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ECG > Arrhythmias > Flashcards

Arrhythmias Flashcards

1
Q

What is the classification of tachycardia based on QRS complex?

A

Supraventricular
* Sinus tachycardia
* Focal atrial tachycardia
* Multifocal atrial tachycardia
* Atrial fibrillation
* Atrial flutter
* AVNRT and AVRT = PSVT

Ventricular
* Ventricular tachycardia has 2 types: monomorphic and polymorphic VT (more than 1 irritable area) with normal QT
* Polymorphic VT wth prolonged QT interval: Torsades de Pointes
* Ventricualr fibrillation

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1
Q

What is the classification of tachycardia based on origin of depolarization?

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2
Q

What is the ECG changes in atrial flutter?

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3
Q

What is the ECG changes in atrial tachycardia?

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4
Q

What is the ECG changes in junctional (nodal) tachycardia?

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5
Q

What is the ECG changes in atrial fibrillation?

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6
Q

What is the ECG changes in ventricular tachycardia?

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7
Q

What is the ECG changes in Wolff-Parkinson-White syndrome?

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8
Q

What is the diagnostic algorithm for narrow QRS tachycardia?

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9
Q

What is the algorithm for wide complex tachycardia?

A

brugada algorithm

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10
Q

What is treatment algorithm for tachycardia?

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11
Q

What are the different classes of antiarrhythmics and when are they used?

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12
Q

What is treatment algorithm for stable regular narrow complex tachycardia?

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13
Q

What is treatment algorithm for stable wide complex tachycardia?

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14
Q

What is the moa of vagal manouevres (carotid sinus massage) and ATP?

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15
Q

What is the management of AF and atrial flutter?

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16
Q

What is the management of regular narrow complex tachycardias?

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17
Q

What is the management of irregular narrow complex tachycardias?

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18
Q

What is the management of wide complex tachycardias?

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19
Q

What is the classification of bradycardia?

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20
Q

What are the ECG changes and causes for 1st, 2nd and 3rd degree heart block?

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21
Q

What are the ECG changes and causes for RBBB?

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22
Q

What are the ECG changes and causes for LBBB?

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23
Q

What are the ECG changes and causes for left anterior fascicular block, bifascicular block?

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24
Q

What are the ECG changes and causes for sick sinus syndrome?

A

SAN dysfunctional (fibrosis/myocardial scarring/ idiopathic) causing sinus bradycardia

Due to SAN dysfunction –> develops SVT –> AFl, AF, PAC which produces tachycardia
Sometimes known as tachybrady syndrome

25
Q

What is the treatment algorithm for bradycardia?

A
26
Q

What is management protocol for VF or pulseless ventricular tachycardia?

A
27
Q

List the 6H and 6Ts of pulseless electrical activity

A
28
Q

What is management of pulseless electrical activity?

A
29
Q

A patient presented with irregularly irregular pulse. What are the 6 main differential diagnosis?

A

 Atrial fibrillation
 Atrial flutter with variable AV block
 Atrial tachycardia with variable AV block  Multi-focal atrial tachycardia (MAT)
* Atrial rate > 100 bpm
* Absence of one dominant pacemaker
* P waves of at least 3 morphologies
 Multi-focal atrial rhythm (MAR)
* Atrial rate ≤ 100 bpm
* Absence of one dominant pacemaker
* P waves of at least 3 morphologies
 Very frequent ectopic beats

30
Q

What is physiological cause of tachyarryhthmias?

A
  • Increased automaticity
  • Triggered activity
  • Reentrant circuit
31
Q

What is physiological cause of bradyarryhthmias?

A
  • Decreased automaticity
  • Conduction block
32
Q

What controls the automaticity of the heart?

A
33
Q

What causes decreased automaticity of heart?

A

ICP causes brain herniation and compression on CN10 stimulating PSNS –> bradycardia

34
Q

What are the causes for increased automaticity in heart?

A

Increased SNS tone
* Hypovolemia
* Hypoxia: anemia, lung ddx, pulmonary embolism
* Sympathomimetics
* Pain/anxiety
* Increased metabolic activity: fever (sepsis), hyperthyroidism

35
Q

What are the causes of early after depolarization?
Associated with what condition?

A

Associated with: Polymorphic VT + prolonged QTi –> torsades de Pointes

36
Q

What are the causes of delayed after depolarization?
Associated with what condition?

A
  • Ischemia (MI, CAD)
  • Hypoxia (lung disease)
  • Inflammation (myocarditis)
  • Stretch (DCM, MR)
  • Increased SNS tone
  • Digoxin toxicity

DADs
* MAT
* FAT (focal atrial tachycardia)
* VT

37
Q

What are the 2 types of AVRT and QRS morphology?

