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CVS > Arrhythmia - Narrow Complex / Cardiac Arrest / Pacemaker > Flashcards

Arrhythmia - Narrow Complex / Cardiac Arrest / Pacemaker Flashcards

1
Q

What should all elderly / people with syncope / stroke get

Other investigations for arrhythmia

A

ECG
Can do continuous if think paroxysmal
FBC, U+E, LFT, glucose, Ca, TSH, Mg
Drug review

Other 
ECHO 
Exercise ECG
Angiogam
Drug review
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2
Q

What type of arrhythmia’s can you get

A

Sinus
Tachy
Brady

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3
Q

What cardiac causes arrhythmia

A 
IHD
Structural changes - dilatation due to MR
Cardiomyopathy
Pericarditis
Myocarditis
Conduction issues
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4
Q

What are non-cardiac causes

A 
Electrolyte imbalane
Metabolic - hypoxia / acidosis / thyroid
Caffiene
Smoking
Alcohol
Phaeochromocytoma
Pneumonia 
Drugs - digoxin / TCA / B2 agonist
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5
Q

How does an arrhythmia present

A 
Asymptomatic
Palpitations
Chest pain
Syncope
Hypotension
Pulmonary oedema
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6
Q

What should you ask in the history of someone with palpitations

A 
SOCRATES
Other cardiac Sx 
Review drugs
PMH
FH sudden cardiac death
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7
Q

What is concerning with syncope

A

Syncope when exercise

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8
Q

What is a sinus arrhythmia

A

Normal conduction at faster frequency
HR increases inspiration
Decreases expiration

Infection / dehydration / pain / exercise / drugs / adrenaline / salbutamol / PE / hypothyroid / hypovolaemia/ MI / fever

No Rx needed

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9
Q

What are indications for temporary pacing

A

Symptomatic bradycardia - particularly if syncope

Prophylactic 2nd or 3rd degree block

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10
Q

What are indications for permanent pacing

A 
2 or 3rd degree block symptomatic
RBBB / LBBB
Sinus node disease
Carotid sinus hypersensitivity
Severe HF 
Malignant vasovagal syncope
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11
Q

When is a ICD indicated

A

Cardiac arrest due to VT or VF not caused by a reversible cause
Often get in HCM
Sustained VT causing syncope
Sustained VT with poor LV function

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12
Q

What type of tachycardia’s is there

A

Supraventricular - narrow complex
Ventricular - broad complex
Sinus

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13
Q

What is sinus arrest

A

SA node fails to generate an impulse

No pulse

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14
Q

How do you Rx sinus arrest

A

CPR pathway

Adrenaline ASAP

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15
Q

Where do narrow complex arise

A

Atria (supraventricular)

Due to extra pathway or extra electrical loop through AV node and back into atria

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16
Q

What is a narrow complex tachycardia

A

> 100BPM
QRS <120
Short P wave
Ventricles depolarised via normal pathway so QRS normal

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17
Q

What causes a regular narrow complex tachycardia

A

Sinus tachycardia
Atrial tachycardia - due to abnormal signal in atria other than SA node
Atrial flutter
AV re-entry tachycardia - WPW
AV nodal re-entrant tachycardia = most common cause of paroxysmal (re-entrant point through AV node)

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18
Q

What is WPW

A

AV re-entrant tachycardia - another pathway through atrial and ventricle not AV ode

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19
Q

What causes irregular narrow complex

A

Atrial fibrillation
Ectopic
Atrial flutter with variable block

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20
Q

What are the symptoms

A 
Asymptomatic
Fast HR 
Palpitations
SOB
Dizzy
Chest pain
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21
Q

What terminates supra ventricular tachycardia

A

Valsalva

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22
Q

What do you suspect if a patient with no history presents with supraventricular tachy / AF / palpitations

A

Alcohol binge

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23
Q

What is atrial tachycardia

A

Group of atrial cells act as pacemaker

P wave different (more pointy) but everything else same

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24
Q

What can cause an atrial tachycardia

A

Digoxin toxicity

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25
Q

What is AVRT

A

Accessory pathway e.g. WPW allows electrical activity from atrial to ventricles
New circuit created

