Arrhythmias Flashcards
Sick sinus syndrome/Tachy-Brady
Hospitalize Unstable-ACLS, Atropine, Dopamine, Epi Stop CCB/BB Transcutaneous/Transvenous pacing Ultimately=Permanent pacemaker
Sinus arrest (>2 seconds)
If >6 seconds- Permanent pacemaker
First degree AV block
No tx
PR int over 200msec
Second degree AV block, Mobitz I
No tx
AKA Wekenbach, lengthening PR interval
Second degree AV block, Mobitz II
Emergency, need pacemaker.
Consistent PR interval. Dropped QRS, sometimes 2:1.
Block=below HIS (NOT AV)
Complete heart block
Emergency, need pacemaker.
Sx: SOB, Syncope, HF
Independent/Unassoc P & QRS
Bundle branch block
No tx. QRS >0.12 RBBB= bunny-ears, may be normal LBBB= negative V1 & positive V6. Never normal. Can't r/o MI EKG changes. ST/T waves in opposite direction.
Tachycardia
Unstable–SHOCK
DONT use Adenosine with WPW/AFib
PAC
Usually asx
Tx: BB or CCB for palpitations
P waves early & may be different morphology
SVT types
- AVRT- path within AV node
2. AVNRT - path outside the AV node. WPW.
SVT tx
Unstable-cardioversion
Stable-Adenosine or Vasovagal maneuver will terminate.
1st line: Catheter ablation
Other options: BB, CCB, anti-arrhythmics
SVT sx/EKG
P waves usually hidden, if seen will be different morphology.
Regular narrow QRS at 140-240 bpm.
Sx: palpitations & syncope
WPW EKG
Delta wave on resting/sinus (pre-excitation of ventricles)
Syndrome: Delta + SVT + Sx
WPW with AFib
NO Adenosine, if you block AV node conduction will only go through alternative pathway.
Adenosine will send into VFib
OK tx: Cardioversion, BB, CCB, acute anti-arrhythmics
Need cath ablation
Atrial fibrillation EKG
Irregularly irregular, no discernable P waves (300-600 if measurable).
Ventricular rates-100, but may be slow/normal. QRS same morphology but variable at intervals.
QT interval difficult to measure.
Most common chronic arrhythmia
AF risk factors/presentation
Age, Sleep apnea, Valve disease, Obesity, CAD, HTN
May present with embolic event.
Other sx same as others.
AF classifications
- Paroxysmal-terminates spontaneously/w/in 7 days
- Persistent-fails to terminates w/in 7 days of tx
- Longstanding persistent-continuous for >12mo.
- Permanent-constant & agreed on no rhythm meds.
Valvular AF
AF with MS/Rheumatic valve ds Requires Warfarin (higher stroke risk)
CHADSVASC
C ongestive heart failure H TN A ge (65 1, >75 2) D M S troke (2) V A scular ds S ex (F) C haracteristic
2 or more=Anticoag
1=grey area
0=aspirin is an option
AFib tx (anticoag vs procedure)
WATCHMAN/left atrial ligation procedure for CI to anti-coag.
1st line=NOAC
2nd line= Warfarin
NOACs & CI
Adjust for renal fxn
2 hours effective.
Direct=Dabigitran/Pradaxa
Xa inhibitor=Apixiban/Eliquis (best safety)
CI: Bleeding, thrombocytopenia, Severe uncontrolled HTn
Warfarin
Vitamin K antagonist (Vit K reverses)
Narrow therapeutic window-INR checks
Effective in 2-3 days
Afib acute tx
- Rate: Metoprolol/Diltiazem (Digoxin if difficult)
- Cardioversion: Electric or with Amiodarone (Class III)
W/o anticoag, OK 24-48hrs IF no MS or enlarged LA
Unsure-TEE to look for LAA thrombus
Anit-coag 4 wks before & after cardioversion.
AFib long term tx
- Rhythm: (early) Anti-arrhythmics, Cath ablation, MAZE
- Rate: (older) BB, CCB, Digoxin
- AV ablation + pacemaker: if unable to get on BB, etc (low blood pressure)
AFlutter EKG
Saw tooth P waves in inferior leads (II, III, aVF)
RA re-entry circuit, 300bpm
Ventricular response typically regular (2:1/3:1)
2:1 can show up as HR of 150, be suspicious
AFlutter tx
- CHADSVASC anticoag.
- Same acute tx as AFib
- Chronic=catheter ablation is primary tx
Antiarrhythmics if cannot undergo ablation. (not as good)
Atrial tachycardia EKG
From atria, not SA node.
P waves hidden, 140-220.
Versus SVT (Adenosine does not terminate atrial tachy)
Atrial tachycardia Tx
Normal self-limited, will terminate on its own.
BB, CCB, Ic & III for sx.
Rarely need cardioversion.
PVC EKG/Sx
Wide premature QRS w/o preceding P wave
Sx=Palpitation
Need a holter monitor to assess Tx need
Effective bradycardia
When PVC does not perfuse blood to extremities.
No pulse on that beat.
PVC Indication for tx
> 20% burden of QRS are PVC
& Underlyig structural heart issues
PVC Tx
Sotalol (antiarrhythmic)
Ablation (for uncontrolled sx or PVC causing CM)
Ventricular Tachycardia EKG
3 or more PVC in a row Rate 160-200 Nonsustained= less than 30 sec Sustained= more than 30 sec Cause: Previous MI scar/LVOTO
V tach Acute Tx
- Unstable: Shock
- Stable: IV Amioradone & BB
Lidocaine/Procanimide if Am doesn’t work
If still SV not restored–Cardiovert
Full Cardiac workup including cath
Always treat as VT (may be aberrant SVT)
Monomorphic vs. Polymorphic VT
- Monomorphic: Re-entry circuit via MI scar
2. Polymorphic: More unstable, AMI
Chronic VT Tx
- ICD
- Sotalol/Amiodarone
- Ablation
- BB (improves survival)
Torsades & Acute Tx
Polymorphic VT due to long QTc/Complete hrt block
Tx: Mg & Cardioversion & IV BB
Temporary pace @ 100bpm (decreases QTc)
Torsade chronic Tx
- Stop offending QTc agents
2. Congenital– BB long term
Common QTc meds
- Antiarrhythmics
- Antihistamines
- Antimicrobials (Macrolide, Fluoroquinolones, Fungal)
- Antipsychotics
- Gastric motility agents
VFib
No discernable activity, 200-300 if you could count
Need to shock ASAP
Death, pulseless.
MCC= CAD (Other CHF, Primary arrhythmia)
VFib Tx
ACLS: Emergent DFib Epinephrine Chest compressions Secure airway
Hypothermia minimizes brain injury.
ICD needed if not caused by MI.
