CLASP - sudden death Flashcards
What does the following ECG show?
Sinus bradycardia - divide 300 by the numbers of squares in between the QRS complexes
Tx for bradycardia
1st: Atropine IV
2nd: Transcutaenous pacing or isoprenaline or adrenaline
What does the following ECG show?
A-fib
What type of heart block is shown here?
Mobitz type 2
What does the following ECG show?
Ventricular tachycardia
What does the following ECG show?
Ventricular fibrillation
Mx for PEA and asystole
CPR should be commenced immediately with interruptions minimised
Adrenaline 1mg IV is given in the first cycle and if a non-shockable rhythm persist, every other cycle (i.e. cycles 1, 3, 5 etc.)
Mx for V-tach and V-fib
Defibrillation and CPR
If persistent, Amiodarone 300mg IV and Adrenaline 1mg IV can be given after the third shock
Amiodarone is given as a one-off dose but Adrenaline may be repeated every other cycle following a shock (i.e. cycles 3, 5, 7 etc.)
What does the following ECG show?
Long QTc syndrome
QT interval is roughly equivalent to three to four large squares (600–800 ms). A prolonged QT interval is defined as being above 440 ms in men and 470 ms in women
Mx for acquired LQTS
Address underlying cause of LQTS (e.g. cease medications or address dyselectrolytaemia)
Mx for congenital LQTS
1st: beta-blockade (as long as no bradycardia)
2nd: ICD insertion (if risk of cardiac arrest) or cardiac pacing
What does the following ECG show?
Sinus tachycardia
Tx for sinus tachy if there are adverse signs (e.g. shock, syncope, heart failure, myocardial ischaemia)
1st line = synchronised DC cardioversion +/- amiodarone.
Tx for sinus tachy if there are no adverse signs (e.g. shock, syncope, heart failure, myocardial ischaemia) but rhythm is regular
1st line = vagal manouevres
2nd line = IV adenosine. 6mg >12mg > 18mg
3rd line = verapamil or beta-blocker
4th line = synchronised DC cardioversion
Tx for sinus tachy if there are no adverse signs (e.g. shock, syncope, heart failure, myocardial ischaemia) but rhythm is irregular
Probable atrial fibrillation and to treat with beta-blockers
If there are signs of heart failure digoxin may be trialled
If onset >48h the patient will need to be anticoagulated
What does the following ECG show?
Asystole
Reversible causes of cardiac arrest
“4Hs and 4Ts”
What does the following ECG show?
Narrow complex tachy
What does the following ECG show?
Torsades de pointes
What does the following ECG show?
Ventricular tachycardia
What does the following ECG show?
Brugada syndrome - ST elevation in V1–V3, followed immediately by a negative T wave, also known as the ‘Brugada sign
What does the following ECG show?
V-fib
What does the following ECG show?
Sinus rhythm
What does the following ECG show?
Torsades de pointes
VT vs V-fib in terms of consciousness
VT - conscious
V-fib - unconscious
What does the following ECG show?
V-tach
What does the following ECG show?
Polymorphic VT
Outline ALS/BLS
Which drugs are given during ALS in non-shockable rhythms?
Adrenaline as soon as possible
Repeat every 3-5 minutes whilst ALS continues
Which drugs are given during ALS in shockable rhythms?
Adrenaline + amiodarone once chest compressions have restarted after the third shock
Repeat adrenaline every 3-5 minutes whilst ALS continues
Repeat amiodarone after 5 shocks administered
Alternative to amiodarone in ALS/BLS?
Lidocaine
In BLS/ALS, _________ drugs should be considered if a pulmonary embolus is suspected
Thrombolytic
In ALS/BLS, if thrombolytic drugs are given, CPR should be continue for..
60-90 minutes
Metabolic acidosis and raised lactate
Sepsis
Most common cause of cardiac arrest in children are..
Respiratory - hypoxia
What does the following ECG show?
SVT
What does the following ECG show?
SVT
No discernible P waves, QRS duration 90ms
SVT
What does the following ECG show?
