Cardiology: Peri-Arrest Rhythms

Question 1

What is the management of bradycardia depend centered around?

Answer 1

1) Identifying the presence of signs indicating haemodynamic compromise - ‘adverse signs’

2) Identifying the potential risk of asystole

Question 2

What adverse signs indicate haemodynamic compromise and hence the need for treatment in extreme bradycardia?

Answer 2

1) shock: hypotension (systolic blood pressure < 90 mmHg), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness

2) syncope

3) myocardial ischaemia

4) HF

Question 3

1st line management of extreme bradycardia with adverse signs?

Answer 3

Atropine (500mcg IV)

Question 4

What is the max dose of atropine that can be used in the management of severe bradycardia?

Answer 4

Up to 3mg

Question 5

Stepwise management of severe bradycardia with adverse signs?

Answer 5

1) atropine 500mcg IV

2) atropine 500mcg IV, repeat to maximum of 3mg

3) transcutaneous pacing

4) isoprenaline/adrenaline infusion titrated to response

5) transvenous pacing (seek expert help)

Question 6

If there is a satisfactory response to IV atropine in severe bradycardia, what is the next step?

Answer 6

Figure out is there a risk of asystole?

If yes –> go back to other intermin measures:
- atropine 500mcg IV, repeat to maximum of 3mg
- transcutaneous pacing
- isoprenaline/adrenaline infusion titrated to response
- transvenous pacing (seek expert help)

If no –> observe

Question 7

What are some risk factors for asystole in patients with severe bradycardia?

Answer 7

1) complete heart block

2) recent asystole

3) Mobitz type II AV block

4) ventricular pause > 3 seconds

Question 8

What is the approach to adult tachycardia?

Answer 8

1) ABCDE approach

2) Identify is there are any life-threatening features (adverse signs)?

3) If yes –> Synchronised DC shock up to 3 attempts

4) If no –> is the QRS narrow or broad (< or >0.12s)

5) For both broad and narrow QRS, is it regular or irregular?

Manage accordingly.

Question 9

What adverse signs indicate the need for synchronised DC shock in adult tachycardia?

Answer 9

1) shock features: hypotension, pallor, sweating, cold, clammy extremities, confusion or impaired consciousness

2) syncope

3) myocardial ischaemia

4) severe HF

Question 10

If adverse signs are present in an adult with tachycardia, what is the immediate management?

Answer 10

Synchronised DC shocks (up to 3).

After this, seek expert help.

Question 11

How many synchronised DC shocks can be given in tachycardia with adverse signs?

Answer 11

Up to 3

Question 12

If tachycardia is broad complex with REGULAR rhythm, what should you assume it is?

Answer 12

Assume ventricular tachycardia (VT) unless previously confirmed SVT with bundle branch block.

Question 13

Management of ventricular tachycardia?

Answer 13

Loading dose of amiodarone (300mg IV over 10-60 mins) followed by 24 hour infusion.

Question 14

If patient with broad complex regular tachycardia has previously confirmed SVT with bundle branch block, what is managemnet?

Answer 14

Treat as for regular narrow complex tachycardia (i.e. vagal maouevres –> adenosine –> verapamil or beta blockers –> synchronised DC shocks).

Question 15

If tachycardia is broad complex with IRREGULAR rhythm, what are the possibilities of causes?

Answer 15

1) AF with bundle branch block - most likely cause in stable patient

2) AF with ventricular pre-excitation

3) torsades de points

Question 16

If tachycardia is broad complex with IRREGULAR rhythm, what is the management?

Answer 16

Seek expert help!

If AF with BBB –> treat as for irregular narow complex (beta blocker & anticoagulate if duration >48h)

Polymorphic VT (e.g. tosades de pointes) –> IV magnesium sulphate

Question 17

If tachycardia is NARROW complex with REGULAR rhythm, what is the immediate management?

