Arrhythmia - broad complex / Brady / genetic Flashcards
What are broad complex tachycardia / ventricular
HR >100
QRS >120
If there is no clear QRS what is the Dx
VF (chaotic / no pattern)
Unusual to capture on ECG as cardiac arrest rhythm
What is DDX of broad complex tachycardia
Ventricular fibrillation
Ventricular tachycardia
SVT with BBB / metabolic disturbance
WPW with anti-dromic tachy
What causes irregular ventricular tachycardia (broaD)
Torsades de points
Any cause of SVT + BBB / metabolic usually AF if irregular
What is VF
Cardiac arrest
No P wave or QRS
Random signals generated through ventricles
What is VT
Signal from AV sets of own impulse instead of going down bundle of His
Very broad QRS
What types of VT can you get
Monomorphic - usually MI
Polymorphic - torsade de points
What are symptoms of ventricular tachycardia / broad complex tachy
Palpitations CHest pain SOB Dizzy Syncope if fast enough Low BP Heart failure
What are adverse signs suggesting immediate cardio version
Decreased consciousness Syncope BP <90 Clammy Oliguria Angina Pulmonary oedema
Who is at risk of broad complex tachycardia / ventricular
Post MI IHD for VT Long QT syndrome Cardiomyoapthy Hypokalaemia Hypomagneisum
How do you deal with VT / broad
12 lead ECG Cardiac monitor Have defibrillator close O2 sats Bloods - U+E
How do you differentiate SVT from VT
Hx
12 lead ECG showing broad vs narrow
Response to medication
If peri-arrest what do you assume
Ventricular and Rx as this
If no pulse
Cardiac arrest
If patient is stable what do you do
IV access O2 if low sats Correct electrolyte Identify underlying rhythm If in doubt treat as VT (most common cause)
What do you do if unstable VT or uncertain
HELP FAST
DC Cardioversion if adverse signs
CPR
Correct electorlyte
What do you follow up with
IV amiadarone 300mg then 24 hour infusion 900
Lidocaine if fails
ICD / EPS if this fails
Can have maintenance treatment of BB or amiadarone
When do you caution with lidocaine
Severe left ventricular impairment
What do you never use in ventricular tachy
Verapamil
What do you do after correct
Establish cause
Maintenance AA - BB / amiadarone
ICD / surgery may help esp if LV functional impairment
How do you Rx VF
Cardiac arrest
DC cardio version
AA
ICD
What is Tornado de point
Form of polymorphic VT associated with long QT
Have long QT syndrome then ectopic hits to generate abnormality
What is it associated with / what causes
Long QT syndrome Ischaemia - may see STEMI Drugs - Amiadarone - Sotolol - Anti-psychotics - TCA - Macrolide Ax - mycin Electrolyte - Hypocalcaemia - Hypomagnesium - Hypokalaemia SAH Hypothermia Myocarditis
What is seen on ECG
VT with polymorphic QRS so height changes
How do you Rx
Correct underlying cause
IV Mg sulphate
Stop any drugs that prolong QT
Long term
- BB (not sotolol)
- Pacemaker
What can it progress to
Usually revert back but can translate to VT and cardiac arrest
Cardiac arrest so have defibrillator ready
What is ventricular ectopic
Random beat originating out with atria
When is it common
Post MI / IHD / HF
Can occur in healthy
How does it present
Asymptomatic Palpitation Thumbing heart Heart missing a peace Irregular pulse if frequent
How does it present on ECG
Broad QRS with random extra
How do you investigate
Blood for anaemia, thyroid, electrolyte
How do you Dx
Reassure
If post MI can lead to more serious arrhythmia
What types of bradycardia
Sinus Heart block AF with slow ventricular response Flutter + high degree block Junctional
When is Brady physiological
