MDSO Arrhythmias

Question 1

MDSO: Symptomatic Bradycardia: Meds, Dose, Procedure, Patch

Answer 1

1) Atropine 0.5 mg q 3-5 min - total max 3 mg (6 doses) - IP

2) Dopamine - 5-20 mcg/kg/min - Target MAP > 65 ; HR > 50 ; IP - - - - consider EPI (but not in MDSO)

3) TCP - rate 70, start at 10 mAmps, dial up to mechanical capture + 10% - - - with proceedural sedation

4) PROCEDURAL Sedation - 2 options:
A) Midaz 0.05 mg/kg + Fentanyl 1 mcg/kg - - - MP (ACP>)
B) *** MAP > 65 —-> Ketamine 0.1 mg/kg - MAX 0.5 mg/kg. …..OR. Midaz + Fentanyl as above (IP as CCP

Question 2

Causes of Bradycardia: - 6

Answer 2

Ischemia, Toxins, Electrolytes, Hypothermia, OD, BRASH

Question 3

BRASH ?

Answer 3

Bradycardia, Renal Failure, AV Nodal Bockade, Shock, Hyperkalemia

Ex CCB or BBlockers accumulation due to renal insufficiency - which causes Hyper K (BB mediated) and more effect on rate of heart (CCB, BBlocker) - which caused more renal insufficiency

Question 4

MDSO Symptomatic Atrial Fib/Flutter:

Treatment:n ?

Answer 4

Synchronized Cardioversion with Proceedural Sedation/ Analgesia (can skip sedation / analgesia if peri-arrest)

1) Cardioversion

2) Proceedural Sedation CCP - IP
Ketamine 0.1 mg/kg MAX 0.5
OR
Midaz 0.05 mg/kg + Fentanyl 1mcg/kg (IF MAP > 65)

Question 5

Joules to use for Synchronized Cardioversion of A fib, A flutter (flow chart)

Answer 5

Joules are 100, 150, 200

A flutter start at 100
A fib start at 150

Question 6

When do you cardiovert A fib / A flutter ?

Answer 6

“Cardio respiratory Compromise” , HR > 150

= hypotension, acute LOA, signs of shocks,. Ischemic CP, Significant SOB +/- CHF

Question 7

MDSO : PSVT (Tachydys - but not Afib/Aflutter)

Tx:?

Answer 7

Stable (no cardio resp compromise) - -> Adenosine 6 mg, 20 mL Flush, Adenosine 12 mg , 20 mL flush

Unstable (cardio / resp compromise + Pre-arrest) - consider 1st dose of Adenosine while preparing for Cardioversion. (=pre-arrest - unable to coach vasalva)

Unstable (cardio/resp compromise , but NOT peri-arrest ) —> Vasalva, 6, 12, Cardiovert.

Question 8

MDSO: PSVT

Underlying causes to fix (Flowchart)

Answer 8

Hypovolemia
Sympathomimetic
Hypoxemia

Question 9

MDSO: Adult - VTach with Pulse (Wide Tachydysrhytmia):

Tx:

Answer 9

1) Synchronized Cardioversion +/- Proceedural Sedation
2) Proceedural Sedation: CCP: Ketamine 0.1 mg/kg, MAX 0.5 mg/kg OR Midaz 0.05mg/kg + 1 mcg/kg of Fentanyl (this second option MAP must be > 65) - - - both of these are IP
3) Amiodarone: 150 mg > 10 min, may repeat 1 x as adjunct to cardioversion (rarely given, work on treating the underlying cause - ex: low K, (Mg follows K, so treat as well) ** remember Amio is a K channel blocker **

AMIO can be a terrible choice in some rarer cases of VT - Procainamide Safer…..exact details of this / why I need to clarify.

Question 10

Cardioversion Joules for VT

Answer 10

100, 150, 200

Question 11

What other interventions for VT with pulse ?

Answer 11

From Flowchart:

O2—> Intubation if indicated
Bolus - 150 cc challenge x 2 prn
After 3rd attempt at cardioversion, consider Amiodarone 150mg > 10 min

Question 12

VT - no cardiocompromise, what do you treat with ?

Answer 12

As per flow chart…… try Amio 150 mg > 10 min

Question 13

What’s the min HR for consideration of cardioversion of VTp

Answer 13

> 150

Question 14

TRUE or FALSE:

Cardioversion may be preferable to antiarrhythmics in borderline stable patients: acute MI, WPW syndrome

Answer 14

TRUE