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26
Q

What is AVNRT

A

Circuits form in AVN

Very common

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27
Q

What are adverse signs of supra ventricular tachy which you should assess for

A 
Chest pain / MI 
Syncope
Shock 
- Hypo / pallor / sweating / confusion / impaired consicous
Heart failure 
- Pulmonary oedema or raised JVP

Can be peri-arrest and go into VF or asystole = emergency

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28
Q

If rate is irregular what is the most likely Dx

A

AF

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29
Q

What do you do if rate is regular

A

Continuous ECG
Valsalva manœuvre
Carotid sinus massage

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30
Q

What do you do when someone presents in SVT

A 
ABCDE 
O2 if low sats
IV access
Bloods 
Monitor ECG and BP 
12 lead ECG to see if narrow or broad 
Identify and treat reversible cause e.g. electrolyte
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31
Q

What should you do if someone has adverse signs

A 
Treat as VT rater than SVT
Put out crash call 
DC shock up to 3 times under sedation  
SEEK EXPERT HELP 
Correct electrolyte
IV Amiadarone after shock 300mg over 10-20 mins
Repeat shock 
IV amiadarone infusion over 24 hours
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32
Q

What do you do for sinus tachy

A

Not an arrhythmia so no cardio version
Rx = treat cause
If no cause can be found = BB

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33
Q

What do you do if suspect AVRT / AVNRT

A

Block AV node by performing Valsalva or carotid sinus massage (will stop tachy)

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34
Q

What do you do if Valsalva / carotid sinus massage fails

What is needed
When is it CI and what do you give instead
What do you warn patient about

A

IV adenosine - resets back to sinus rhythm
6mg then 12mg then 12mg if no response
Need continuous ECG
Given as rapid bolus into large proximal vein
Can cause Brady which is scary but transient - warn patient as half life 10s
Do ECG during infusion
CI in asthma / COPD / HF / heart block / severe hypo so give verapamil
May need to cardiovert if doesn’t work

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35
Q

If sinus rhythm is restored what does this suggest

A

AVRT

Consider anti-arrhythmia prophylaxis if recurs

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36
Q

What do you suspect if sinus rhythm not achieved with adenosine and what is required

A

Atrial flutter
AF if irregular
SEEK expert help and rate control with BB

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37
Q

How do you prevent supra ventricular tachy

A

BB / CCB / amiadarone - block AV node

Ablation to take out accessory pathway

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38
Q

What is the Valsalva manoeuvre

A 
Forced expiration against closed glottis
Increases intrathoracic pressure
Reduced venous return due to increased atrial pressure
Reduced preload 
Reduced CO
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39
Q

What is WPW

A

Congenital accessory conduction pathway
Leads to AVRT
Early excitation of ventricles by bypassing AV node

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40
Q

What is risk of WPW

A

Degneration to VF as does not slow conduction as AV node is bypassed

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41
Q

How does WPW present

A 
SVT - associated AF / flutter or tachy 
Palpitations
SOB
Dizzy
Chest pain
Sweating 
Anxious
Syncope
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42
Q

What is associated with WPW

A

HOCM
Mitral valve prolapse
Ebstein
Thyrotoxicosis

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43
Q

What does ECG show

A

Short PR <0.12
Wide QRS with slurred upstroke and delta wave which is the accessory pathway
ST changes

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44
Q

What is type A

A

L pathway so RAD

Dominant R in V1

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45
Q

What is type B

A

R pathway so LAD

No dominant R wave

46
Q

How do you treat WPW

A

Radiofrequency Ablation = definite

Amiadarone / fliecanide if AF (rhythm control)

47
Q

What should you avoid

A

Verapamil as blocks AV node

Possibly digoxin

48
Q

What causes atrial fibrillation

A

SA node isn’t firing properly = disorganised signal
Other sites as well as SA node initiate conduction
CO drops as ventricles not primed reliably leading to cariogenic shock / HF / increased risk of stroke

