Arrhythmias

Question 1

List the 5 H’s and 4 T’s:

Answer 1

1- hypovolemia
2- hypoxia
3- hyponatremia
4- hyperkalemia
5- hypothermia

1- tamponade
2- toxins
3- thrombosis (MI or PE)
4- tension pneumothorax

Question 2

IO access: (locations-4)

Answer 2

• proximal tibia (preferred site)
• distal tibia
• proximal humerus
• distal femur

Question 3

Complications of IO access:

Answer 3

• osteomyelitis
• subQ abscess
• compartment syndrome
• fractures

Question 4

Triggering Factors for Atrial Fibrillation: (9)

Answer 4

1- hypoxia
2- caffeine
3- medications (beta-agonists, theophylline)
4- etoh intake
5- etoh withdrawal
6- surgery, particularly heart and lung
7- thyrotoxicosis
8- pericarditis
9- chest trauma

Question 5

Persistent AF:

Answer 5

> 7 days; likely requires pharm tx or cardioversion

Question 6

Paroxysmal AF:

Answer 6

2+ episodes, lasting <7 days (commonly less than 24h)

Question 7

Permanent AF:

Answer 7

Lasting >1 year and cardioversion not attempted or failed

Question 8

Lone AF:

Answer 8

Pts. <60 y.o. w/ any type of AF w/o structural changes
MC in young male pts. W/ specific trigger
1/3 w/ familial hx of a. Fib

Question 9

MC AF sxs:

Answer 9

DOE
Fatigue
Decreased endurance
- can range from asxs to HF sxs

Question 10

Atrial fibrillation dx test:

Answer 10

EKG, evaluating for CLUB

- conduction system dz, LVH, underlying MI, baseline QT interval

Question 11

AF w/u:

Answer 11

• new onset: require TTE
• cardiac enzymes (3 sets Q6-8 hours)
• BNP
• TSH and free T4
• baseline CBC, Renal fx, glucose level and UA
• if ischemia sxs, consider stress testing/cath
• normal ekg, consider holster monitoring or event device implant

Question 12

Unstable A. Fib tx:

Answer 12

Immediate synchronized cardioversion

Question 13

Stable A. Fib treatment:

Answer 13

• telemetry bed and admission
• Rate control:
  1- cardizem: 10-20 mg IV bolus, followed by titration IV drip for a HR 80-100
  2- metoprolol IV bolus w/ cardiac ischemia or infarction
  3- digoxin IV bolus for hypotension
  4- amiodarone IV bolus (potential to re-cardiovert)
• begin A.fib w/u
• anticoagulate if appropriate and >48h

Question 14

Describe CHADS-2 VAS criteria:

Answer 14

CHF
HTN
Age >65 y.o.
DM
Secondary prevention of emboli events (ischemia/stroke)
Vascular dz (PAD, MI, aortic dz)
Age >75 y.o.
Sex (women)

Question 15

Describe CHADS-2 VAS scoring system:

Answer 15

0-1: ASA only
2: ASA vs. anticoagulant (preferred)
3 or more: warfarin or NOAC

Question 16

Describe HAS-BLED criteria for warfarin use:

Answer 16

HTN w/ SBP >160 mm Hg
Abnormal liver or renal fx
Stroke
Bleeding hx (major: IC, hospitalization, hgb drop 2 gm, or required transfusion)
Labeled INRs
Elderly (>65 y.o.)
Drugs: antiplatelets or etoh

Question 17

HAS BLED scoring system:

Answer 17

> 3 indicates high risk

Question 18

If a pt. has valvular atrial fibrillation and you need to anticoagulate, what should you use?

Answer 18

Warfarin

Question 19

MC cause of third degree AV heart block: (3)

Answer 19

MI
Chronic degeneration
Drug toxicity (digitalis toxicity)

Question 20

Describe the process of synchronized cardioversion: (6)

Answer 20

*this is a controlled and planned process
1- consent pt.
2- hook pt. up to CMU w/ airway support ready
3- establish IV access
4- Give sedation and anti-anxiety meds (versed and fentanyl)
5- ekg pre and post procedure
6- verify cardioversion threshold and voltage

Question 21

Unstable Atrial fibrillation cardioversion voltage:

Answer 21

150-200 joules

Question 22

Unstable Atrial flutter cardioversion voltage:

Answer 22

100 joules

Question 23

What conditions should you do unsynchronized cardioversion defibrillation?

Answer 23

1- ventricular fibrillation
2- pulseless vtach
3- polymorphic v tach (torsades)
- 200 joules

Question 24

C/I to unsynchronized cardioversion defibrillation:

Answer 24

1- NSR
2- PEA
3- asystole
4- stable v-tach
5- dangerous operator conditions (wet paint or surroundings)

Question 25

PAC sxs and causes:

Answer 25

MC asxs
If s/s: palpitations
Secondary to caffeine, emotional stress, etoh

Question 26

MC causes of 3rd degree AV heart block:

Answer 26

MI
Chronic degeneration
Drug toxicity (digitalis toxicity)

Question 27

Describe the BHAT findings:

Answer 27

The addition of a BB in post-MI patients showed decreased MI recurrence and overall mortality