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Bachelor of Paramedic Science > Electrophysiology > Flashcards

Electrophysiology Flashcards

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1
Q

anatomical location of the heart

A

in the front of the chest, slightly behind and to the left of the sternum

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2
Q

3 layers of the heart

A
  1. endocardium (inner)
  2. myocardium (middle)
  3. pericardium (outer)
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3
Q

Gross Anatomy of the Heart

A
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4
Q

Blood Flow Through the Heart

A

deoxygenated blood from vena cava into the right atrium, through tricuspid valve into right ventrical, through pulmonary semi-lunar valve into pulmonary arteries into the lungs, oxygenated blood travels through pulmonary veins into left atrium through bicuspid/mitral valve into left ventrical

then pumped through the aortic semi-lunar valve into the aorta

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5
Q

Steps in the Cardiac Cycle

A
  1. Atrial diastole - atrial fill, all valves closed, increasing atrial pressure opens AV valves, ventricals fill
  2. Atrial systole begins - atria contract, ventricles are full
  3. Early ventricular systole - ventricles begin contraction, pressure closes AV valves, atria relax
  4. Ventricular systole - ventricles contract, increased pressure in ventricles, aortic and pulmonary valves open, blood ejected into aorta and pulmonary artery
  5. Ventricular diastole - ventricles empty, ventricles relax, aortic and pulmonary valves close
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6
Q

Normal Conduction Pathway of Electrical Activity Through the Heart

A

electrical impulses are initiated in the sinoatrial node (SA node), conducted through both atria, and directed to the atrioventricular node (AV node). Transmission of the signal to the ventricles is delayed, allowing them to completely fill with blood. Depolarization continues toward the apex of the heart through the bundle of His and the left and right bundle branches, and terminate in the Purkinje fibers. As the electrical impulses reach the myocardium, the muscle cells depolarize and contract.

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7
Q

Phases of Cardiac Action Potential

A

Phase 0: Depolarisation (systole) - Fast Na+ & slow Ca++ influx causes rapid depolarisation and contraction

Phase 1: Notch - K+ channels open briefly to partially repolarise the cell

Phase 2: Plateau - Slow repolarisation with K+, Ca++, Na+ & Cl-exchange

Phase 3: Rapid Repolarisation - Ca++ influx close; K+ efflux continues to repolarise the cell

Phase 4: Baseline (diastole) - K+/Na+ pumps maintain equilibrium

  • Long absolute refractory period in cardiac muscles cells phase 0 to phase 3
  • Second action potential cannot be initiated
  • Protective mechanism against tetanus (state of maximal contraction)
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8
Q

Pacemaker Sites Within The Heart

A

Sinoatrial (SA) Node - right upper chamber of the right atria - 60-100 fires per minute

Atrioventricular (AV) Node - Koch triangle, near the coronary sinus on the interatrial septum - 46-60 fires per minute

Bundle Branches/Purkinje Network - interventricular septum/sub endocardium - <40 fires per minute

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9
Q

General Discontinuation Criteria

A
  • CPR for no less than 20 continuous minutes
    -And ALL the following criteria are met
    • No ROSC at any stage
    • Cardiac arrest not witnessed by QAS personnel
    • No shockable rhythm at any stage

NB : If the above criteria are not met QAS Clinical Consultation and Advice Line must be contacted

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10
Q

Rapid Discontinuation Criteria

A
  • CPR may be withdrawn before 20 minutes if ALL criteria are met:
    • Patient unresponsive and pulseless for >10 min prior to ambulance arrival
    • No bystander CPR during this period
    • Signs of life extinct
    • Asystole or Broad complex PEA <40bpm
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11
Q

Recognition of Life Extinct/Verification of Death

A
  • No palpable pulse
  • No heart sounds heard for 30 continuous seconds
  • No breath sounds heard for 30 continuous seconds
  • Fixed and dilated puils
  • No response to centralised stimuli
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12
Q

Correct CPR Technique

A

Hand placement
* Lower half of sternum

Depth
* 1/3 chest or 5cm

Rate
* 100-120
* Equal time compress and release

Compression:ventilation ratio
* 30:2 (adult and single officer child)
* 15:2 (multiple officers - Child)

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13
Q

Defibrillation Safety Checks

A
  • Non Conductive
  • Non Explosive
  • No Movement
  • No Contact
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14
Q

