Peri-arrest arrhythmias

Question 1

What adverse features are signs of potential deterioration in an arrhythmia?

Answer 1

Shock - Low BP, Pallor, Sweating, Cold, Confusion, Low S/S

Syncope - Transient LOC

HF - Pulmonary Oedema / Raised JVP

M. Ischaemia - CP or on ECG

Extremes of HR (> 150 or < 40) (This may be less in people with severe lung disease or HF)

Question 2

What are Tx options for peri-arrest arrhythmia?

Answer 2

None

Vagal manoeuvres, Percussion pacing

Drugs

Electrical

Correct electrolyte abnormalities

Question 3

In Synchronised Shock, when is the shock delivered

Answer 3

On the R wave

Question 4

What Joules for cardioversion

Answer 4

Broad QRS or AF - 120-150J

Narrow QRS or Flutter - 70-120J

Question 5

If cardioversion fails, then what (and adverse features remain)?

Answer 5

Give amiodarone 300mg IV over 10-20 mins and attempt another shock

Then give 900mg amiodarone over 24 hours

Question 6

What is broad vs narrow complex?

Answer 6

0.12 s (3 small squares) or larger is broad - They can be ventricular or SVT with aberrant conduction like a BBB

<0.12 s is narrow

Question 7

What are the potential rhythms of irregular broad complex?

Answer 7

AF, or AF with pre-excitation like WPW, or polymorphic VT like torsade de pointes

Question 8

What are common narrow complex tachycardias?

Answer 8

ST, AVNRT, AVRT, Atrial flutter or AF

Do NOT treat ST - Treat the underlying problem

Question 9

Tx of regular narrow complex tachyarrhythmia?

Answer 9

Synchronised cardioversion if unstable

Otherwise, vagal and adenosine

You can try vagal / adenosine while defib is being prepared

Question 10

If in SVT and not flutter, adenosine is contraindicated or doesn’t work, what other drug can you try?

Answer 10

Verapamil 2.5-5mg over 2 min

Question 11

What kind of rhythm is an irregular narrow complex tachycardia?

Answer 11

AF and much less common is Atrial flutter with variable AV conduction

Question 12

If in AF for greater than 48 hours, what needs to happen before cardioversion

Answer 12

TOE or fully anticoagulated

Question 12

After cardioversion of AF, what drug therapies should be immediately started?

Answer 12

low molecular weight heparin or unfractionated heparin

Question 13

If amiodarone is used with AF, how?

Answer 13

300mg over 20-60 mins and then the 900mg over 24 hrs

Question 14

Run through the Tachy Algo

Answer 14

Question 15

Run through the Brady Algo

Answer 15

Be wary of atropine in mi / ischaemia as it can worsen damage

Question 16

What rate is brady?

Answer 16

< 60 HR

Question 17

What causes bradycardia?

Answer 17

Sleep, fitness

AV block, sinus disease, MI

Vagal, low temp, hypothyroid, hyperk+

Beta block, diltiazem, digoxin, amiodarone

Question 18

When to be weary with atropine?

Answer 18

MI or ischaemia

Do not give atropine to heart transplant patients - hearts are denervated - causing sinus arrest or AV block

Question 19

If torsades, what tx

If adverse features, then what

If pulseless, then what

Answer 19

Stop all qt prolongation drugs

Correct electrolytes (esp hypokalemia)

Consider mgso4 2g over 10 minutes

Seek expert help and sync cardioversion

If pulseless, defib immediately

Question 20

If the patient is narrow complex tachy but with no pulse

Answer 20

This is an exception to pea rules
Gets immediate synchronised shock at 200j or if not possible just defib