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Immediate Life Support and Critical illness > Peri-Arrest Rhythms > Flashcards

Peri-Arrest Rhythms Flashcards

1
Q

What are causes of bradycardia?

A
  • Sleep
  • Athletes
  • AV node block
  • Sinus nose disease
  • Vasovagal
  • Hypothermia
  • Hypothyroid
  • Hyperkalaemia
  • Beta Blockade
  • Diltiazem
  • Digoxin
  • Amiodarone
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2
Q

What are adverse features of bradycardia?

A
  • Shock - SBP < 90 mmHg
  • Syncope
  • HR - < 40 BPM
  • MI
  • Heart failure
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3
Q

How would you assess someone with bradycardia?

A

ABCDE

  • Monitor SPO2 +/- oxygen if hypoxic
  • Monitor ECG and BP
  • Obtain IV access
  • Identify and treat reversible cause
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4
Q

If someone with bradycardia was showing adverse features, how would you treat them?

A

Atropine 500 mcg IV

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5
Q

IF someone with bradycardia had no red flag features, what would you do?

A

Determine risk of asystole

  • Recent asystole
  • Mobitz II AV block
  • Complete heart block with broad QRS
  • Ventricular pause > 3s
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6
Q

If there was no satisfactory response to intially treating symptomatic bradycardia with atropine, how would you proceed?

A

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
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7
Q

If someone with asymptomatic bradycardia had no risk factors for asystole, how would you proceed?

A

Continue observation

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8
Q

When would you consider second-line medication for treating bradycardia?

A

If bradycardia with adverse features persists despite atropine, and if pacing is unavailable

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9
Q

What are the causes of AF?

A
  • 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
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10
Q

What are high risk features of AF?

A
  • HR > 150
  • Ongoing chest Pain
  • Critical perfusion/haemodynamic instability - shock, syncope, MI, heart failure
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11
Q

If someone was displaying high risk features of AF, what would you do?

A

Seek expert help

  • Immediate heparin and synchronised DC cardioversion
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12
Q

What defibrillation setting should you begin on for synchronised DC cardioversion?

A

120-150J biphasic. Increase in increments if this fails

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13
Q

If intial DC cardioversion fails to treat AF with adverse features, what else can be done?

A
  • Amiodarone 300 mg IV over 60 minutes, followed by IV infusion 900mg over 24 hours
  • Repeat shock
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14
Q

What are immediate risk features of AF?

A
  • Rate 100-150
  • Breathlessness
  • Poor perfusion
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15
Q

If someone had immediate risk features of AF, what would you want to establish?

A

Are there features of haemodynamic compromise +/- known structural heart disease

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16
Q

When are patients with unstable AF most at risk of develop embolic complications?

A

>48 hours after onset

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17
Q

If someone was not displaying haemodynamic disruption or adverse features of AF, but was symptomatic with AF, what would you want to know?

A

How long it had been since onset? (>48hours?)

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18
Q

If someone with AF was not displaying features of haemodynamic instability, and it had been <48 hours, how would you manage them?

A
  • 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
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19
Q

How would you attempt to chemically cardiovert someone with AF?

A

Flecanide 100-150 mg IV over 30 minutes

or

Amiodarone 300 mg over 1 hr

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20
Q

If someone with AF was haemodynamically stable but had been experiencing AF for >48 hours, how would you manage them?

A

Initial rate control

  • B-blockers
  • Verapimil/Diltiazem
  • Digoxin

TOE + Consider Anticoagulation

  • DOAC
  • Heparin, followed by Warfarin

DC CArdioversion after 3 weeks anticoagulation

21
Q

If someone had narrow complex tachycardia, was pulseless and had a rate >250 BPM, how would you manage them?

A

Synchronised DC cardioversion

22
Q

If someone had a narrow complex tachycardia that was regular and showing no adverse features, how would you manage them?

A
  • 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
23
Q

If someone with narrow complex tachycardia was given adenosine, and sinus rhythm was not restored, what would you do?

A

Seek expert help

24
Q

How would you initially manage a broad complex tachycardia?

A
  • IV access
  • Oxygen
  • Assess for pulse
25
If there was no pulse with a broad complex tachycardia, how would you manage the situation?
As per VF protocol
26
If someone had broad complex tachycardia with a pulse, what would you want to do?
Assess for adverse signs * **SBP \< 90 mmHg** * **Chest Pain** * **Heart failure** * **HR \> 150 bpm**
27
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**
28
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**
29
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**
30
Under what conditions is DC cardioversion performed in a peri-arrest situation?
Sedated or under GA
31
What is the generic approach you should take to assessing and intervening with peri-arrest arrythmias?
1. **Assess a patient using ABCDE** 2. **Note presence or absence of ‘adverse features’** 3. **Give oxygen immediately to hypoxaemic patients - adjust as per SpO2** 4. **IV cannula** 5. **ECG -** will help identify the precise rhythm 6. **Correct any electrolyte abnormalities (e.g. K+, Mg2+, Ca2+).**
32
What is a regular broad complex tachycardia likely to be?
* **VT** * **Regular SVT with BBB**
33
How would you approach managing SVT with BBB?
Similarly to treating regular, narrow complex tachycardia
34
What is the most likely cause of Irregular broad complex tachycardia?
AF with BBB
35
What are causes of irregular broad complex tachycardias?
* **AF with BBB** * **AF with ventricular pre-excitation (WPW patients)** * **Torsades de pointes**
36
How would you manage torsades de pointes VT?
* **Stop all QT prolonging drugs** * **Correct electrolyte abnormalities** * **Give magnesium sulphate 2g over 10 minutes**
37
What would you not give in torsades de pointes?
Amiodarone
38
How would you manage someone with adverse features of torsades de pointes?
Synchronised cardioversion
39
How would you manage someone with torsades de pointes who became pulseless?
Attempt defibrillation immediately
40
What are the types of regular narrow complex tachycardias that can occur?
* **Sinus tachycardia** * **AVNRT** * **AVRT** * **Atrial flutter with regular AV conduction**
41
What regular narrow complex tacycardias are usually benign?
* **AVNRT** * **AVRT**
42
When can AVNRT not be benign?
If there are additional structural heart problems/coronary disease
43
When would you not give adenosine when treating regular, narrow complex tachycardia?
If it is atrial flutter
44
How quickly should adenosine or vagal manouvres terminate AVNRT or AVRT?
Within seconds
45
What would failure to terminate regular, narrow complex tachycardia using either vagal manouvre or adenosine suggest as the cause?
Atrial flutter - unless adenosine injected too slowly/into peripheral vein
46
When might you consider chemical cardioversion when treating AF?
If duration \< 48hrs and rhythm control is deemed appropriate
47
When would you not use flecanide when chemically cardioverting someone in AF?
* **Heart failure** * **Left ventricular impairment** * **IHD** * **Prolonged QT interval**
48
What patient group should you not give atropine to to trreat bradycardia?
Cardiac transplant patients

Immediate Life Support and Critical illness (6 decks)

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