Cardiac Skills

Question 1

Signs of symptomatic bradycardia?

Answer 1

Hypotension, acute altered mental status, signs of poor perfusion/shock, ischemic chest discomfort, or acute heart failure.

Question 2

What is relative bradycardia?

Answer 2

Defined as heart rate less than expected for patients condition. Eg.) Septic Pt with a HR less than 70bpm is not adequate.

Question 3

Should you rely on atropine in 2nd degree type 2 or 3rd degree blocks?

Answer 3

NO. It’s not likely to work. Use TCP instead.

Question 4

When do you use atropine for symptomatic bradycardia? What’s the dose?

Answer 4

When they’re stable or as a bridge to TCP. Give 0.5mg IV bolus, q 3-5min, to max 3mg. (New 2020 ACLS guidelines mention 1mg)

Question 5

If you have continued symptomatic bradycardia refractory to atropine and or TCP, what’s next?

Answer 5

Dopamine first at 2-10mcg/kg/min (5-10mcg in latest ACLS update) for B1 effects, and 10-20mcg/kg/min for B1 and A1 effects. Titrate to response and then taper slowly.

Question 6

What’s the epinephrine dose for symptomatic bradycardia with hypotension? How do you mix it?

Answer 6

IV infusion 2-10mcg/min

Mix 4mg (1mg/mL) in 250mL of NS (concentration of 16mcg/mL).

Question 7

Your Pt has wide complex bradycardia with hyperkalemia/acidosis. How might you treat that? (considering that we do not carry insulin)

Answer 7

Sodium Bicarbonate 1mEq/kg SIVP/IO, q 5min, max 2mEq/kg.

Calcium gluconate 1 to 2g in 50mL NS over 10min

Question 8

Your patient has bradycardia from a STEMI. What is a precaution?

Answer 8

Be careful increasing the HR as this can cause increased stress and myocardial O2 demand.

Question 9

Your bradycardic patient presents with hypotension and shock. How much fluids do you give?

Answer 9

NS 500mL bolus PRN. Titrate SBP to 90 or a MAP of >65. Max fluids 2L then use a vasopressor.

Question 10

What are the criteria for deciding if tachycardia (with a pulse) >150 is unstable?

Answer 10

If the Pt presents with hypotension, acute altered mental status, signs of poor perfusion/shock, ischemic chest pain, or acute heart failure.

Question 11

What is the treatment for an unstable tachycardia >150bpm?

Answer 11

Synchronized Cardioversion (R wave)
Narrow regular = 50-100J
Narrow irregular = 120-200J bi, or 200J mono
Wide regular = 100J
Wide irregular = Defib dose (360J mono, or 120-200J bi)

Question 12

When should a beta blocker or CCB be given for stable tachycardia >150bpm with a regular rhythm?

Answer 12

After IV access, a vagal maneuver was tried, and adenosine (6/12) was given without a successful conversion, or there’s refractory PSVT, or new rhythm disclosed. Only give CCB to Pts with narrow complex as it can impair ventricular function.

Question 13

What dose of metoprolol is used to treat stable irregular narrow complex tachycardia >150bpm (IE., rapid a-fib)?

Answer 13

5mg SIVP over 1-2min q5 min PRN, Total 15mg

Once stable then 50mg PO

Question 14

When could you consider adenosine for wide complex tachycardia >150?

Answer 14

Only if it is regular, monomorphic, and the Pt is stable.