49
Q

What are the types of AF

A 
First episode
Paraoxysmal - <7 days and self terminate (most in <48 hours) 
Will often become persistent 
Persistent - >7 days 
Permanent - resistant to Rx
50
Q

What are cardiac causes of AF

A

Valvular vs non valvular
Valvular = MS / prosthetic heart valve issue

Non-valvular
Ischaemia = most common UK
Rheumatic = common world wide 
HF
Hypertension
IHD
Cardiomyopathy
Myocarditis 
Endocarditis
Surgery
51
Q

What ar non-cardiac causes

A 
Sepsis
PE 
Bleed 
Pneumonia
Hyperthyroid
Alcohol
Caffiene
Drugs
Post op
Decreased K / Mg / Ca
Acidosis
52
Q

Mneumonic for causes

A

THE ATRIAL FIBS
Thyroid
Hypothermia
Embolism

Alcohol
Trauma
Recent surgery
Ischaemia 
Atrial enlargmenet
Lone

Fever / anaemia / high output
Infarct
Bad valves -MS
Stimulants - cocaine / caffeine

OR PIRATES

P - pulmonary - COPD / PE or phaeochromocytoma
I - ischaemia
R - rheumatic heart disease
A - anaemia / acid base
T - thyrotoxicosis / tachy
E - ethanol / endocarditis / elevated BP
S - sepsis

Most common causes = SMITH
Sepsis
Mitral valve - S or R
IHD
Thyrotoxicosis
Hypertension
53
Q

How does AF present

A 
Asymptomatic
May feel irregular irregular pulse 
Tachycardia 
Palpitations
SOB 
Chest pain
Fatigue 
Syncope
Collapse 
Heart failure
54
Q

What are signs of unstable patients (most present stable)

A 
Hypotension
Syncope 
HF
Chest pain / signs of ischaemia 
WPW 
Known severe valve disease
HR >150
HCM
55
Q

What is DDX of irregularly irregular heart beat

A

Ventricular ectopic

Flutter with block

56
Q

What will ECG show

A

Narrow complex QRS
Irregular
Tachycardia
No clear P wave (wobbly baseline) suggest AF
Irregular QRS
- Tachy can make it look regular so really have to look
Flutter waves often accompany AF

57
Q

What do you do if present in ED if stable or alongside DC cardioversion

A 
Immediate 
IV access
12 lead ECG 
Full bloods
VBG for K 
Look and correct underlying cause - e.g. sepsis / bleed / MI  
Control rate and rhythm 
Anti-coagulant - LMWH 
Stop anti-platelet

After
Calculate CHADVAS
Decide long term Rx / OAC

58
Q

What do you do if unstable

A 
ABCDE 
Crash call 
DC cardioversion
Immediate life support
ATLS tachy
59
Q

How do you investigate AF

A 
ECG on everyone with irregular pulse 
24 ECG if symptomatic = useful 
Bloods 
CXR 
- Look for pulmonary oedema / cardiomegaly 
May get fast abdominal USS in A+E to rule out bleed 
HASBLED / CHAD score
ECHO within 6 months 
Angio to check carotid
60
Q

What bloods

A 
Look for cause
FBC
U+E
LFT
TFT  
CRP 
Bone profile + Mg 
Cardiac enzymes + troponin for MI
61
Q

What may ECHO show

A

LA enlargement
Mitral valve
Poor LV function

62
Q

What are the risks of AF / tachycardia

A

Risk of stroke = 6x greater
Reduced CO as heart can’t fill
Can get cardiogenic shock if acute presentation
Heart failure

63
Q

What score is used to determine appropriate long-term coagulation in patient with AF and what does it look at

A 
CHA2-DS2-VAS 
CCF
HTN
Age = >75 (2) >65 (1) 
DM
Stroke or TIA previous = 2 
Vascular disease
Sex - F
64
Q

