Cardiac Arrhythmias Flashcards by Zelds Collins

Originates at the SA node
Follow appropriate conduction pathways 
Intrinsic rate 60-100 beats/min 
Rhythm is regular 
Every beat has a P wave and followed by QRS complex

Normal sinus rhythm

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PR interval remains constant
R-R interval is regular and constant
P-P interval is constant

Normal Sinus Rhythm

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PE findings:
Disappears with breath holding or with an increased heart rate ( from activity or exercise)

No clinical significance
Common in both the young and elderly

Normal sinus rhythm

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Heart beat less than 60 ( due to increased vagal tone on normal pacemaker, organic disease of the SA node, or due to medications

Sinus Bradycardia

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Physical findings of sinus bradycardia?

Severe bradycardia < 45 beats/min 
Weakness
Chest pain
Lightheadedness 
N/V
Confusion
Syncope

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Severe bradycardial rate usually increases with

Exercise

Administration of atropine

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EKG findings of heart rate less that 60
Normal and consistent P wave morphology followed by QRS complex
Normal PR interval

Indicative?

Sinus bradycardia

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Treatment for bradyarrhythmia

Rapid and primary assessments
Determine HR is less than 50bpm
Determine if stable or unstable

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Unstable patient If have

Changes in mental status 
Ischemic chest discomfort 
Hypotension
Signs of shock
Acute heart failure

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If the patient is stable? ( bradyarrhythmia)

Monitor patient
Obtain vitals
Obtain 12 lead if able, attempt to identify and treat underlying causes

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If patient is unstable ( bradyarrhythmia)

Give atropine 0.5mg IV push and repeat q 3-5 minutes for a max of 3 mg

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What works by inhibiting all vagal input into the SA node

Atropine

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Atropine does not work for patients that have undergone?

A heart transplant

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Alternate treatments of atropine is ineffective

Transcutaneous pacing

Dopamine IV infusion at 2-10mcg/kg/min

Epi IV infusion 2-10 mcg/ min

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What are the complications of bradyarrhythmia?

Atrial, junctional, and/or ventricular ectopic rhythms

AMI

Cerebral or renal ischemic

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HR faster than 100 bpm ( rapid impulse formation from the SA node)

Occurs w/ fever, exercise, emotion, pain, anemia, heart failure, pregnancy, early shock, thyrotoxicosis, alcohol withdrawal or in response to many drugs

HR exceeds 150 bpm

Sinus tachycardia

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Are abnormalities in cardiac rhythm and/ or conduction

Cardiac arrhythmias

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How are arrhythmias differentiated?

Rate ( tachy vs Brady)
QRS duration ( wide vs narrow)

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PE of cardiac arrhythmias

Lethal ( sudden cardiac arrest)

Asymptomatic to palpitations to dizziness to pre syncope to syncope

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What is a gold standard for monitoring and dx cardiac arrhythmias

ECG

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Treatments

Depends on dysthymia and patient presentation

ABCs
IV
Oxygen 
Monitor 
Antiarrhythic drugs

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Definitive treatments

Catheter ablation by cardiologist

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Complications

Decreased perfusion can lead to AMI, syncope, cardiac arrest, and/or death

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Disposition

Stabilize and MEDEVAC

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ECG findings: HR > 100 bpm P wave is followed by a QRS complex and each QRS has a P wave preceding it Normal duration ( QRS complex) Indicative of?

Sinus tachycardia

Treatment for sinus tachycardia

ABCs, monitor, IV, O2 > 94% | Treat underlying condition

If no identifiable etiology of sinus tachycardia is determined and patient is unstable then start

ACLs protocol

Comes and goes Originates above the ventricles HR > 100 bpm Often occurs in patients w/o structural heart disease Most common mechanism is reentry ( AV node reentry)

Paroxysmal supraventricular tachycardia

``` EKG findings: HR 150-240 ( common 160-220) Reg. R-R interval Narrow QRS complex P wave often buried in the narrow QRS complex ```

Paroxysmal supraventricular tachycardia

PE findings of PSVT

``` Maybe asymptomatic Associated w/ palpitations mild chest pain or SOB Episodes begin and end abruptly May cause syncope May cause AMI ```

Treatments for PSVT

ABCs IV Monitor O2 > 94% Determine if stable or not Terminate attack if unstable via cardio version

