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LMCC - Medicine > Cardiology - Rhythm Disturbances > Flashcards

Cardiology - Rhythm Disturbances Flashcards

1
Q

Discuss junctional escape and ventricular escape rhythms

A

Junctional
- rate 40-60 bpm with no or negative P wave and normal QRS
Ventricular
- rate 20-40 bpm with no P wave, widened QRS with abnormal ST segment

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2
Q

Discuss 1st degree AV block

A
  • block at AV node
  • PR interval consistent length and prolonged >200ms
  • regular RR interval
  • 1 P wave to QRS
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3
Q

Discuss second degree AV block Mobitz Type 1 (Wenkebach)

A
  • block at AV node
  • P wave constant but PR interval progressively lengthens from one beat to the next until single QRS complex is absent after which PR interval returns to initial length and cycle repeats
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4
Q

Discuss 2nd degree AV block Mobitz Type 2

A
  • block at His-Purkinje system (more serious as it can lead to complete heart block)
  • No gradual lengthening of PR interval,
  • have no QRS after P wave which may persist for >2 beats
  • may also have widened QRS
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5
Q

Discuss 3rd degree AV block

A
  • P waves an QRS complexes are independent of eachother and match at constant pace
  • regular P to P distance
  • Regular QRS to QRS distance
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6
Q

Discuss sick sinus syndrome

A
  • Bradycardia - Tachycardia syndrome where have combination of bradycardia and SVT
  • severe bradycardia with paroxysmal tachycardia (AF)
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7
Q

Discuss multifocal atrial tachycardia

A 
- each QRS preceded by P wave but irregular rhythm with >3 different P wave morphology
Causes
- COPD leading to pulmonary hypertension
- impaired or hypertrophied atrium
- digoxin toxicity
- acute coronary syndrome
- Rheumatic heart disease
Treatment
- Vagal maneuver, adenosine
- Amiodarone
- If preserved heart function then CCB (pulmonary disease excludes BB)
- if impaired heart function then diltiazem
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8
Q

Discuss AV nodal re-entrant tachycardia (AVNRT)

A
  • heart rate around 180 bpm
  • Initiated by PVC
  • P wave hidden in QRS and can be superimposed on end of QRS
  • hidden P wave at end of QRS as pseudo R in lead 1
    Presentation
  • palpitations
  • exercise tolerance low
    Treatment
  • cardioversion if unstable
  • vagal stimulation, adenosine 6mg IV
  • preserved heart function: BB (metoprolol 5mg IV), CCB or digoxin
  • impaired heart function: Digoxin, amiodarone, diltiazem 20mg IV over 2 min
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9
Q

Discuss AV re-entrant tachycardia (AVRT)

A
  • include wolfe-parkinson-white syndrome
    - short PR interval (<120ms) and prolonged QRS preceded by delta wave
    - Conduction through bundle of Kent
  • orthodromic AVRT narrow QRS followed by retrograde inverted P wave
    - PVC triggers that travels through conduction tract to AV node, this allows for narrow QRS
    - 95% of those with WPW
  • antidromic AVRT have wide QRS followed immediately by inverted P wave
    - PVC travel up to AV node and then done accessory tract
    - avoid long active AV node blockades
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10
Q

Discuss atrial flutter

A
  • rate 150 bpm

- saw toothed P wave before each QRS best seen in II, III, aVF

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11
Q

Discuss atrial fibrillation

A
  • irregularly irregular QRS complex
  • no discernible P wave
    Cause
  • ACS, CAD, CHF
  • valvular disease
  • PE, COPD
  • hyperthyroidism
  • Alcohol
  • Post-operative
    Management
  • control heart rate if >120 with Diltiazem 20mg IV, verapamil 2.5-5mg IV, metoprolol 5mg IV, amiodarone 150mg if narrow complex
  • control heart rate >120 with procainamide 30mg/min for wide complex
  • A fib <48hrs then cardiovert electrocically or with drugs
  • A fib >48hrs then three weeks of anticoagulants before and 4 weeks after cardioversion
    - will then require long term rate control with BB or CCB
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12
Q

