Arrhythmias/alcs

Front 1

Causes of Cardiac Arrest in Adults

Back 1

*H's and T's -- Think Cardiac*
1. Hypovolemia
2. Hypoxia
3. Hydogen Ion (acidosis)
4. Hypo/Hyperkalemia
5. Hypoglycemia
6. Hypothermia
7. Toxins
8. Tamponade
9. Tension pneumothorax
10. Trauma
11. Thrombosis

Front 2

Causes of Cardiac Arrest in Children

Back 2

*Think Non-Cardiac*
1. Shock
2. Trauma
3. SIDS
4. Choking
5. Drowning
6. Severe Asthma
7. Poisoning
8. Pneumonia

Front 3

First thing done in Cardiac Arrest

Back 3

*CAB assessment*
1. Circulation and chest compression (begin immediately)
2. Airway
3. Breathing (trained - give 2 rescue breaths)

Front 4

Patient has pulse but inadequate respiration (Cardiac arrest)

Back 4

1 breath every 6-8 seconds

Front 5

Patient has no pulse or adequate respiration (Cardiac arrest)

Back 5

1. Chest compression - 2 inches, 100/min

Trained - 30 compression : 2 breaths

Front 6

Goals of therapy for Cardiac Arrest

Back 6

SHORT - return of spontaneous circulation
LONG - survival

Front 7

Phase 0

Back 7

1. Rapid depolarization
2. Rapid influx of Na

Front 8

Phase 1

Back 8

1. initial repolarization
2. efflux of K

Front 9

Phase 2

Back 9

1. repolarization balanced by depolarization
2. K efflux balanced by Ca influx

Front 10

Phase 3

Back 10

1. rapid depolarization
2. K efflux increases and Ca influx decreases

Front 11

Phase 4

Back 11

1. resting membrane potential (diastole)
2. Na/K ATPase

Front 12

Path of the electrical impulse

Back 12

1. Sa node
2. atria
3. AV node
4. purkinje system
5. ventricles
6. out of the heart

Front 13

Normal pacemaker in the heart and normal heart rate

Back 13

SA node

60 - 100 bpm

Front 14

Ectopy (ectopic sites)

Back 14

beats arising from fibers other than the normal pacemakers

Front 15

P-wave of ECG

Back 15

atrial depolarization and contraction

ATRIA

Front 16

PR interval of ECG

Back 16

AV nodal conduction duration

'time of contraction from atria to ventricle'

Front 17

QRS complex of ECG

Back 17

ventricular depolarization and contraction

Front 18

T-wave of ECG

Back 18

ventricular repolarization

Front 19

ST segment of ECG

Back 19

ventricles are depolarized

Front 20

QT interval of ECG

Back 20

duration of ventricular action potential duration

Front 21

Effects of QT interval in
a) tachycardia
b) bradycardia

Back 21

a) QT interval shortens
b) QT interval lengthens

Front 22

Arrhythmias

Back 22

loss of the regular cardiac rhythm and results from alterations in impulse formation or conduction

Front 23

Possible presentation of arrhythmias

Back 23

1. asymptomatic
2. minor symptoms such as palpitations
3. life-threatening

Front 24

mechanism of bradyarrhythmias

Back 24

1. failure of impulse initiation
2. decreased automaticity

Front 25

mechanism of "heart block"

Back 25

1. failure of impulse propagation from atrium to ventricles

Front 26

Mechanism of tachyarrhythmias

Back 26

1. enhanced automaticity
2. triggered automaticity (ectopy)
3. re-entry

Front 27

Sinus bradycardia

Back 27

1. sinus nodes fire slower (QRS more spaced out)
2. rate < 50bpm, regular

Causes: vagal stimulation, hypoxia, meds

Front 28

Sinus tachycardia

Back 28

1. sinus nodes fire faster (QRS closer together)
2. rate > 100bpm, regular

Causes: fever, anxiety, PE, MI, drugs

Front 29

Atrial arrhythmias

Back 29

1. due to one or more irritable focus in the atrium
2. characterized by P-wave changes
3. usually tachyarrhythmias

Front 30

Supraventricular tachycardia (SVT)

Back 30

1. originates above the ventricles
2. rate >/= 130bpm, regular, p-waves discernible

Causes: meds(stimulants), hypoxia, heart disease

Front 31

Atrial Fibrillation (Afib)

Back 31

1. hundreds of atrial ectopic foci fire at once (contraction impaired)
2. rate 350-700bpm, irregularly irregular, no p-waves, QRS at irregular intervals

Causes: MI, lung disease, valvular heart disease, stimulants, alcohol

Front 32

Atrial flutter (AFL)

Back 32

*not immediately life-threatening*
1. one atrial ectopic focus fires at a rapid rate
2. rate 250-350bpm, p-waves look like sawtooth

Causes: underlying heart disease, lung disease

Front 33

Ventricular arrhythmias

Back 33

1. 1+ irritable foci in the ventricles
2. characterized by changes in QRS complex

Front 34

Ventricular tachycardia (VT)

Back 34

1. single irritable focus in ventricle fires rapidly
2. rate > 100bpm, p-waves not present, large and wide QRS, regular

Causes: H's and T's

Front 35

Ventricular fibrillation (VF)

Back 35

1. many irritable foci in the ventricles fire rapidly
2. no cardiac output - functionally dead
3. very irregular with no discernible pwaves or QRS complexes

Causes: heart disease, hypokalemia, hypoxia, stimulants

Front 36

Torsades de pointes (TdP)