ROSC Management

A
  • ABC
  • 12 lead ECG
  • Treat presenting dysrhythmias
  • Consider and manage reversible causes
  • Maintain SpO2 ≥94%
  • Consider advanced airway (Igel or LMA)
  • Maintain EtCO2 of 30-40mmHg
  • If no EtCO2 ventilate at rate of 8-12 p/minute
  • Do not hyperventilate
  • Aim for SBP ≥100mmHg for adults and ≥80mmHg for children
  • Transport to hospital
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15
Q

Aims of ROSC Management

A

respiratory support

maintain cerebral perfusion

treat and prevent cardiac arrhythmias

determine and treat cause of arrest

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16
Q

Recognition of Cardiac Arrest/CPR ICC

A

Cardiopulmonary Resuscitation (CPR)

Indications
There are no signs of life:
• Unresponsive
• Not breathing normally
• Carotid pulse cannot be confidently palpated within 10 seconds OR
There are signs of inadequate perfusion:
• Unresponsive
• Pallor or central cyanosis
• Inadequate pulse, evidenced by:
• Less than 40 BPM in an adult or child 1 year or older
• Less than 60 BPM in an infant less than 1 year old
• Less than 60 BPM in a newly born (following ventilations)

Contraindications
• Nil in this setting

Complications
• Using the presence or absence of a pulse as the primary indicator of cardiac arrest is unreliable
• Injury to the chest may occur in some patients.

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17
Q

Why does an inferior STEMI/STEAC present pale, diaphoretic, vomiting, possibly with AV block and bradycardic?

A

pale due to lack of perfusion

diaphoresis due to activation of sympathetic nervous system

vomiting due to vagus nerve activation

AV block and bradycardia due to lack of perfusion to AV node

18
Q

How could an anterior STEMI/STEAC cause APO?

A

catecholamine (adrenaline or noradrenaline) release causes vasoconstriction, increased HR and increased systemic vascular resistnace which impedes emptying of left ventricle and fluid backs up into lungs

19
Q

Why would an occlusion of the left anterior descending be called a widow maker?

A

it supplies blood and oxygen to the big portion of the larger, front part of the heart

20
Q

What is the pathophysiology of CPAP?

A
  • increases intrathoracic pressure, compressing inferior and superior vena cava and decreases venous return
  • Decreases Afterload and cardiac workload
  • Improves oxygenation
  • Recruits (reinflates) and splints alveoli that were previous collapsed and tiny bronchioles open
21
Q

4 Priorities in Cardiac Arrest

A
  1. Early recognition and call for back-up
  2. Early effective CPR with effective chest compressions
  3. Rapid defibrillation, if indicated
  4. Post ROSC cares
22
Q

Indications for Defibrillation

A

A patient who is in cardiac arrest who presents with:

  • Ventricular Fibrillation; or
  • Pulseless Ventricular Tachycardia
23
Q

Contraindications for cardiac arrest defibrillation

A

non-shockable rhythms:

asystole (shock if unsure if fine VF or asystole)

pulseless electrical activity (PEA)

perfusing rhythms

patients with no signs of life

24
Q

Surface of the Heart Viewed

A

Hi Lateral - I, aVL

Inferior - II, III, aVF

Septal - V1, V2

Anterior - V3, V4

Lateral - V5, V6

25
Q

3 Stages of the clotting cascade

A

Stage 1 - platelets attach to the endothelium

Stage 2 - platelets start to release fibrin and begin to seal the endothelium

Stage 3 - the gibrin network traps teh RBC and completely seal the endothelium

26
Q

Fibrinolysis Pathophysiology

A

converts plasminogen into its active form plasmin, degrading fibrin components (mesh) of a thrombus

27
Q

What is PCI (percutaneous coronary intervention)?

A

nonsurgical technique for treating obstructive coronary artery disease

28
Q

What is pPCI?

A

taking a STEMI Pt directly to the cardiac cath lab (within 1st 90 mins)

29
Q

What are the pPCI indications?

A

Must be considered for all adult pts who meet the following criteria:

  • Proximity to a pPCI facility
    • <60mins transport time (from time of first STEMI 12-lead ECG) to a QAS approved hospital
  • Pt assessment:
    • GCS =15 AND
    • classic ongoing ischaemic chest pain less than 12hrs in duration
  • 12-lead ECG consistent with STEMI:
    • Persistent ST elevation; AND
    • normal QRS width; OR
    • RBBB
30
Q

What are the pPCI decision steps?

