrow tachycardia

Answer 25

Narrow = comes from atria e.g. sinus tachycardia

Causes:

PE, anxiety, hyperthyroid, AF, flutter

Question 26

Treatment of Supraventricular tachycardia (2)

Answer 26

Management:

• Vagal Manoeuvres -> trying to increase activity of Vagus nerve (e.g. people block the nose, carotid sinus massage, blowing into syringe)

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• Adenosine -> (if Vagal Manoeuvres do not work) -> to reset the heart / chemically cardiovert

It is useful, but scary to give- patient will feel like ‘everything will go’ - there will be a pause on the monitor

Question 27

Treatment of ventricular tachycardia

Answer 27

• shock (electric)
• medication (Amiodarone)

*Amiodarone -> anti-arrhythmic medication -> used to treat and prevent

III class anti-arrhythmic -> prolongs phase 3

Question 28

Algorithm for treatment of supra-ventricular tachycardia

Answer 28