A

Orthodromic AVRT: goes through normal conduction pathway (SAN –> AVN –> bundle of His –> bundle branches –> purkinje fibers –> Bundle of Kent)
Antidromic AVRT (less common): down B.Kent –> purkinje fibers –> bundle branch –> bundle of His –> AVN

38
Q

What is the mechanism of AVNRT?

A

Scars or fibrosis in the AVN: which prolongs conduction pathway

1st step goes down both alpha and beta pathway
2nd step: B pathway is refractory, sends signal down slow alpha pathway. By the time it reaches the bottom B pathway is no longer refractory and gets depolarized
3rd step: becomes a self containing reentrant cycle sending signals back up to the atrium and down to the ventricle

Most common is slow-fast pathway

39
Q

What are the reentry circuit causes?

A
  • AVNRT, AVRT –> PSVT
  • AFl: cavotricuspid isthmus –> reentry
  • AF
  • VT/VF
40
Q

What are causes of conduction block in AVN?

A
  • Inferior wall MI (RCA)
  • Fibrosis
  • HyperK
  • Drugs: BB/CCB/digoxin (AVN blockers)
  • Infiltration: sarcoidosis, amyloidosis
  • Lymes disease (borellia burgdorferi)
41
Q

How to classify tachycarrhythmias?

A

Wide or narrow QRS complex
Regular/irregular rhythm

42
Q

How to determine in ECG if sinus tachycardia?
Treatment?

A

P waves present in all QRS
* Go up in lead II
* Go down in lead aVR
P –> QRS –> T

Treat underlying cause
* If hypovolemic: give fluids
* If fever: antipyretics
* If hypoxia: oxygen
* If pulmonary embolism: heparin, tPA

43
Q

How to determine in ECG if focal atrial tachycardia?
Treatment?

A

P waves present: goes down in lead II (depolarization is away from positive electrode lead II), goes up in lead aVR
P –> QRS –> T
Ensure that electrodes are placed on correct side

Treatment for all SVTs
Vagal manouvre: hold breath (increased intrathoracic pressure –> increase vagal tone –> bradycardia)
Adenosine
BB/CCB (depend on contraindications)
Cardioversion (if hypotensive, altered mental status, chest pain, pulmonary edema must do instantly as they are unstable)

Long term treatment: radiofrequency ablation of ectopic foci

44
Q

How to determine in ECG if atrial flutter?
Treatment?

A
  • Saw tooth waves most common in lead II, III, aVF
  • Lead V1
  • 2/3/4: 1 ratio

Treatment for all SVTs
Vagal manouvre: hold breath (increased intrathoracic pressure –> increase vagal tone –> bradycardia)
Adenosine
BB/CCB (depend on contraindications)
Cardioversion (if hypotensive, altered mental status, chest pain, pulmonary edema must do instantly as they are unstable)

Long term treatment: radiofrequency ablation of cavotricuspid isthmus

45
Q

How to determine in ECG if AVRT/AVNRT?
Treatment?

A

Narrow QRS, regular rhythm tachycardia
No p waves present –> most likely AVRT/AVNRT (SVT)

  • No visible P waves (hidden within the QRS complex)
  • Retrograde P waves: leads II, III, aVF (AVN produces depolarization into atrium)

Treatment for all SVTs
Vagal manouvre: hold breath (increased intrathoracic pressure –> increase vagal tone –> bradycardia)
Adenosine
BB/CCB (depend on contraindications)
Cardioversion (if hypotensive, altered mental status, chest pain, pulmonary edema must do instantly as they are unstable)

Long term treatment: radiofrequency ablation

46
Q

How to determine in ECG if AFib?
Treatment?

A
  • Fibrillization in lead V1
  • Irregular irregular rhythm narrow QRS complex

Treatment
* Try adenosine (doesn’t really work)
* BB/CCB
* Cardioversion (if at any point unstable –> do cardioversion immediately)

Long term treatment: RFA + AFIB –> CHADVAS (>2 –> requires anticoag)

47
Q

How to determine in ECG if AFlutter with variable block?
Treatment?

A
  • Saw tooth waves in lead II, III, AVF. Also lead V1.
  • 2:1 + 1:1 ratio
  • Irregular rhythm narrow QRS complex

Treatment
* Try adenosine (doesn’t really work)
* BB/CCB
* Cardioversion (if at any point unstable –> do cardioversion immediately)

Long term treatment: RFA (cavotricuspid isthmus)

If + AFIB –> CHADVAS (>2 –> requires anticoag)

48
Q

How to determine in ECG if MAT?
What is causes?
Treatment?

