Cardiology: Peri-Arrest Rhythms Flashcards

1
Q

What is the management of bradycardia depend centered around?

A

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

2) Identifying the potential risk of asystole

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2
Q

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

A

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

2) syncope

3) myocardial ischaemia

4) HF

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3
Q

1st line management of extreme bradycardia with adverse signs?

A

Atropine (500mcg IV)

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4
Q

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

A

Up to 3mg

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5
Q

Stepwise management of severe bradycardia with adverse signs?

A

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)

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6
Q

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

A

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

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7
Q

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

A

1) complete heart block

2) recent asystole

3) Mobitz type II AV block

4) ventricular pause > 3 seconds

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8
Q

What is the approach to adult tachycardia?

A

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.

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9
Q

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

A

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

2) syncope

3) myocardial ischaemia

4) severe HF

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10
Q

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

A

Synchronised DC shocks (up to 3).

After this, seek expert help.

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11
Q

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

A

Up to 3

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12
Q

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

A

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

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13
Q

Management of ventricular tachycardia?

A

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

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14
Q

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

A

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

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15
Q

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

A

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

2) AF with ventricular pre-excitation

3) torsades de points

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16
Q

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

A

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

17
Q

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

A

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)

18
Q

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

A

Probable AF

19
Q

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

A

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

20
Q

What are the 2 ‘shockable’ rhythms?

A

1) VF

2) Pulseless VT

21
Q

What are the 2 non shockable rhythms?

A

1) asystole

2) pulseless-electrical activity (PEA)

22
Q

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

A

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

23
Q

What is the ratio of chest compressions to ventilation?

A

30:2

24
Q

How should drugs be delivered in ALS?

A

IV access should be attempted and is first-line

25
Q

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

A

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

26
Q

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

A

Adrenaline 1mg

27
Q

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

A

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

28
Q

How often should adrenaline be given in cardiac arrest?

A

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

29
Q

What are the reversible causes of cardiac arrest?

(the H’s and the T’s)

A

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

30
Q

When is amiodarone given in cardiac arrest?

A

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

31
Q

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

A

Lidocaine

32
Q

Contraindications of adenosine?

A

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

33
Q

Side effects of adenosine?

A

1) flushing

2) chest pain

3) dyspnoea

4) sense of impending doom

34
Q

What is alternative to IV adenosine in asthmatics?

A

Verapamil

35
Q

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

A

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

36
Q

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

A

1st: vagal manoeuvres

2nd: adenosine in a rapid IV bolus (6mg –> 12mg –> 18mg)

3rd: if adenosine contraindicated –> give verapamil

37
Q

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

A

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.

38
Q
A