What are mechanical measures for stable patients with PSVT

``` Stimulate vagus nerve and increase tone Valsalva Breath hold Dunk face in bowl of ICE cold water Carotid sinus massage ```

What interrupts up to 50% of PSVT | Firm gentle pressure over R carotid sinus for 10-20 seconds, if unsuccessful attempt over left

Carotid sinus message

What is the drug therapy for PSVT

IV agents | Adenosine 6 mg ( double the dose if first dose does not work)

Second line meds for PSVT

Metoprolol 5mg IV repeat dose q 5 minutes up to 15 mg max Or 50mg PO BID Diltiazem ( CCB) 0.25mg/kg IV over 2 minutes ( followed by a second bolus of 0.35mg/kg if needed and then start an infusion at 5 mg/h and titrate up to 15mg/hr to keep HR <100

If patient, with PSVT, is hemodynamically unstable what’s the treatment

Synchronized cardioversion ( 50-150 J )

Complications of PSVT

Myocardial dysfunction/ischemia CHF Syncope

An accessory electrical pathway or bypass tract between the atrium and the ventricle bypassing the AV node and can predispose to reentrant arrhythmias Associated with PSVT rhythm

Wolf Parkinson white syndrome

EKG findings: Short PR interval ( < 0.12 seconds) Wide, slurred QRS complex called a delta wave

Wolf Parkinson white syndrome

Patients with wolf Parkinson white syndrome and unstable perform immediate

Synchronized cardioversion 50-150 J

If stable and in PSVT you can attempt? | wolf Parkinson white syndrome

Vagal maneuvers

Meds for Wolfs Parkinson white syndrome

Adenosine Metoprolol ( same as PSVT)

Complications ( WPWS)

Myocardial dysfunction/ischemia CHF Syncope

Most common Chronic arrhythmias Prevalence increases with age

Atrial fibrillation

Multiple areas of atrial myocardium continuously discharging causing the atrium to fibrillate rather than contract in an organized manner

Atrial fibrillation

Heart rate may vary but the R-R pattern is irregularly irregular

Atrial fibrillation

What diseases have an increased of atrial fibrillation

``` Rheumatic heart disease HTN Ischemic heart disease Thyrotoxicosis Pericarditis Excess ETOH or withdrawal ( holiday heart Cardiomyopathy CHF OSA Electrolyte abnormalities esp. K and Mg Excessive caffeine intake ```

An A-Fib predisposes patients to?

Thromboembolic events

A-FIB: frequently anti-coagulant with what medications on an outpatient basis

Coumadin Rivaroxaban Apixaban

EKG readings: R-R interval is irregularly irregular Atrial rate ~400 bpm Wavy baseline ( fibrillation waves)

Atrial fibrillation

``` Palpitations Dyspnea on exertion Lightheadedness Fatigue Weakness Chest pain Symptoms for? ```

Atrial fibrillation

Up to 2/3 of patients experiencing their 1st episode of A-fib will spontaneously revert to sinus rhythm within?

24 hours

What is the treatment for atrial fib?

Goal is to focus on ventricular rate control, conversion of hemodynamically unstable AF to sinus rhythm or both

Patients with AF> 48 hours are at risk for?

Cardioembolic events and should not be cardioverted until anti-coagulated for a minimum of 3 weeks prior to attempting elective cardioversion

Atrial fibrillation treatments

ABCs, IV, Monitor, vitals, oxygen if sat <94% Assess to see if patient is unstable if so, perform synchronized cardioversion at 100-200j

Medications for AFIB

Beta blockers: metoprolol 5mg IV q 5 minutes CCB: Diltiazem 0.25 mg/kg IV over 2 minutes Anticoagulant: enoxaoarin ( lovenox) 1mg/kg SC q 12hrs ( creatinine at baseline, CBC at baseline)

Complications of AFIB

Embolic event leading to: ischemia stroke, or ischemic extremities Rapid ventricular rate leading to myocardial dysfunction or ischemia

Usually associated with pulmonary disease Originates from a localized area in the atria Predisposed to thromboembolic events

Atrial flutter

Disorders that can cause A flutter

``` Thyrotoxicosis Obesity OSA Sick sinus syndrome Pericarditis Pulmonary disease Pulmonary embolism ```

EKG findings: Saw tooth flutter waves between QRS complexes Atrial rate between 250-350 bpm AV block ( Look in TG for specifics)

A-flutter

A flutter sx

``` Palpitations Dyspnea on exertion Lightheadedness Fatigue Weakness Chest pain ```

Treatments

Focus on ventricular rate control with metoprolol or diltiazem ( however more difficult to control) If unstable ( cardioversion 100-200J)

Complications of A flutter

Embolic event in chronic flutter Myocardial ischemia Dizziness or syncope Heart failure