Ward 12 (guidelines)

Question 1

What is a bolus?

Answer 1

A single dose of a drug or other substance given over a short period of time. It is usually given by infusion or injection into a blood vessel

Question 2

What is bradycardia defined as?

Answer 2

heart rate <60bpm

Question 3

Symptoms of bradycardia?

Answer 3

• Often asymptomatic. Fatigue, nausea, dizziness.
• The presence of syncope,
  chest pain, or breathlessness is concerning and suggests the presence of adverse signs; sudden cardiac death can occur

Question 4

Possible underlying rythms in bradycardia

Answer 4

• Sinus bradycardia
• Heart block
• AF with a slow ventricular response
• Atrial flutter with a high-degree
  block
• Junctional bradycardia.

Question 5

What can causes of bradycardia be divided into?

Answer 5

• Cardiac
• Non-cardiac
• Physiological
• Drug induced

Question 6

Physiological causes of bradycardia

Answer 6

Heart rates as low as 40bpm at rest and 30bpm in sleep can be accepted
in asymptomatic trained athletes

Question 7

Cardiac causes of bradycardia

Answer 7

• Degenerative changes causing fi brosis of conduction pathways (risk in elderly
  patients; may have previous ECGs showing bundle branch block or 1st- or 2nd degree heart block).
• Post-MI—particularly after an inferior MI (the right coronary artery supplies the
  sinoatrial node and atrioventricular node in most people).
• Sick sinus syndrome
• Iatrogenic—ablation, surgery.
• Aortic valve disease, eg infective endocarditis (do daily ECGs looking for
  heart block).
• Myocarditis, cardiomyopathy, amyloid, sarcoid, SLE.

Question 8

Non-cardiac causes of bradycardia

Answer 8

• Vasovagal—very common
• Endocrine—hypothyroidism, adrenal insufficiency.
• Metabolic—hyperkalaemia, hypoxia.
• Other—hypothermia, Increased intracranial pressure

Question 9

Symptoms of increased intracranial pressure

Answer 9

Cushing’s triad: bradycardia, hypertension, and irregular
breathing: –> urgent senior input needed

Question 10

Drug induced causes of bradycardia

Answer 10

Beta-blockers, amiodarone, verapamil, diltiazem, digoxin

Question 11

Important thing to consider in a bradycardic patient

Answer 11

It is possible to have two patients sat next to each other with identical bradycardic ECG tracings, one of whom is peri-arrest, the other is sat comfortably and cannot
understand your concern. The clinical state is more important than the numbers on the screen

Question 12

Management of bradycardia

Answer 12

Follow a logical approach (see pic)
- Think ahead: If you may need an anaesthetist to sedate the patient for transcutaneous pacing, or a cardiologist for transvenous pacing, call them now.
- Perform a 12-lead ECG, check electrolytes (including K+, Ca2+, Mg2+), do digoxin levels.
- Connect patient to cardiac monitor/telemetry.
- Address the cause: correct metabolic defects; if the patient has adverse signs or is deteriorating, give antidotes to medicines likely to have caused the bradycardia.
- If the patient has adverse signs or risk of asystole, give atropine
- If atropine is insufficient and adverse signs persist, transcutaneous pacing should be considered. If this cannot be initiated immediately (eg waiting for an
anaesthetist), consider other medications such as isoprenaline infusion.
- Remember electrical ‘capture’ with transcutaneous pacing does not guarantee mechanical
‘capture’.
- Once pacing is established, check the patient’s pulse.

Question 13

Beta blocker overdose medication

Answer 13

Glucagon

Question 14

When should atropine not be given in bradycardia?

Answer 14

Not to be given if patient has a transplanted heart

Question 15

Bradycardia caued by calcium channel blocker antidote

Answer 15

IV Calcium

Question 16

Bradycardia caused by digoxin overdose antidote

Answer 16

Anti-digoxin Fab

Question 17

What is tachycardia?

Answer 17

Hearth rhythm greater than 100