Peri-Arrest Rhythms Flashcards
What are causes of bradycardia?
- Sleep
- Athletes
- AV node block
- Sinus nose disease
- Vasovagal
- Hypothermia
- Hypothyroid
- Hyperkalaemia
- Beta Blockade
- Diltiazem
- Digoxin
- Amiodarone
What are adverse features of bradycardia?
- Shock - SBP < 90 mmHg
- Syncope
- HR - < 40 BPM
- MI
- Heart failure
How would you assess someone with bradycardia?
ABCDE
- Monitor SPO2 +/- oxygen if hypoxic
- Monitor ECG and BP
- Obtain IV access
- Identify and treat reversible cause
If someone with bradycardia was showing adverse features, how would you treat them?
Atropine 500 mcg IV
IF someone with bradycardia had no red flag features, what would you do?
Determine risk of asystole
- Recent asystole
- Mobitz II AV block
- Complete heart block with broad QRS
- Ventricular pause > 3s
If there was no satisfactory response to intially treating symptomatic bradycardia with atropine, how would you proceed?
Consider interim measures (any of below), then seek expert help and transvenous pacing
- Atropine 500 mcg IV repeat to max 3 mg
- Trancutaneous pacing
- Adrenaline 2-10 ug/mon IV
If someone with asymptomatic bradycardia had no risk factors for asystole, how would you proceed?
Continue observation
When would you consider second-line medication for treating bradycardia?
If bradycardia with adverse features persists despite atropine, and if pacing is unavailable
What are the causes of AF?
- Ischaemic heart disease
- Hypertension
- Valvular heart disease (esp. mitral stenosis / regurgitation)
- Acute infections
- Electrolyte disturbance (hypokalaemia, hypomagnesaemia)
- Thyrotoxicosis
- Drugs (e.g. sympathomimetics)
- Pulmonary embolus
- Pericardial disease
- Acid-base disturbance
- Pre-excitation syndromes
- Cardiomyopathies: dilated, hypertrophic.
- Phaeochromocytoma
What are high risk features of AF?
- HR > 150
- Ongoing chest Pain
- Critical perfusion/haemodynamic instability - shock, syncope, MI, heart failure
If someone was displaying high risk features of AF, what would you do?
Seek expert help
- Immediate heparin and synchronised DC cardioversion
What defibrillation setting should you begin on for synchronised DC cardioversion?
120-150J biphasic. Increase in increments if this fails
If intial DC cardioversion fails to treat AF with adverse features, what else can be done?
- Amiodarone 300 mg IV over 60 minutes, followed by IV infusion 900mg over 24 hours
- Repeat shock
What are immediate risk features of AF?
- Rate 100-150
- Breathlessness
- Poor perfusion
If someone had immediate risk features of AF, what would you want to establish?
Are there features of haemodynamic compromise +/- known structural heart disease
When are patients with unstable AF most at risk of develop embolic complications?
>48 hours after onset
If someone was not displaying haemodynamic disruption or adverse features of AF, but was symptomatic with AF, what would you want to know?
How long it had been since onset? (>48hours?)
If someone with AF was not displaying features of haemodynamic instability, and it had been <48 hours, how would you manage them?
- Give oxygen if needed
- Assess for heart failure
- Consider ECHO - look for TE
- Treat based on “48 hr window” and presence of TE
- Determine thromboembolism and bleeding risks
How would you attempt to chemically cardiovert someone with AF?
Flecanide 100-150 mg IV over 30 minutes
or
Amiodarone 300 mg over 1 hr
If someone with AF was haemodynamically stable but had been experiencing AF for >48 hours, how would you manage them?
Initial rate control
- B-blockers
- Verapimil/Diltiazem
- Digoxin
TOE + Consider Anticoagulation
- DOAC
- Heparin, followed by Warfarin
DC CArdioversion after 3 weeks anticoagulation
If someone had narrow complex tachycardia, was pulseless and had a rate >250 BPM, how would you manage them?
Synchronised DC cardioversion
If someone had a narrow complex tachycardia that was regular and showing no adverse features, how would you manage them?
- Give oxygen and monitor SpO2
- Obtain IV access
- ECG monitoring + BP
- Vagal manouvres
- Adenosine 6 mg rapid bolus - followed by 12 mg every 2-3 mins if unsuccsessful
If someone with narrow complex tachycardia was given adenosine, and sinus rhythm was not restored, what would you do?
Seek expert help
How would you initially manage a broad complex tachycardia?
- IV access
- Oxygen
- Assess for pulse
If there was no pulse with a broad complex tachycardia, how would you manage the situation?
As per VF protocol
If someone had broad complex tachycardia with no adverse signs, how would you manage them?
Assess potassium - intervene if low
Medication administration
- Amiodarone 300 mg IV over 10mins
- Lidocaine IV 50 mg over 2 minutes, every 5 minutes up to 200 mg
If someone with broad complex tachycardia with a pulse was showing signs of haemodynamic instability, how would you manage them?
Seek expert advise
- Synchronised DC cardioversion
- Treat potassium if low
- Amiodarone 150 mg IV over 10 mins
If someone with broad complex tachycardia with a pulse had low potassium, what would you do?
- Give KCl up to 60 mmol
- Give Magnesium sulphate IV 5ml 50% in 30 minutes
How would you approach managing SVT with BBB?
Similarly to treating regular, narrow complex tachycardia
