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ARRYTHMIAS FOR FINALS Dr S. Moosa FY1CONTENTS ▪ Important ECGs ▪ SBAs for arrythmias 1. Cardiac Arrest 2. Narrow Complex Tachycardia 3. Broad Complex Tachycardia 4. Heart blockA 54-year-old male on the ward has a cardiac arrest. You start compressions and the resuscitation team are contacted. Assessment of the rhythm shows ventricular tachycardia (VT). Three cycles of CPR are performed and successive shocks given. After the third shock which two medications are indicated in the ALS protocol? A. Amiodarone 300mg and adrenaline 100mg B. Amiodarone 300mg and adrenaline 10mg C. Amiodarone 300mg and adrenaline 1mg D. Amiodarone 300mg and adrenaline E. Lidocaine 1mg and adrenaline 10mgThe cardiac arrest team is called to the bedside of a 67-year-old male patient, 2 days post-myocardial infarction. Two nurses are currently performing chest compressions and a manual defibrillator has just been attached. Chest electrical activity is observed.so that the rhythm can be analysed: pulseless Given the above, which of the following should happen in this scenario? A. Adrenaline should be commenced after the first shock B. Adrenaline should be commenced immediately C. Adrenaline should be given after the third cycle D. Amiodarone should be commenced after the first shock E. Amiodarone should be commenced immediatelyA 58 year old man is rushed into the Emergency Department via ambulance. He was found unresponsive on the roadside. No further information was available. The following is the ECG. What is the rhythm? A. Ventricular fibrillation B. Ventricular Tachycardia C. PEA D. Wolff Parkinsons white E. Atrial fibrillation SHOCKABLE VS NON-SHOCKABLE RYTHMS Cardiac Arrest Rhythms These are the four possible rhythms in a pulseless patient. They are either shockable (meaning defibrillation may be effective) or non- shockable (meaning defibrillation will not be effective). Shockable rhythms: • Ventricular tachycardia • Ventricular fibrillation Non-shockable rhythms: • Pulseless electrical activity (all electrical activity except VF/VT, including sinus rhythm without a pulse) • Asystole (no significant electrical activity)ProtocolNARROW COMPLEX TACHYCARDIAYou are asked to urgently review a 61-year-old female on the cardiology ward due to difficulty in breathing. On examination, she has a raised JVP with bilateral fine crackles to the mid zones. Blood pressure is 100/60 mmHg and the pulse is 140-150 and irregular. An ECG confirms atrial fibrillation. A review of her notes and previous ECGs show no prior history of atrial fibrillation. What is the most appropriate management? A. IV amiodarone B. IV digoxin C. Urgent synchronised DC cardioversion D. Oral digoxin E. IV flecainideHAEMODYNAMIC COMPROMISE ▪ HISS - HEART FAILURE - MYOCARDIAL INFARCTION - SYNCOPE - SHOCK ▪ heart failure ▪ myocardial ischemia ▪ shock: hypotension (systolic blood pressure < 90 mmHg), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness ▪ syncope▪ A 45-year-old male presents to the emergency department with a sudden onset of palpitations and dizziness. He describes the palpitations as a rapid, regular heartbeat that began suddenly while he was resting at home. On mmHg, and oxygen saturation is 98% on room air. An electrocardiogramis 140/90 (ECG) is obtained, which shows a narrow QRS complex tachycardia with absent P waves. Vagal maneuvers are attempted without success in terminating the tachycardia. What is the most appropriate next step in management? A) Administer adenosine intravenously B) Perform synchronized cardioversion C) Initiate amiodarone infusion D) Proceed with electrical cardioversion E) Observe the patient and repeat vagal maneuversNarrow-complex tachycardia ❖Regular • vagal manoeuvres followed by IV adenosine • if the above is unsuccessful consider a diagnosis of atrial flutter and control rate (e.g. beta-blockers) ❖Irregular probable atrial fibrillation • if onset < 48 hr consider electrical or chemical cardioversion • rate control: beta-blockers are usually first-line unless there is a contraindicationBROAD COMPLEX TACHYCARDIAA 50-year-old female presents with palpitations and dizziness. Her ECG reveals a broad complex tachycardia with a rate of 200 beats per minute and an irregular rhythm. Which of the following is the most likely diagnosis? a) Atrial fibrillation with aberrant conduction b) Ventricular tachycardia c) Supraventricular tachycardia with aberrant conduction d) Atrial flutter with variable conduction e) Atrial fibrillation with rapid ventricular responseA 31-year-old man presents to the Emergency Department feeling very unwell. He states that he has recently been prescribed a course of antibiotics by his GP for a chest infection. An ECG shows polymorphic ventricular tachycardia (torsades de pointes). Which medication is he most likely to be taking? A. Flucloxacillin B. Cephalexin