Cardio Quickfire 5

Question 1

Acute percarditis
a) ESC diagnostic guidelines
b) Management

Answer 1

a) 2 out of 4 of:
- Typical pericarditic pain - sharp, pleuritic, relieved by sitting forward
- Pericardial friction rub
- New widespread STE or PRD
- Pericardial effusion

b) - NSAIDs first line. Colchicine or steroids 2nd line. Generally needed for 1-2 weeks but guided by clinical picture
- Avoid strenuous exercise for 3 months

Question 2

ALS tachycardia algorithm

Synchronised DC cardioversion - https://www.youtube.com/watch?v=doCkwjHf23U

Answer 2

Initial ABCDE approach:
- Administer oxygen
- IV access, bloods, continuous cardiac monitoring, ECG

Life-threatening features (HISS - heart failure, ischaemia, syncope, shock):
- Synchronised DC cardioversion* up to 3 attempts (with sedation/anaesthesia if conscious)
- If unsuccessful, amiodarone 300mg IV over 10-20 mins. Then repeat synchronised DC shock.

*- Broad-complex - start at 120-150J biphasic and increase energy if this fails (e.g. 150 –> 250 –> 360)
- AF - start at max energy (e.g. 360J)
- Flutter/SVT - start at 70-120J biphasic and increase if this energy fails (e.g. 100 –> 200 –> 360)

No life-threatening features:
- Narrow QRS and regular (AVRT, AVNRT or flutter)
1. Vagal manoeuvres
2. Adenosine - 6mg rapid bolus, then 12mg, then 18mg
3. Verapamil or beta-blocker
4. Synchronised DC shock up to 3 attempts (

• Narrow QRS and irregular (AF):
  1. Beta-blocker to control rate - IV atenolol/ metoprolol / esmolol (Consider digoxin or amiodarone if evidence of heart failure)
  2. Anticoagulate if >48h
• Broad QRS and regular:
  1. If likely VT/undetermined -> Amiodarone 300mg IV over 10-60 mins
  2. If previous certain SVT with BBB/aberrant conduction –> treat as for regular narrow complex tachycardia
  3. If ineffective, synchronised DC shock up to 3 attempts
• Broad QRS and irregular:
  1. If likely AF with conduction block - treat as for irregular narrow complex tachycardia
  2. If likely torsades (polymorphic VT) - give magnesium 2g over 10 mins

Question 3

ALS bradycardia algorithm

Answer 3

Initial ABCDE:
- Give oxygen
- IV access, bloods, ECG, continuous cardiac monitoring

Life-threatening features (HISS - heart failure, ischaemia, syncope, shock):
- Give atropine 500mcg IV
- If atropine successful, assess risk of asystole and if no risk simply observe patient
- If unsuccessful or any risks of asystole (recent asystole, Mobitz 2 or CHB, ventricular pause >3s), consider further interim measures (prior to arranging transvenous pacing or PPM):
1. Medical - atropine 0.5mg can be repeated up to 3g max dose. Alternatives - isoprenaline, adrenaline, glycopyrrolate, aminophylline, dopamine. Also glucagon can be given in cases of beta-blocker or CCB overdose
2. Transcutaneous pacing

No life-threatening features:
- Assess risk of asystole. If risks present, proceed as above. If no risks, simply observe

Question 4

Transcutaneous pacing
a) How is it performed
b) If patient is not tolerating the pacing

https://www.youtube.com/watch?v=D1mRVVd9NRs

Answer 4

a) - Attach pads and 3-lead ECG
- Turn dial to pacing
- Set rate at 70bpm and up-titrate current from 0 to around 70mA until electrical capture (spike followed by QRS)
- When electrical capture seen, dial up a further 10mA
- Then assess for pulse which aligns with each QRS (mechanical capture)

b) - Analgesia/sedation
- Consider lower heart rate
- Consider lower current