approach to dysrhythmias

Question 1

Step 1 or the basics

Answer 1

Basics:

ABCs & IV, Oxygen, Cardiac Monitor

Question 2

step 2 in the 6 step approach

Answer 2

Patient Assessment

Stable or Unstable?

• Interpretation based on a spectrum
• ALOC, ↓BP, CP, pulmonary edema

Question 3

step 3

Answer 3

–> Regular or Irregular EKG

• Irregular
• Issue that happens above the ventricles (atrium/AV node issue)
• NOT VTach (usually regular)
• Block AV Node

Question 4

Step 4

Answer 4

fast or slow

Question 5

step 5

Answer 5

indentify complexes

Are P wave present?

Indicates sinus rhythm/normal axis –> DO NOT DEFIBRILLATE!

Question 6

step 6

Answer 6

Complex Distance –> Narrow or Wide?

Question 7

what is the ddx of Narrow, Regular, No P waves

Answer 7

PSVT

Atrial flutter

WPW

Narrow complex VT

Question 8

two types of WPW

Answer 8

orthodromic=narrow

orthodromic=wide

Question 9

AV node can not go faster than

if it does you have to assume there is ___

Answer 9

200-220

if it goes higher than that it is because there is an accessory pathway

Question 10

A flutter is what type of issue

Answer 10

macrocircuit

• global re-entry; different foci; circular

Question 11

WPW is due to

Answer 11

• d/t accessory pathway – P wave buried QRS; Delta wave
  
  • Drives the rate really high

Question 12

what are some vagal maneuvers

Answer 12

• Vagal maneuvers –> have them blow on a syringe while they are sitting up and then drop their head back

Question 13

medication for – Narrow, Regular, No P waves

Answer 13

• AV Nodal blockers: Adenosine (PSVT), CCB,* *ẞ-Blocker
  
  • Block AV node b/c it is receiving too much stimulation
• Cardioversion – synchronized
  
  • Delivers right after the R complex
  • Used for Vtach or Vfib

Question 14

if someone is unstable with narrow regular no P waves can you consider adenosine

Answer 14

• UNSTABLE
• Can consider Adenosine but…
• Cardioversion start at 50J and 2x every time

adenosine feels like DYING

Question 15

if you give adenosine to somone with A flutter

Answer 15

works on the AV node for a short period of time. need to use a longer agent

Question 16

Narrow, Irregular, No P waves DDX

Answer 16

A-fib

A-flutter w/ variable block

Question 17

what is the cause of AFIB

Answer 17

: increased automaticity within the atria

Question 18

Tx of A fib -chronic (stable)

Answer 18

nodel blocker agent

• CBB –>**Diltiazem 5-10mg IVP slow. If tolerated can 2x it. Up to 60mg in 30 min
• Beta Blockers
• Digoxin ….**Old Drug

Question 19

Tx of chornic unstable A fib

Answer 19

• Rapid Cardioversion: Start high! Sync! b/c chronic A-fib pts are electrically stable??
• Support Blood Pressure: Pressers b/c if you do not perfuse brain/heart –>**ALOC + harder to shock
  
  • ​this is just a measure so thta you can cardiovert
• Slow down heart: drips not IV Push – do not give elderly of CCB/BB
  
  • Infuse it–> can bottom out BP and lead to cardiac arrest
  • will have to push higher dose of dilt in a bigger pt
• Magnesium if drip does not work (caution: vasodilator)
• Repeat Cardioversion
• Other considerations: Is it really A-Fib? TREAT UNDERLYING CAUSE
  
  • ​sepsis?
  • necrotizing fascitis?
  • is there something causing low blood pressure

Question 20

what is dilt and what does it do

Answer 20

By blocking calcium, diltiazem relaxes and widens blood vessels and can normalize heart rates. Diltiazem injection is used to treat irregular heartbeats

Question 21

New Onset = Rhythm Conversion Tx

Answer 21

• Clear Hx with in 48 hours
• No structural heart dz
• Age not a C/I
  
  • Caution Elderly - don’t ruse often p/w vague sxs
• Chemical cardioversion: Procainamide: 1g over 1 hour –> Electrical cardioversion: Biphasic 200J –> D/C home without meds
  
  • If procainamide doesn’t work, then do electrical cardioversion
• this all really depends on how connected they are to care (may need to schedule a follow up