C. Clarithromycin D. Amoxicillin E. DoxycyclineCauses of long QT syndrome: Electrolytes: ▪ Hypocalcaemia • Hypomagnesaemia • Hypokalaemia Drugs: ▪ Antiarrhythmics (e.g. amiodarone, sotalol) • Antibiotics (e.g. erythromycin, clarithromycin, ciprofloxacin) • Psychotropic drugs (e.g. serotonin reuptake inhibitors, tricyclic antidepressants, neuroleptic agents)There are two main types of VT: ▪ monomorphic VT: most commonly caused by myocardial infarction • polymorphic VTVENTRICULAR TACHYCARDIA: MONOMORPHIC Management If the patient has adverse signs : immediate cardioversion is indicated Drug therapy amiodarone: ideally administered through a central line • lidocaine: use with caution in severe left ventricular impairment • Procainamide ❖If drug therapy fails • implant able cardioverter-defibrillator (ICD) - this is particularly indicated in patients with significantly impaired LV functionHEART BLOCKA 72-year-old presents to the surgery complaining of dizziness. An ECG is taken and shows the following: What is the diagnosis? A. Ventricular tachycardia B. Second degree heart block Mobitz type 2 C. First degree heart block D. Second degree heart block - Mobitz type 1 E. Third degree heart block Heart block 1.First-Degree Heart Block: A delay in electrical signals passing through the heart's AV node, but all signals eventually reach the ventricles. 2.Second-Degree Heart Block: Further divided into Mobitz Type I (Wenckebach) and Mobitz Type II. Wenckebach involves a progressive lengthening of the PR interval until a QRS complex is dropped, while Mobitz Type II features occasional dropped QRS complexes without PR interval lengthening. 3.Third-Degree (Complete) Heart Block: Complete blockage between the atria and ventricles, resulting in independent beating of the two chambers.OTHER RYTHMS + ECGsA 59-year-old man is brought into the emergency department with a 2-hour history of dizziness and palpitations. He denies chest pain or shortness of breath. His past medical history includes hypertension and stable angina. Temperature 36.7ºCre as follows: • Heart rate 44bpm. Blood pressure 90/51mmHg. Respiratory rate 18 breaths/min, Oxygen saturations 94% on air On examination, he has a regular pulse bilaterally. His calves are soft and non-tender. On auscultation, vesicular breath sounds are heard and heart sounds are normal. ECG: sinus rhythm,PR interval 210ms (120-200ms). What is the most appropriate next step in the management of this patient? A. Intravenous adenosine B. Intravenous atropine C. Isoprenaline infusion D. Transcutaneous pacing E. Transvenous pacingPeri-arrest rhythms: bradycardia The 2021 Resuscitation Council (UK) guidelines emphasise that the management of bradycardia depends on: •1. identifyingthe presence of signs indicating haemodynamic compromise - 'adverse signs' •2. identifyingthe potential risk of asystole Adverse signs The following factors indicate haemodynamic compromise and hence the need for treatment: •shock: hypotension(systolic blood pressure < 90 mmHg), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness •syncope •myocardial ischaemia •heart failure Atropine (500mcg IV) is the first line treatmentin this situation. If there is an unsatisfactoryresponse the following interventionsmay be used: •atropine, up to a maximum of 3mg •transcutaneous pacing •isoprenaline/adrenaline infusion titratedto response Specialist help should be sought for consideration of transvenouspacing if there is no response to the above measures.Potential risk of asystole The following are risk factors for asystole. Even if there is a satisfactory response to atropine specialist help is indicated to consider the need for transvenous pacing: ▪ complete heart block with broad complex QRS • recent asystole • Mobitz type II AV block • ventricular pause > 3 secondsA 32-year-old pilot attends for his annual physical check. He has had no medical has a healthy lifestyle and is a keen runner in ultramarathons.s concerning him. He As part of the physical check, he has an ECG performed. His previous ECG from last year was unremarkable. What ECG feature would be the greatest cause for concern? A. J wave B. left axis deviation C. left bundle branch block (LBBB) D. Second-degree heart block (Mobitz I) E. Short QT intervalA 58-year-old male presents to the emergency department with severe chest pain radiating to his left arm and jaw. An ECG is obtained, showing ST-segment depression in leads V1-V6, with tall, symmetrical T waves. The patient's vital signs are stable. What is the most appropriate next step in management? A. Administer oxygen therapy and initiate antiplatelet therapy with aspirin B. Perform immediate percutaneous coronary intervention (PCI) C. Start intravenous nitroglycerin infusion for symptom relief D. Admit the patient for serial Troponin monitoring and further evaluation E. Treat for hyperkalaemiaTHANK YOU, QUESTIONS?