Answer 17

1st line –> vagal manoeuvres

2nd line (if ineffective) –> give adenosine:
- 6mg rapid IV volus
- if unsuccessful, give 12mg
- if unsuccessful, give 18mg

3rd line (if ineffective) –> give verapamil or beta blocker

4th line (if ineffective) –> synchronised DC shock up to 3 attempts (sedation or anaesthesia if conscious)

Question 18

If tachycardia is NARROW complex with IRREGULAR rhythm, what is the most likely cause?

Answer 18

Probable AF

Question 19

If tachycardia is NARROW complex with IRREGULAR rhythm, what is the immediate management?

Answer 19

1) control rate with beta blocker (unless contraindication e.g. asthma)

2) consider digoxin or amiodarone if evidence of HF

3) anticoagulate if duration >48h

Question 20

What are the 2 ‘shockable’ rhythms?

Answer 20

1) VF

2) Pulseless VT

Question 21

What are the 2 non shockable rhythms?

Answer 21

1) asystole

2) pulseless-electrical activity (PEA)

Question 22

Stepwise management of a patient who is unresponsive and not breathing normally?

Answer 22

1) Call resus team/ambulance

2) CPR 30:2

3) Attach defib/monitor

4) Assess rhythm

5) If shockable –> give 1 shock, immediately resume CPR for 2 mins then assess rhythm again (then repeat if needed)

6) If non-shockable –> immediately resume CPR for 2 mins then assess rhythm again

Question 23

What is the ratio of chest compressions to ventilation?

Answer 23

30:2

Question 24

How should drugs be delivered in ALS?

Answer 24

IV access should be attempted and is first-line

Question 25

If IV access cannot be achieved in ALS, what is next route?

Answer 25

then drugs should be given via the intraosseous route (IO)

Question 26

What drug should be given as soon as possible for non-shockable rhythms?

Answer 26

Adrenaline 1mg

Question 27

When is adrenaline given during a VF/VT cardiac arrest?

Answer 27

Adrenaline 1 mg is given once chest compressions have restarted after the third shock

Question 28

How often should adrenaline be given in cardiac arrest?

Answer 28

Repeat adrenaline 1mg every 3-5 minutes whilst ALS continues

Question 29

What are the reversible causes of cardiac arrest? (the H's and the T's)

Answer 29

H's: 1) Hypoxia 2) Hypovolaemia 3) Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders 4) Hypothermia T's: 1) Thrombosis (coronary or pulmonary) 2) Tension pneumothorax 3) Tamponade (cardiac) 4) Toxins

Question 30

When is amiodarone given in cardiac arrest?

Answer 30

Amiodarone 300 mg should be given to patients who are in VF/pulseless VT after 3 shocks have been administered.

Question 31

What can be used as an alternative if amiodarone is not available?

Answer 31

Lidocaine

Question 32

Contraindications of adenosine?

Answer 32

1) ASTHMA 2) COPD 3) Decompensated heart failure 4) Long QT syndrome 5) Second- or third-degree AV block 6) Sick sinus syndrome (unless pacemaker fitted) 7) Severe hypotension

Question 33

Side effects of adenosine?

Answer 33

1) flushing 2) chest pain 3) dyspnoea 4) sense of impending doom

Question 34

What is alternative to IV adenosine in asthmatics?

Answer 34

Verapamil

Question 35

Immediate management of regular narrow-complex tachycardia with haemodynamic instability?

Answer 35

DC cardioversion (should be performed under sedation or general anaesthesia)

Question 36

Immediate management of regular narrow-complex tachycardia in patients who are haemodynamically stable?

Answer 36

1st: vagal manoeuvres 2nd: adenosine in a rapid IV bolus (6mg --> 12mg --> 18mg) 3rd: if adenosine contraindicated --> give verapamil

Question 37

Immediate management of irregular narrow-complex tachycardia in patients who are haemodynamically stable?

Answer 37

This is most likely to be in the setting of atrial fibrillation, or less commonly atrial flutter with a variable atrio-ventricular block. Treat as per AF guidelines.