Question 22

magnesium is a vasodilator or vasoconstrictor

Answer 22

vasodilator

Question 23

Wide, Regular, No P waves (If wide, signal coming from ventricles)-ddx

Answer 23

Vtach*******

SVT with abberancy (bb block)

antidromic WPW

Question 24

cause of Vtach, SVT with BBblock, and Antidromic WPW

Answer 24

circuit re-entry in the ventricles

Question 25

how do you know WPW

Answer 25

shortened PR interval with delta wave

Question 26

if your Vtach is unstable

Answer 26

cardioversion

Question 27

why would you consider adenosine in a wide regular without p

Answer 27

SVT with abberancy

Question 28

why do you want to exercise caution when administering adenosine to a wide irregular no p

Answer 28

* *Careful when giving adenosine to WPW (conduction can reverse)*

Question 29

why do you admit after seeing a pt with VTACH

Answer 29

ADMIT

Question 30

**Wide, Irregular, No P waves**

Answer 30

* _A-fib w/ BBB_ * _A-fib w/ WPW_ * _A-flutter w/ variable block & BBB_ * _Polymophic VT_ = Torsades

Question 31

A-fibb tx

Answer 31

* *A-Fib = Rate control: Be careful If…* * *WPW* * ***Regular****: Consider Adenosine (can send into overdrive), Electricity* * ***Irregular****: No AV nodal blocker--\>* *Yes Electricity (synchronized), Procainamide (anti-arrhythmic)* * ***Torsades*** *= Magnesium*

Question 32

how does tx for stable SVT work

Answer 32

vagal maneuvers 6 rapid push (doesn't last long) 12 (can do 18) synchronized cardioversion

Question 33

unstable rapid irregular narrow tx

Answer 33

rapid high synch cardioversion can sedate with etomidate +ketamine (less risk of dropping BP but still some) Elevating BP to decrease irritation on heart increase profusion and improve chances of cardioverting target diastolic \>60mg) push dose pressors with phnylephrine 50-299mcgIVP

Question 34

chronic A-fib

Question 35

6 step approach

Answer 35

1. ABC’s, IV, O2, Monitor 2. Stable or Unstable 3. Regular or Irregular 4. Fast or Slow

Question 36

appraoch to the brady pt (big 3)

Answer 36

DRUGS ISCHEMIA ELECTROLYTES

Question 37

WHAT DO WE NEED TO THINK ABOUT HWEN LOOKING AT BRADY (other than big 3)

Answer 37

* Block is below AV node * Slower rhythm * More likely to stop/asystole * Not atropine sensitive

Question 38

Brady treatment

Answer 38

* Algorithm **B**radys **A**re **T**oo **D**arn **E**asy * **Atropine**: start 0.25-0.5mg bolus * **Transcutaneous Pacing**: Sedation (might need transvenous pacer in obese pt) * **Dopamine**: 2-10 mcg/kg per min * **Epinephrine**: 2-10 mcg per min * 1ml of crash cart epi (1:10,000) = 100mcg * Put 1ml in 100ml of NS = 1mcg per ml **Pacemaker** for all **3^rd degree AVB** + **_symptomatic_ Mobitz Type II**

Question 39

which AV blocks are unstable

Answer 39

mobitz type two can move into third degree and of course third degree

Question 40

electrolyte abnormalities that could lead to pronloged qt

Answer 40

Electrolyte abnormalities hypokalemia hypocalcemia hypomagnesmia Na channel blockers miscellaneous: elevated ICP, ACS hypothermia, hereditary

Question 41

what are the considerations with determining prolonged QT

Answer 41

if QT lengthening due to stretching of ST segment = hypocalcemia and hypothermia if QT lengthen due to stretching of T wave=ischemia

Question 42

2 EKG findings for burgadas

Answer 42

cove type (Seal) saddle type

Question 43

treatment is brugada

Answer 43

defibb | (ICD)

Question 44

leads to focus on when suspecting cardiomyopathy

Answer 44

lateral look at Q waves if super sharb and super deep (dagger like) thing hypertrophic cardiomyopathy

Question 45

41 y/o female no sig past medical hx c/o CP over the past 2 days, no sx now

Answer 45

* : Wellen’s → Highly specific to LAD → V2-V3, +/- V4 * type 1 = deep symmetric T-wave in precordial leads * type 2= biphasic T waves in precordial leads * needs PCI with proximal LAD lesion *