What score indicated need for coagulation and what do you give

A

0= no Rx
1 = Rx if M
2 = Definite Rx
Warfarin vs DOAC

65
Q

What score is used to weight up risk of bleeding on anti-coagulation

A 
HASBLED 
Hypertension
Abnormal renal or liver
Stroke Hx
Bleeding tendency
Labile INR
Elderly
Drugs that predispose - NSAID / anti-platelet / alcohol
66
Q

What suggests high risk of bleeding

67
Q

What do you do if develop AF post stroke

A

Aspirin for 2 weeks
Anti-Coagulation after life long
Warfarin or DOAC
Give LMWH to bridge gap until stable INR if using warfarin
Only give anti-platelet if needed for co-morbid as higher risk of haemorrhoid stroke

68
Q

What is summary of AF Rx

A 
All patients anti-coagulation for 4 weeks 
Life-long anti- coagulation if CHADVAS
Control ventricular rate
Control rhythm 
If unstable = immediate cardio version
69
Q

What always requires anti-coagulation and what do you give

When would you delay cardioversion

A

ACUTE PRESENTATION
If <48 hours LMWH until DC cardio version as quick acting
Must do TOE to rule out if LAA thrombosis if not on anti-coagulation

Delay for 3 weeks and do rhythm if

  • No anti-coagulation and >48 hours
  • TOE unavailable
  • TOE shows LAA thrombus
  • Suspicion of self-termination
  • Reversible cause e.g thyroid
70
Q

Wha do you do if >48 hours since symptoms

A

Anti-coagulate with warfarin / DOAC for 3 weeks before elective DC Cardioversion or pharmacological cardioversion
Warfarin always if valvular heart disease

71
Q

Who gets life-long anticoagulation

A

Do CHAD-VAS

72
Q

Who may not get anticoagulation

A

If sinus rhythm
No RF
No risk of recurrence

73
Q

What is target INR on anti-coagulation

74
Q

What are your options if <48 hours since symptoms

A 
Unstable = cardiovert 
Rate or rhythm control
If choosing rhythm must decide whether early or delayed cardioversion
Most get delayed 
Anti-coagulate with LMWH

Delay for 3 weeks and do rhythm if

  • No anti-coagulation and >48 hours
  • TOE unavailable
  • TOE shows LAA thrombus
  • Suspicion of self-termination
  • Reversible cause e.g thyroid
75
Q

What ar your options if >48 hours from symptom onset

A

Rate control
Need 3 weeks anti-coagulation as risk clot has developed in heart if going to do rhythm control
LMWH to bridge gap if using warfarin

76
Q

How do you control rate

A

Need to know LVEF as CCB can only be given if normal as -ve inotropic so perform ECHO

LVEF >40%
BB = 1st line 
- Can't be given if acute HF 
Rate limiting CCB - diltiazem / verapamil 
Add digoxin if not controlled

LVEF <40%

  • Use smallest dose of BB to get rate control but avoid if acutely decompensated
  • Digoxin - 1st choice if HF / acutely decompensated / severely reduced
  • Can add amiadarone

Want to titrate to <110

77
Q

What do you add if not controlled

A

Digoxin (1st choice if HF)

Amiodarone

78
Q

What do you never combine

A

BB and rate limiting CCB as -ve inotrope

79
Q

How does rate control work and when is it 1st line to do and w

A 
Slows rate to avoid -ve cardiac function 
Aim <110 BPM but avoid brady
Usually 1st line especially if 
- IHD
- >65
- Asymptomatic 
- Persistent >1 year
- LA diameter >5cm
80
Q

What must you do prior to rhythm control and when is it preferred

A

ECHO to look for clot and to look for structural abnormality
esp if doing <48 hours

Rhythm if <65 or >65 but failed rate control

81
Q

What are options for rhythm control

A

Elective DC Cardioversion

Chemical cardioversion

82
Q

What is 1st line if harm-dynamically unstable

A

DC cardio version
Do on R wave to prevent VF
Put out crash call and start tachy arrhythmia ATLS guidelines