A
  • treat the ACS
  • identify STEMI
  • call for back-up
  • choose your pathway based on suitability
  • go through the initiate othe pPCI checklist
  • look to see the defib identifies STEMI (your decision support)
  • have scrpit ready and call teh interventional cardiologist
  • confirm you have the correct hospital
31
Q

What is this rhythm?

A

Junctional Rhythm

32
Q

What is this rhythm?

A

Idioventricular

33
Q

What are the decision supported fibrinolysis administration indications?

A
  • Pt located more than 60 minutes transport time (from first STEMI 12-Lead) to a pPCI capable hospital
  • GCS = 15
  • Classic ongoing ischaemic chest pain less than 6 hours in duration (excluding atypical ischaemic chest pain)
  • 12-Lead consistent with STEMI
34
Q

What are the decision supported fibrinolysis administration contraindications?

A
  • <18 or 75 or older
  • Uncontrolled hypertension (SBP > 180 mmHg AND/OR
  • DBP > than 110 at any stage during current acute episode)
  • Allergy to tenecteplase, enoxaparin or clopidogrel
  • Left BBB
  • Current or history of thrombocytopenia
  • Active tuberculosis
  • Known cerebral disease, in particular a malignant intracranial neoplasm OR arteriovenous malformation
  • Prior intracranial haemorrhage
  • Ischaemic stroke OR TIA within the last 3 months
  • Hx of significant closed head or facial trauma within last the 3 months
  • Suspected aortic dissection (including new neurological symptoms)
  • Hx of major trauma or surgery (including laser eye surgery) within the last 6 weeks
  • Internal bleeding (e.g. GI or urinary tract bleed) within the last 6 weeks (excluding menses)
  • Bleeding or clotting disorder (e.g. haemophilia)
  • Current use of anticoagulants (e.g. apixaban, dabigatran,
  • rivaroxaban, warfarin)
  • Non-compressible vascular punctures
  • Prolonged (greater than 10 minutes) CPR.
  • Known pregnancy or delivered within the last 2 weeks
  • History of serious systemic disease
  • (advanced/ terminal cancer, severe liver or kidney disease)
  • Resident of an aged care facility requiring significant assistance with activities of daily living
  • Acute myocardial infarction in the setting of trauma
35
Q

What are the decision supported fibrinolysis administration complications?

A

Life-threatening stroke
Haemorrhage
Failure to achieve reperfusion

36
Q

What are the decision supported fibrinolysis administration steps?

A
  • Request Code 1 CCP backup
  • STEMI
  • Complete decision supported fibrinolysis checklist and confirm Pt meets criteria
  • Consult clinical consult and advice line
  • Patient informed consent obtained for tenecteplase, enoxaparin, and clopidogrel administration and checklist signed
  • Administer medications
  • If Pt has contraindications treat as per relevant QS CPG and transport Code 1
  • Consult line will notify retrieval services coordinator
37
Q

What are the decision supported pPCI referral contraindications?

A
  • Hx of serious systemic disease (e.g. advanced/terminal cancer, severe liver or kidney disease)
  • Suspected aortic dissection (including new neurological symptoms)
  • Aged care facility resident requiring significant assistance with activities of daily living
  • Myocardial infarction in the setting of acute trauma
38
Q

What are the decision supported pPCI referral indications?

A
  • Patient is located less than 60 minutes transport time
  • (first STEMI 12-Lead) to a pPCI hospital.
  • GCS = 15
  • Classic ongoing ischaemic chest pain less than 12 hours
  • in duration. Excluding atypical chest pain
  • 12-Lead ECG consistent with STEMI
39
Q

What are the decision supported pPCI referral complications?

A

haemorrhage

40
Q

What are the decision supported pPCI referral steps?

A
  • Request Code 1 CCP backupSTEMI
  • Complete QAS decision supported pPCI checklist and ensure Pt meets criteria
  • Patient informed consent obtained for heparin AND EITHER ticagrelor OR clopidogrel administration and have Pt sign checklist
  • At the earliest opportunity contact appropriate pPCI facility
  • Confirm with the interventional cardiologist their preferred antiplatelet agent (ticagrelor OR alternative) and requested heparin dose
  • If Pt not accepted, treat as per relevant CPG
  • Transport code 1 to hospital

Bachelor of Paramedic Science (19 decks)

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