Peri-arrest arrhythmias

Question 1

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What are the two divisions of peri-arrest arrhythmias?

Answer 1

1. arrhythmias that may lead to cardiac arrest
2. arrhythmias that occur after initial resuscitation from cardiac arrest

Question 2

What features indicate an arrhythmia is causing instability

Answer 2

1. Shock
2. syncope
3. heart failure
4. myocardial ischaemia
5. extremes of heart rate

Question 3

What is extreme tachycardia?

Answer 3

When heart rate increases, diastole is shortened to a greater degree than systole

Question 4

What is extreme bradycardia?

Answer 4

Less than 40

Question 5

What are the treatment options available for an arrhythmia?

Answer 5

1. none
2. vagal maneovures/percussion pacing
3. pharmacological
4. electrical

Question 6

What should you remember to do after treating an arrhythmia?

Answer 6

Record an ECG

Question 7

What could an unsynchronised shock cause?

Answer 7

Could co-incide with the T wave and cause VFib

Question 8

What energy should be used in a broad-complex tachycardia needing shocked?

Answer 8

Start with 120-150J

Question 9

What energy should you use for unstable AFib needing shocked?

Answer 9

maximum defib output

Question 10

What energy is needed for atrial flutter and narrow complex tachycardia needing shocked?

Answer 10

70-120 J

Question 11

What pad position should be used for AFib/flutter needing shocked?

Answer 11

AP

Question 12

In a broad complex regular tachycardia treated with amiodarone, what are the next steps?

Answer 12

If successful then infusion of 900mg iver 24h

Question 13

What is an irregular broad-complex tachycardia most likely to be?

Answer 13

AF with BBB

Question 14

How is TDP treated?

Answer 14

• stop all drugs that prolong the QT interval
• correct electrolyte abnormalities
• give mg sulphate 2mg over 10 minutes
• get expert help
• if unstable features - shock
• If pulseless commence ALS

Question 15

What are the different regular narrow complex tachycardias?

Answer 15

• sinus tachycardia
• paroxysmal SVT
• AF with regular AV conduction

Question 16

What may the patient present like in pSVT

Answer 16

usually benign unless structural heart disease, patient may have symptoms they find frightening

Question 17

What is the atrial rate in atrial flutter?

Answer 17

About 300

Question 18

What are the different vagal maneovres?

Answer 18

• carotid sinus massage
• valsalva

Question 19

How effective are vagal maneovres?

Answer 19

They will terminate up to 1/4 of SVT

Question 20

If vagal maneovres are not successful and the rhythm is not flutter what should you do?

Answer 20

Give adenosine 6mg

Question 22

Why is a rapid narrow-complex pulseless tachycardia an exception to the ALS protocol?

Answer 22

Despite being PEA it is treatable by shock

Question 23

In general, people who have been in AF for >48 hours should not be treated with cardioversion until they have been anticoagulated for how long?

Answer 23

3 weeks

unless trans-oesophageal echo has detected no evidence of thrombus

Question 24

If the clinical situation indicates a patient who has been in AF requires urgent cardioversion what should you do?

Answer 24

Give LMWH in therapeutic dose or IV bolus of unfractionated heparin followed by an infusion to maintain the APTT at 1.5-2 times the reference control value

Question 25

What are the contraindications of propafenone and flecainide?

Drugs used in chemical cardioversion of AF

Answer 25

• heart failure
• ihd
• left ventricular impairment
• prolonged QT

Question 26

Which drugs should be avoided in cardioversion of pre-excited AF or A flutter and why?

Answer 26

• adenosine
• diltiazem
• verapamil
• digoxin

They may cause a relative increase in pre-excitation as they block the AV node

Question 27

What are the cardiac causes of bradyarrhythmia?

Answer 27

AV block or sinus node disease

Question 28

What are the non-cardiac causes of bradyarrhythmia

Answer 28

vasovagal, hypothermia, hypothyroidism, hyperkalaemia

Question 29

What are the drug induced causes of bradyarrhythmia

Answer 29

beta-blockade, diltiazem, digoxin and amiodarone

Question 30

What is usually the initial treatment in patients with adverse effects from a bradyarrhythmia?

Answer 30

Pharmacological
Pacing is used in those who have an ineffective/inadequate response and those at risk of asystole

Question 31

What should you consider if beta-blockade or calcium-channel blockade is thought to be the cause of bradycardia?

Answer 31

consider giving IV glucagon

Question 32

If digoxin is thought to be the cause of bradycardia- what should be done?

Answer 32

Consider use of digoxin specific antibody fragments

Question 33

When should aminophylline be considered?

Answer 33

In bradycardia complicating;
* acute inferior wall infarction
* spinal cord injury
* cardiac transplantation

dose= 100-200mg by slow IV injection

Question 34

Why should patients with cardiac transplants not be given adenosine?

Answer 34

Hearts are denervated and will not respond to vagal blockade by atropine, which may cause paradoxical sinus arrest or high-grade AV block

Question 35

What are the second line options for treatment of bradycardia?

Answer 35

• isoprenaline (starting at 5mcg per min)
• adrenaline (2-10mcg min)
• dopamine (2.5-10mcg kg min)