83
Q

What must you do after DC Cardioversion

A

Anti-coagulate for at least 4 weeks

84
Q

What are options for rhythm control with chemical cardioversion

A

Fleicanide = 1st line as fast onset

  • Can do IV or pill in pocket if paroxysmal
  • Unsuitable if LV dysfunction / CAD / structural heart)

Amiadarone if structural heart disease

  • Central venous career due to thrombophlebitis risk
  • Longer onset of action so delayed conversion to sinus
85
Q

When are you more likely to do rhythm over rate which is usually 1st line

A 
New onset - 48 hours 
<65
Symptomatic despite rate control - feel themselves go into AF 
First presentation
Reversible causes e.g. infection
Congestive HF

As AF worsens more go onto rate

86
Q

What do you do if refractory to Rx

A

AVN ablation
Pulmonary vein isolation

Done if refractory to drugs or younger patients paroxysmal

87
Q

What drug is good in HF and what drug is bad

A

Digoxin good as small inotrope affect

Verapamil bad as depresses cardiac function

88
Q

What is atrial flutter

A

Form of SVT
Rapid atrial depolarisation faster and more often than ventricles
May have 4 atrial to one ventricular contraction - 4P to 1 QRS
Re-entrant due to extra irregular pathway through AV node which goes round and round
Heart beat is regular but faster and more often than ventricle

89
Q

What is associated with flutter

A

Hypertension
IHD
Cardiomyopathy
Thyrotoxicosis

90
Q

What does ECG show

A

Clear P wave
QRS removed - not always
Can have 4 P to 1 QRS
Saw tooth appearance

91
Q

How do you Rx

A

Similar to fibrillation
Control rate or rhythm
Anti-coagulate

92
Q

What can be curative in atrial flutter

A

Radiofrequency ablation of extra pathway

93
Q

What does ventricular / HR depend on

A

Degree of AV block

94
Q

What are pacemakers

A

Deliver controlled electrical impulses to improve heart function

95
Q

How are they implanted

A

Under skin - L side usually
Wire fed into relevant chamber of the heart
Battery lasts 5 years

96
Q

What are indications

A 
Symptomatic brady
MObitz type II or c3rd degree
HCM
Severe HF 
Carotid hypersensitivity 
Malignant vasovagal 
BBB
97
Q

What do you have in HCM

A

Implantable defibrillators which detects rhythm and shocks if VT detected

98
Q

What is shown on ECG and how do you know what type of pacemaker

A 
Straight sharp vertical line 
If before P wave = in atria
If before QRS = in ventricle 
If before both = dual chamber
If just one = single chamber
99
Q

What are CI when have a pacemaker

A

MRI - newer ones are compatible
TENS
Diathermy

100
Q

When is Fleicanide CI in chemical cardioversion and amiadarone used

A 
LV dysfunction
Post MI
AV block
Structural - HF
Flutter
101
Q

If shocked what is it important not to give

A

BB as would slow down heart

Digoxin - would slow down CO

102
Q

If someone presents with tachycardia what do you need

A

ECG to decide management

103
Q

What can AF be

A

Paroxysmal due to infection so may hold of putting on anti-coag
Can rate-control in interim with BB

104
Q

DOAC

A

Different DOAC have different timings

105
Q

What does cardioversion required

A

Sedation
If low BP may be difficult as sedation will worsen
May burn

106
Q

How can patient in AF present

A

Cardiogenic shock

107
Q

Who gets warfarin

A

Mechanical heart valve

Moderate or severe mitral stenosis

108
Q

What is issue with DOAC

A

CI severe CKD
Increased risk GI bleed compared to warfarin
Most go on

109
Q

What does amiadarone and flueicanide both require

A

ECG monitoring due to risk of QT prolongation

110
Q

DDX of SOB and chest pain (come and go)

A 
AF 
SVT 
Sinus tachy
ACS
PE 
Pneumothorax
111
Q

How would you investigate

A

ABCDE
12 lead ECG
CXR
Bloods inc cardiac

CVS (30 decks)

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