Discuss ventricular tachycardia

A
  • wide QRS usually at rate between 100-200bpm
    • QRS is discernible and organized
  • polymorphic VT where QRS continually change in shape and rate between beats
    • Torsades de Pointes sine wave QRS due to prolonged QTc
      Cause
  • ACS
  • PVC
  • prolonged QTc
    Management
  • stable can try procainamide 20-50mg/min (max 17mg/kg) before cardioversion
  • Unstable cardioversion
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13
Q

Discuss ventricular fibrillation

A
  • chaotic irregular appearence without discrete QRS waveform
    Management
  • Shock first with 200J if biphasic or 360J if monophasic
  • High quality CPR for 2 minutes
  • Shock
  • CPR
  • Epinephrine 1mg IV after first or second shock and repeat Q3-5min
    - can use vasopressin 40u IV as alternate to epi
  • Amiodarone 300mg IV bolus
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14
Q

Differentiate between SVT with aberrancy and SVT

A

SVT with Aberrancy
- QRS morphology same as when in sinus rhythm
- responds to vagal stimulation
SVT
- history of prior MI or heart failure
- no relatonship between P waves and QRS complexes
- Concordance of QRS complexes in chest leads

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15
Q

Discuss pulseless electrical activity

A 
ECG
- rhythm displaying organized electrical activity but without pulse
Cause (5H's and 5T's)
- Hypovolemia
- Hypoxia
- Hydrogen ion-acidosis
- Hyper/hypokalemia
- Hypothermia
- Tablets (Overdose)
- Tamponade
- Tension pneumothorax
- Thrombosis coronary
- Thrombosis pulmonary
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16
Q

Discuss the causes of heart block and treatment

A

Cause
- vasovagal event
- Acute inferior MI (RCA) in 1st Degree and Type 1
- Acute MI (LDA) in 3rd degree and Type 2
Treatment
- if no serious signs and 1st degree or type 1 then observe
- if no serious signs and type 2 or 3rd degree then transcutaneous pacing
- if severe signs then atropine 0.5mg q3-5min
- transcutaneous pacing or dopamine 2-10mcg/kg/min or epi 2-10mcg/min

17
Q

Discuss when to initiate rate vs rhythm control for atrial fibrillation

A 
Rate Control
- persistent atrial fibrillation
- less symptomatic
- age >65
- hypertension
- no history of CHF
- failure with rhythm control
Rhythm Control
- paroxysmal atrial fibrillation
- new atrial fibrillation
- more symptomatic
- age <65
- no hypertension
- CHF exacerbated by AF
- failure with rate control
18
Q

Discuss first line medications for rate and rhythm control

A 
Rate Control
- target <100 bpm
- BB or CCD
- digoxin
Rhythm Control
- electrical cardioversion if unstable
- propafenone
- fleicainide
- amiodarone 100-200mg OD
- catheter ablation
19
Q

Discuss anticoagulation for atrial fibrillation

A 
CHADS2
- Congestive Heart Failure
- Hypertension
- Age >75
- Diabetes
- Stroke/TIA prior (2 points)
Severity
- 0: ASA 81-325mg OD
- 1: dabigitran or warfarin (INR 2-3) or ASA 81-325mg OD
- 2-6: dabigitran or warfarin (INR 2-3)
20
Q

Discuss Wolff-Parkinson-White syndrome

A
  • is a pre-excitation syndrome with accessory conduction path
    ECG Features
  • PR interval <120ms
  • Delta wave
  • Widening of QRS due to premature activation
  • Secondary ST segment and T wave changes
  • Tachyarrhythmia (AVRT or Afib)
    WPW and AFib
  • conduct through accessory path resulting in very fast ventricular rate
  • Wide QRS
  • Do not treat with agents that slow AV node (BB or digoxin) as may lead to VF
  • Treat with cardioversion, IV amio, electrical ablation
21
Q

Discuss Torsades de Pointes

A
  • variant of ventricular tachycardia where QRS rotates around baseline
    Prolonged QT Interval Causes
  • Congenital
  • Drugs (TCA, erythromycin, fluroquinolones, antihistamines)
  • Electrolyte disturbances (hypoK, hypoMg)
    Treatment
  • IV Magnesium
  • Temporary pacing
  • Cardioversion

LMCC - Medicine (40 decks)

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