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5 - A&E > Arrhythmias > Flashcards

Arrhythmias Flashcards

1
Q

What is the definition of a narrow complex tachycardia?

A

Heart rate > 100bpm and a QRS less than 120ms

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2
Q

What are some examples of REGULAR narrow complex tachycardia?

A

Sinus tachycardia
focal atrial tachycardia
Atrial flutter,
Atrioventricular re-entry tachycardia (occurs when there is an accessory pathway - WPW)
Atrioventricular nodal re-entry tachycardia - SVT
Junctional tachycardia

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3
Q

What are some causes of IRREGULAR narrow complex tachycardia?

A

Atrial fibrillation - irregularly irregular rhythm with no P waves.
Atrial flutter with variable block
Multifocal atrial tachycardia (COPD)

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4
Q

What are the investigations for a narrow complex tachycardia?

A

ECG,
24 hour tape is rhythm is paroxysmal
Bloods (electrolytes)
Imaging (ECHO)

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5
Q

What is the management of a regular narrow complex tachycardia?

A

A-E exam. If signs of hemodynamic instability then synchronized DC cardioversion +/- amiodarone
1st line = Vagal maneuvers (valsalva or carotid sinus massage)
2nd line = Rapid bolus of adenosine (verapamil is asthmatic). Start with 6mg, if unsuccessful then 12mg, if unsuccessful then 18mg.
3rd line is electrical cardioversion

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6
Q

How can you prevent episodes of SVT?

A

Beta blockers or radiofrequency ablation

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7
Q

What are the causes of AF?

A

Ischaemic heart disease,
Hypertension,
Symptomatic heart failure,
Valvular heart disease,
Cardiomyopathies,
ASD/other congenital heart disease,
Coronary artery disease,
Thyroid dysfunction,
Obesity,
Diabetes mellitus,
COPD and sleep apnoea,
Chronic renal disease
Non cardiac causes: dehydration, hyperthyroidism, sepsis, pneumonia/PE, alcohol abuse, hypokalaemia or hypomagnesaemia

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8
Q

When should rhythm control be offered for AF?

A

AF secondary to a reversible cause,
Heart failure thought to be caused by AF,
New onset AF
Younger patients
Symptomatic patients despite good rate control

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9
Q

Describe features of rate control for AF

A

First line - Beta blocker (bisoprolol) or rate limiting calcium channel blocker (contra-indicated in heart failure).
If hypotension or heart failure then use Digoxin as first line
Second line = Combination of 2 of following: beta-blocker, diltiazem or digoxin
Aim for HR <110 but if still symptomatic then aim <80bpm

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10
Q

Describe features of rhythm control for AF?

A

Can only be done if onset is less than 48h or they have been anti-coagulated for >3 weeks. Can be done via meds or DC cardioversion.
Meds: Flecanide (pill in pocket or given regularly. Fatal in those with structural heart disease). Amiodarone (for older, sedentary patients). Sotalol (for those who dont meet demographics for flecanide or amiodarone)

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11
Q

Explain the CHA2DS2VASc score

A

C - congestive HF,
H - Hypertension
A2 - Age > 75
D - diabetes,
S2 - Prior stroke, TIA or thromboembolism
V - vascular disease
A - Age 65-74
S - Female sex
Offer anticoagulation if men score 1+ and women score 2+

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12
Q

Importnat to note with use of warfarin?

A

Must cover with LMWH for the first 5 days as warfarin is initially prothrombotic.

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13
Q

What are the complications of atrial fibrillation?

A

Heart failure
Systemic emboli
Bleeding

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14
Q

What is the treatment for atrial flutter

A

If haemodynamically unstable - Cardioversion
If haemodynamically stable then treat reversible cause and rate control using BB or CCB

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15
Q

Name examples of broad complex tachycardia

A

Monomorphic ventricular tachycardia: Most commonly caused by MI.
Polyphorphic VT, eg, torsades de pointes which is caused by prolongation of the QT interval.

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16
Q

what are some causes of QT prolongation?

A

Congenital: Jervell-Lange-Nielsen syndrome, Romano-Ward syndrome
Drugs: Amiodarone, Tricyclic antidepressants, fluoxitine, cloroquine, erythromycin, quinolones.
Other: Hypokalaemia, hypocalaemia, hypomagnesaemia, acute MI, myocarditis, hypothermia, SAH

17
Q

What is the management of VT?

A

Pulseless - 200J unsynchronised shock, IC adrenaline and IV amiodarone administered after 3rd shock. Then Adrenaline every 3-5mins.
Pulsed VT with haemodynamic instability - Synchronised DC shocks and senior guided amiodarone
Pulsed VT with haemodynamic stability - Amiodarone 300mg over 10-60mins, if ineffective then DC shocks
Never use verapamil!!

18
Q

What are features of ventricular fibrillation and ECG findings

A

VF is an irregular broad complex tachy. It is ALWAYS pulseless.
ECG: Tachycardia, QRS complexes which are polymorphic and irregular

19
Q

What is the management of VF?

A

200J biphasic unsynchronised shock
IV adrenaline (1mg of 10ml 1:10,000) and IV amiodarone (300mg) after 3rd shock.
Adrenaline every 3-5mins thereafter

20
Q

What is the management of torsades de pointes

A

IV magnesium sulphate

21
Q

Describe features of first degree heart block, causes and management

A

PR prolongation >200ms
Caused by high vagal tone (athletes), inferior MI, hyperkalaemia, beta blockers, digoxin
Benign so doesn’t need treated

22
Q

Describe features of Morbitz type I heart block, causes and management

A

Progressive lengthening of PR till P wave fails to conduct QRS
Causes: MI, drugs (BBs, CCBs, digoxin), professional athletes, myocarditis
Generally asymptomatic and doesn’t need treatment. If symptomatic then stop precipitating drugs, if adverse features then Atropine.

23
Q

Describe features of Morbitz type II heart block, causes and management

A

Regular non conducted P waves
Causes: MI, surgery, autoimmune diseases (SLE, sclerosis, myocarditis), fibrosis, infiltration (sarcoid, haemochromatosis), meds (BBs, CCBs, dig)
-High risk of developing complete heart block so they require a permanent pacemaker

24
Q

Describe features of third degree/complete heart block, causes and management

A

Complete dissociation between P waves and QRS.
Causes: MI, drugs (BBs, CCBs, adenosine), idiopathic fibrosis
Permanent pacemaker and acute bradycardia guideline

25
Q

What are the adverse signs of bradycaria?

A

Shock (hypotension, pallor, sweating, cold, clammy, confusion)
Syncope,
Myocardial ischaemia
Heart failure

26
Q

What is the management of Bradycardia with adverse signs?

A

First line = 500mg atropine. This can be repeated up to 3mg
Second line = transcutaneous pacing or IV isoprenaline/adrenaline

27
Q

What are some potential risk factors for asystole?

A

Complete heart block with broad complex QRS
Recent asystole,
Morbitz type II AV block,
Ventricular pause > 3 seconds

5 - A&E (20 decks)

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