A
  • 3 or more morphologically different p waves
  • Underlying disease is the cause (COPD/PE/underlying heart failure)

Treatment
* Try adenosine (doesn’t really work)
* BB/CCB
* Cardioversion (if at any point unstable –> do cardioversion immediately)

Long term treatment: RFA of ectopic foci
If + AFIB –> CHADVAS (>2 –> requires anticoag)

49
Q

How to determine in ECG if Vtach?
What is causes?
Treatment?

A
  • Wide QRS regular rhythm: >0.14s
  • AV dissociation
  • Extreme right axis deviation
  • History of CVD (>35 years old)

If wide regular QRS complex always think V tach (if SVT w BBB and treated wrongly will kill patient –> if V tach but actually SVT w BBB –> condition will improve)

If hard to differentiate between PMVT +normal QT and AF +WPW (treat as PVMT + normal QT as same treatment –> dont give AVN blockers)
Treatment
* Amiodarone
* Procainamide
* Synchronized cardioversion (pads should be ready as VT can quickly go into VFib)

Long term treatment
* RFA
* V tach: look for MI
* AICD

50
Q

How to determine in ECG if SVT with BBB?
What is causes?
Treatment?

A
  • <0.14s QRS complex
  • No AV dissociation
  • No extreme right axis deviation
  • No significant past medical history of CVD

If hard to differentiate between PMVT +normal QT and AF +WPW (treat as PVMT + normal QT as same treatment –> dont give AVN blockers)
Treatment
* Adenosine (cautious)

Long term treatment
* RFA
* AICD

51
Q

What is AF + WPW on ECG?
What drugs can you not give?
What Tx?

A

Wide QRS complex irregular rhythm
WPW is likely antidromic going through the Bundle of Kent first

Cannot give AVN blockers (ABCD: adenosine, B blockers, CCB, digoxin) –> will induce VF if given

Treatment is same is pmVT (polymorphic VT with normal QT):
Amiodarone, procainamide
Synchronized cardioversion (may be difficult to sync with R waves) –> Defibrillation

52
Q

What is PMVT with increased QT interval (requires checking ECG rhythm strip prior to TdP) on ECG?
Treatment?

A

Varried ventricular morphology and qtc >500ms

Give MgSO4 if low (hypoMg is cause)
Replete K+ (if hypoK)
Discontinue offending drugs: antiarrhythmics, antibiotics, antipyschotics, antidepressants, antiemetics

Prevent going into TdP again
Overdrive pacing/isoproterenol: increases HR which decreases QT interval (decreases chance of TdP)

53
Q

What is treatment of PMVT (polymorphic Vtach) with normal QT?

A

Amiodarone
Procainamide
Synchronized cardioversion/defibrillation (when cannot sync with R waves)

54
Q

What is most common wide irregular QRS complex rhythm?
Treatment?

A

AF + BBB

Treatment
QRS morphology –> same
* BB/CCB –> cardioversion

Long term treatment
* RFA
* AICD

55
Q

How to determine in ECG is sinus bradycardia?

A

Every P wave has QRS complex

56
Q

How to determine in ECG is 1st degree HB?

A

when PR >200ms

57
Q

How to determine in ECG is 2nd degree HB Mobitz 1?

A

Increased in PR interval than drop in QRS complex (wenkebach drop)

58
Q

How to determine in ECG is 2nd degree HB Mobitz 2?

A

Normal PR interval and dropped QRS

59
Q

How to determine in ECG is 2:1 block?

A

Normal PR interval and drop QRS
2:1 2nd HB

60
Q

How to determine in ECG is 3rd degree HB?

A

PR interval normal + drop QRS + wide QRS (AV dissociation)

61
Q

What HB requires treatment?
What is treatment?

A

2nd degree HB Mobitz 2
2nd degree HB 2:1 block
3rd degree HB

Decreased HR (bradycardia) –> decreased cardiac output –> decreased BP –> hypotension/altered mental status/chest pain/pulmonary edema (unstable –> requires treatment)

Treatment (in this order)
Atropine (decreased PSNS: block acetylcholine –> nothing inhibiting excitation)
Epinephrine (increased SNS)
Pacing: transcutaneous pacing, transvenous, permanent pacemaker

Treat underlying cause of block
* Inferior wall MI (RCA): STEMI/NSTEMI (cTnT, cTnI) –> cath lab –> PCI
* HyperK (give calcium gluconate, insulin (shunt K+ into cell) +D50 (prevent hypoglycemia), albuterol, HCO3-, lasix (excrete K+ through urine)
* Overdose of BB/CCB/digoxin. If BB overdose –> glucagon. If CCB overdose –> calcium. If digoxin overdose –> digibind.
* Lymes disease (borrelia burgdorferi) –> give IV ceftriaxone
* Hypothermia: warm them up
* Hypothyroidism: levothyroxine (myxoedema coma)

ECG (15 decks)

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