Athletes
Sleep
What are cardiac causes of bradycardia
AV block Sinus node disease Degeneration of conduction if Hx of BBB Post MI IHD Sick sinus Ablation Valvular disease IE Myocarditis Cardiomyopathy
What do you do if IE
Daily ECG
What drugs cause Brady
BB
Rate limiting CCB - Verapamil / dilitiazem
Digoxin
Amiodarone
What are non-cardiac causes
Vasovagal = very common Hypothyroid Hypoadrenal Hyperkalemia Hypoxia Hypothrmia Increased ICP / Cushing
What are the symptoms of Brady
Asymptomatic Chest pain SOB Fatigue Nausea Dizzy
What suggests harm-dynamic compromise and the need for Rx as per-arrest with IV atropine
Shock Hypotension Syncope MI Ischaemia HF
What causes hypotension
Brady NOT hypovolemia so no fluid bolus
How do you investigate Brady
ABCDE O2 if hypoxic BP IV access - Bloods - U+E - Digoxin level Reverse and treat electrolyte abnormality 12 lead ECG if come in with bradycardia Cardiac monitor Look at drugs
What do you do if think you will need
Call anaestheist
If adverse signs what do you give
IV atropine
500mcg up to 3mg
What do you do if not improving
Other inotropes
Adrenaline
Transcutaneous pacing
What do you do if stable
O2
IV access
Treat cause
Observation
If Brady improves but still at risk of astyole
Long term pacing
Who is at risk of astyoel
Recent astyole
AV block type II
Complete heart block
Ventricular pause >3s
What is important as well as ECG
Clinical signs
If look unwell= WORRY
What do you do if Cushing’s
SENIOR ADVICE
What causes AV heart block
AV node issue IHD - inferior MI RCA BB Amiodarone Fibrosis
What is 1st degree block
Electrical impulses slow
All reach ventricle
Long PR >0.2s
How does it present and Rx
No symptoms
No Rx
What is 2nd degree MObitzz type 1
PR delayed until beat fails to reach ventricle (no QRS)
May be dizzy
Wha is 2nd degree type II
PR constant but P wave not always followed by QRS
2:! or 3:!
What do you do for type II
Pacemaker
Commonly progresses to type 3
What is type 3
No electrical impulses reach ventricle
Generate own escape beats
Not coordinated with atrial
How do you differentiate type 3 from VF
Atrial faster than ventricle in AV block
What is BBB
Impulses slow or blocked as they travel through conducting tissue in one of two ventricles - either R or L
How does heart block present
SOB Syncope HF Bradycardia Wide pulse pressure JVP shows cannon waves
How do you Rx
Same as Brady above
Observe if stable
IV atropine
Pacing for type 2 and type 3
When is pacing CI
Infection
What causes sick sinus syndrome
Sinus node fibrosis
Common in elderly
How does it present
Sinus Brady AF or atrial tachy Syncope Dizzy Palpitations SOB Cardiac arrest
How do you Rx
PACEMAKER
Anti-coagulant if AF
What causes long QT
Congenital / genetic - Issue with KCN gene Drugs Hypo K, Mg, Ca MI Myocarditis Hypothermia SAH
What drugs
Amiadarone Sotalol TCA SSRI esp citalopram Haloperidol Macrolide - erythromycin Methadone
What is long QT
Delayed depolarisation of ventricle
How does long QT present
Ventricular tachy - paroxysmal polymorphic Torsade de points Leads to - Syncope - Seizure - Sudden death
What exacerbates
Emotion
Exercise
Drugs
How do you Rx
Avoid drugs which prolonged QT
BB
Nicroandil
ICD if high risk e.g. QT >500 or previous cardiac arrest
What BB do you avoid
Sotalol
What is Brugada
AD SCNA5
Na channelopathy
Causes sudden death
What is seen on ECG
ST elevation
-ve T wave
V1-V3
Partial RBBB
How do you cause more apparent ECG
Administer flecainide
What do you do if Dx
Implantable cardiac device
Screen family