Torsades de pointes
Tx for Torsades de pointes
IV magnesium sulphate
Tx for acute SVT
Valsalva manoeuvre/Carotid sinus massage
IV adenosine 6mg → 12mg → 18mg (verapamil if asthmatic)
Electrical cardioversion
Tx for prevention of SVT
Beta-blockers
Radio-frequency ablation
Tx for V-tach if adverse signs (systolic BP < 90 mmHg, chest pain, heart failure)
Cardioversion
Tx for V-tach if no adverse signs (systolic BP < 90 mmHg, chest pain, heart failure)
Amiodarone through a central line
Lidocaine (use with caution in severe left ventricular impairment)
Procainamide
If drug therapy fails:
EPS
ICD
Differentiate between early (compensated) shock and late (decompensated) shock
Sepsis is characterised by..
36C - 38C
HR >90 beats/min
Respiratory rate >20/min
WBC count >12,000/mm3 or < 4,000/mm3
Neurogenic, septic, and anaphylactic shock (together are all distributive shock) will cause _________ peripheries, with the others causing _________ peripheries
Neurogenic, septic, and anaphylactic shock (together are all distributive shock) will cause warm peripheries, with the others causing cool peripheries
What can cause Torsades de pointes?
Hypocalcaemia, hypokalaemia, hypomagnesaemia, hypothermia
increased SVR (vasoconstriction in response to low BP)
Increased HR (sympathetic response)
Decreased cardiac output
Decreased blood pressure
Cardiogenic shock
Blood volume depletion e.g. haemorrhage, vomiting, diarrhoea, dehydration, third-space losses during major operations
Increased SVR
Increased HR
Decreased cardiac output
Decreased blood pressure
Hypovolaemic shock
Peripheral vascular dilatation causes a fall in SVR
Reduced SVR
Increased HR
Normal/increased cardiac output
Decreased blood pressure
Septic shock
Hypovolaemia
Cardiogenic shock
Most common cause of neutropenic sepsis?
Coagulase-negative, Gram-positive bacteria such as Staphylococcus epidermidis
Tx for neutropenic sepsis
Piperacillin with tazobactam (Tazocin) immediately
If still febrile and unwell after 48 hours then meropenem +/- vancomycin
If no response after 4-6 days then order investigations for fungal infections (e.g. HRCT)
Tx for neutropenic sepsis if anticipated they will get it (i.e prophylaxis)
Fluoroquinolone
Which shock is delivered in VF/pulseless VT?
Unsynchronized shock at 200 J
Synchronised is used in haemodynamically stable patients and can send them to VF
In cases of hypothermia causing cardiac arrest, defibrillation is less effective and only 3 shocks should be administered before the patient is…
Rewarmed to 30 degrees centigrade
Causes of Torsades de pointes
Antiarrhythmics: amiodarone, sotalol, class 1a
Tricyclic antidepressants
Antipsychotics
Chloroquine
Terfenadine
Erythromycin
Congenital causes of long QT
Jervell-Lange-Nielsen syndrome (deafness and is due to an abnormal potassium channel)
Romano-Ward syndrome (no deafness)
Drug causes of long QT
Amiodarone, sotalol, class 1a antiarrhythmic drugs
TCAs, SSRIs (citalopram)
Methadone
Chloroquine
Terfenadine
Erythromycin
Haloperidol
Ondanestron
Other causes of long QT
Hypocalcaemia, hypokalaemia, hypomagnesaemia
Acute MI
Myocarditis
Hypothermia
SAH
Long QT1 one is associated with..
Exertional syncope, often swimming
Long QT2 one is associated with..
Syncope occurring following emotional stress, exercise or auditory stimuli
Long QT3 one is associated with..
Events often occur at night or at rest
Mx of long QT
Avoid drugs which prolong the QT interval and other precipitants if appropriate (e.g. Strenuous exercise)
Beta-blockers (NOT sotalol)
ICD in high risk cases
The most common variants of LQTS are caused by defects in the alpha subunit of the slow delayed rectifier ________ channel
Potassium
A normal corrected QT interval is less than ___ms in males and ___ms in females
A normal corrected QT interval is less than 430 ms in males and 450 ms in females
The characteristic ECG findings of a lateral STEMI include…
ST elevation in the lateral leads (I, aVL, V5–V6)
Reciprocal ST depression in the inferior leads (II, III, aVF)
