chapter 11

Question 1

management for broad complex irregular tachycardia ?

Answer 1

polymorphic VT (eg torsa de pointes ) = magnesium 2g over 10 mins
correct electrolyte abnormalities - eg hypokalaemia
strop drugs which prolong QT

expert help for overriding pacing

Question 2

management of broad complex regular VT or uncertain rhythm

Answer 2

amiodarone 300mg IV over 10-60 mins
followed by 900 mg over 24 hours

if persists - synchronised cardioversion

Question 3

management of regular narrow complex regular tachycardia ?

Answer 3

vagal manuevers

if ineffective - adenosine 6mg IV rapid bolus
if unsuccessful 12 mg
if unsuccessful then 18mg

if ineffective
verapamil 2.5-5mg IV over 2 min
or beta blocker - metoprolol 2.5-15mg IV bolus

Question 4

management of irregular narrow complex tachycardia ?

Answer 4

irregular narrow complex tachycardia - most likely AF

offer rate or rhythm control if the onset of the arrhythmia is less than 48 hours, and start rate control if it is more than 48 hours or is uncertain.

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rate control :

beta blocker

digoxin / amiodarone

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rhythm control

1st choice - electrical cardioversion
Gradually increasing strengths of direct current shock (synchronized with the R wave) are administered under procedural sedation until sinus rhythm is restored

2nd choice - pharmacological cardioversion with antiarrythmic drugs such as flecainide
propafenone
ibutilidie
do not use these in HF , left ventricular impairment, IHD , prolonged QT interval

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anticogulate if duration more than 48 hours

Question 5

shocks for unstable tachycardia ?

Answer 5

broad complex = 120-150J start and increase in increment if fails

atrial fib - highest energy output , also use AP lead position
pharmacological (e.g.
Inpatient regimens using intravenous or oral antiarrhythmics:
Dofetilide
Ibutilide
Flecainide

atrial flutter and supra ventricular tachycardia = 70-120J
atrial flutter-use AP lead position

Question 6

origin of broad complex tachycardia ?

Answer 6

ventricular
supra ventricular with bundle branch block

Question 7

what is an exception to the non shockable branch of ALS algorithm

Answer 7

very narrow complex tachycardia can impair cardiac output
pulse may be implacable
and consciousness impaired

this situation is PEA - start CPR and will give synchronised shock

Question 8

treatment of having AF for more than 48 hours ?

Answer 8

should not be treated for cardioversion chemical or electrical until fully anticogulated for atleast 3 weeks
or trans oesophageal echo has indicated no atrial thrombus

clinical situation dictates cardioversion = LMH
IV bolus of unfracyioned heparin followed by continuous infusion to maintain APTT at 1,5-2 times the reference value

continue hearing therapy and commence anticoagulation after successful cardioversion

duration of anticoag after successful cardioversion should be minimum 4 weeks

Question 9

bradycardia causes ?

Answer 9

physiological = athletes

cardiac organ - AV block

non cardiac = vasovagal , hypothermia , hypothyroidism , hyperkalemia

drug induced = beta blocker , diltiazem , digoxin

Question 10

brady cardia tx?

Answer 10

atropine 500mcg IV - repeat every 3-5 min until max of 3mg reached
or isoprenaline
adrenaline 2-10mcg/min
o dopamine

if bradycardia unstable - pacing

Question 11

tx if bradycardia caused by beta blocker and or calcium channel blocker

Answer 11

IV glucagon

Question 12

bradycardia complicating acute inferior wall myocardial infraction / spinal cord injury/ cardiac transplantation

Answer 12

amino-byline 100-200mg by slow iv injection

Question 13

contra for atropine ?

Answer 13

heart transplants