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m4 emergency medicine > Bradyarrhythmias & life threatening causes of syncope > Flashcards

Bradyarrhythmias & life threatening causes of syncope Flashcards

1
Q

Serious signs and symptoms of bradydysrhythmias

A

CHAPS
Chest pain, SOB
AMS
Giddiness
Hypotension (SBP < 90)
Syncope

*Stokes-Adams attack

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2
Q

What is bradycardia

A

Heart rate < 60 bpm

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3
Q

Approach to bradycardia (<60bpm)

A

Bradycardia identified
Ask yourself: where does the problem lie?
- Absent P waves: think SA node
- P waves present: think sinus brady or AV nodal block

LOOK AT LEAD II

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4
Q

Causes of bradycardia:
Where does the problem lie?

A
  1. SA node
  2. AV node
  3. Slow conduction due to drugs and electrolytes
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5
Q

Types of AV blocks

A

1st degree AV block
2nd degree AV block (Mobitz 1: Wenkebach)
2nd degree AV block (Mobitz 2)
2nd degree high grade AV block
3rd degree AV block (complete heart block)

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6
Q

ECG features: 1st degree AV block

A

Prolonged PR interval > 0.2s (1 big square) and constant
Every P wave is associated with a QRS complex

P-P interval: regular
P-R interval: regular
R-R interval: regular

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7
Q

ECG features:
2nd degree AV block, Mobitz 1 (Wenckebach)

A

Progressive lengthening of PR interval followed by a dropped QRS (by right it’s p wave not conducted)

P-P interval: regular
P-R interval: irregular
*P-R longest before the dropped beat
R-R interval: irregular

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8
Q

ECG features:
2nd degree AV block, Mobitz 2

A

Dropped QRS every 3 or more P
- P QRS P QRS P DROP

P-P interval: regular
P-R interval: regular
R-R interval: depends on ratio

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9
Q

ECG features:
High grade block (2:1, 3:1)

A

Conducted beats every 2 or more beats
eg.
2:1 = 1 dropped QRS (aka 1 solo P wave) followed by 1 conducted P+QRS
3:1 = 2 dropped beats (aka 2 solo P waves) followed by 1 conducted P+QRS

P-P interval: regular
P-R interval: regular
R-R interval: depends on ratio

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10
Q

ECG features:
3rd degree AV block

A

Every beat is NOT conducted

AV dissociation (P and QRS. are independent rhythms)

P-P interval: regular
P-R interval: irregular
R-R interval: regular (escape rhythm)

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11
Q

Causes of AV block

A
  1. Ischemia: ACS
  2. Electrolytes:
    - Hyper or hypoK+
    - Hypomagnesium
    - Hypo or hyperCal
  3. Drugs:
    - BB
    - CCB
    - Digoxin
  4. Infection: Myocarditis
  5. Others
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12
Q

Management of bradycardia

A
  1. Identify rhythm
  2. Determine possible cause of heart block and treat reversible cause
  3. Look for serious signs and symptoms (CHAPS)
    - CP, SOB
    - SBP < 90
    - AMS
    - HF (pul edema)
    - Shock
  4. If present -> Unstable

Initiate treatment
1st line: IV atropine 0.6mg every 3-5mins
2nd line: IV dopamine or adrenaline
IV fluid resus
Transcutaneous pacing, then transvenous pacing
Permanent pacemaker

If stable
- BP > 90/60 AND NO symptoms
Monitor - no need intervention
If Mobitz 2 or 3rd degree block, close monitoring + prepare for pacing

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13
Q

ECG features: Sinus bradycardia

A

Any HR < 60bpm
Every P wave is associated with QRS complex

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14
Q

ECG features: Sinus node dysfunction aka sick sinus syndrome

A
  • Absence of P waves
  • Prolonged sinus pause / sinus arrest
  • Tachy-brady syndrome (sinus arrest interspersed with A FIB)
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15
Q

What syndrome can be seen in SSS

A

Tachy-brady syndrome
- sinus arrest interspersed with A FIB

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16
Q

What is the definitive treatment for SSS

A

Permanent pacemaker for sinus pause
Anticoagulation

17
Q

ECG features:
Hyperkalemia

A

A: Tall peaked T waves (Eiffel Tower)
B: Prolonged P-R
C: Flattened P wave
D: Widened QRS
E: Sine wave (serious)

18
Q

HyperK+ management

A

Stop any K+ infusion if any

  1. IV calcium gluconate 10% 10mls over 10 mins (repeat multiple doses if sine waves)
  2. IV 50% dextrose 40mls + 10units of insulin
  3. Oral resonium 15g
  4. +/- Neb Salbutamol
  5. Urgent hemodialysis if got sine waves
19
Q

How to tell QT prolongation?

A

If QT is > than 1/2 of RR interval, QT is likely to be prolonged

20
Q

Implication of prolong QT syndrome

A

Sudden cardiac death from ventricular arrhythmia

21
Q

Definitive treatment in familial QT syndrome

A

Automatic Implantable Cardioverter Defibrillator

22
Q

ECG feature: Brugada syndrome

A

Cove shaped ST elevation in V1-2

23
Q

Risk of Brugada syndrome

A

Sudden cardiac death from ventricular arrhythmia

24
Q

Criteria for brugada syndrome

A

ECG pattern pattern +ve
AND
Syncope OR
Fam hx of SCD OR
Fam hx of PPM/AICD
Genetic testing

25
Q

Definitive treatment in Brugada syndrome

A

Automatic Implantable Cardioverter Defibrillator

26
Q

Massive PE management

A

Reperfusion
1. 1st line: IV thrombolytic rTPA 100mg over 2h
2. Percutaenous embolectomy
3. Open embolectomy

Bridging therapy
- ECMO

27
Q

Syncope causes

A

Hyperkalemia
Brugada
QT prolongation
VFIB

m4 emergency medicine (18 decks)

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