Back 36

1. QRS complex twists around isoelectric line
2. rate > 200bpm, irregular, wide and misshapen QRS

'very weird looking'

Front 37

Drugs associated with QT prolongation

Back 37

1. Amiodarone (females, low risk)
2. Citalopram
3. Clarithromycin
4. Erythromycin (females)
5. Haloperidol (IV or high dose)
6. Methadone (females)
7. Moxifloxacin
8. Procainamide
9. Sotalol (females)

Front 38

Key concepts of ALCS

Back 38

1. effective BLS before is essential
2. prompt CPR and early defibrillation
3. Drug admin is secondary

Front 39

ACLS core rhythms

Back 39

1. Pulseless arrest (VF or pulseless VT or asystole)
2. Symptomatic bradycardia (HR <60)
3. Symptomatic tachycardia (narrow, wide)

Front 40

Special instances with endotracheal routes of medication in ALCS

Back 40

1. doses are 2-2.5 times more
2. dilute in water or saline
3. cannot give (naloxone, atropine, vasopressin, epi, lidocaine)

Front 41

Vasopressors and inotropes used in ACLS

Back 41

1. Epinephrine
2. Vasopressin
3. Dopamine
4. Isoprotenol - 3rd line
5. Norepinephrine - limited data
6. Atropine

Front 42

Epinephrine for ACLS

Back 42

1. alpha agonism - vasoconstrictive effects, increases coronary perfusion
2. beta agonism - don't want!!!

PLACE - 1st line pulseless arrhythmias

Front 43

Vasopressin for ACLS

Back 43

1. non-adrenergic peripheral vasoconstriction

PLACE: alternative for pulseless arrhythmias

Front 44

Dopamine for ACLS

Back 44

1. beta agonism (lower doses)
2. alpha agonism (higher doses)

PLACE: alternative for symptomatic bradycardia if atropine fails

Front 45

Atropine for ACLS

Back 45

1. inhibits cholinergic-mediated cardiovascular effects (increase heart rate, SVR)

PLACE: only for symptomatic bradycardia

Front 46

Antiarrhythmic Class 1a drug for ACLS

Back 46

1. Procainamide

block intermediate Na and Potassium channels

Front 47

Antiarrhythmic Class 1B drug for ACLS

Back 47

1. Lidocaine

Blocks fast sodium channels

Front 48

Antiarrhythmic Class 2 drugs for ACLS

Back 48

1. Metoprolol
2. Atenolol
3. Propranolol
4. Esmolol

Beta Blockers

Front 49

Antiarrhythmic Class 3 drugs for ACLS

Back 49

1. Amiodarone
2. Sotalol

Block potassium channels

Front 50

Antiarrhythmic Class 4 drugs for ACLS

Back 50

1. Diltaizem
2. Verapmil

Non-DHP CCB

Front 51

Other Class of Antiarrhythmic drugs for ACLS

Back 51

1. Adenosine
2. Digoxin
3. Magnesium

Front 52

Procainamide (Class Ia)

Back 52

ADRs: Hypotension, slowed conduction with IV, Prolonged QT interval and TdP

PLACE: 1st line - stable, wide-complex monomorphic tachycardia (likely Ventricular tachycardia)

Front 53

Lidocaine (Class 1b)

Back 53

ADRs: cns issues (seizures, tremor, dizziness, sedation
*not worried about prolonged QT or TdP*

PLACE: 2nd line to amiodarone for refractor VF or pulseless VT OR alternative for stable, wide-complex monomorphic tachycardia

Front 54

Beta Blockers (Class 2)

Back 54

ADRs: hypotension, bradycardia, precipitate HF

PLACE: alternative for stable, narrow complex tachycardia (SVT)

Front 55

Amiodarone (Class 3)

Back 55

ADRs: bradycardia, hypotension, phlebitis (short term, IV admin)

PLACE: 1st line - refractory VF or pulseless VT (may increase suvival to hospital admin) AND 1st line for stable, wide-complex monomorphic tachycardia (VT)

Front 56

Sotalol (Class 3)

Back 56

ADRs: bradycardia, hypotension, QT prolongation, TdP

PLACE: alternative for stable, wide-complex monomorphic tachycardia (VT) *replace procainamide or amiodarone*

Front 57

Non-DHP-CCB (Class 4)

Back 57

ADRs: bradycardia, hypotension, precipitation of HF

PLACE: alternative for stable, narrow-complex tachycardia (SVT) *rarely used-only if 1st lines fail*

Front 58

Adenosine

Back 58

MOA: activates acetylcholine-sensitive K channels in SA and AV nodes *inhibits cAMP - decrease Ca - decrease contraction

Front 59

ADRs of adenosine

Back 59

1. Very short lived
2. dyspnea
3. bronchospasm
4. chest fullness
*feel like you are going to die for a few seconds*

Front 60

Administration and dosing of adenosine

Back 60

if given through a central line - reduce dose by half!!!

Front 61

Place in ALCS for adenosine

Back 61

-1st place for stable, narrow complex regular tachycardia (SVT)

Front 62

Adenosine effect on the ECG

Back 62

pause or short flatline = transient asystole (desired) lasts less than 5 seconds

Front 63

MOA of magnesium sulfate for ALCS

Back 63

1. cofactor in control of sodium and potassium transport
2. may increase inward calcium current to suppress early after-depolarizations

Front 64

ADRs of magnesium sulfate

Back 64

1. hypotension
2. CNS toxicity
3. respiratory depression

Front 65

Place in ALCS for magnesium sulfate

Back 65

1st line for torsades

Front 66

Dose of epinephrine for ALCS

Back 66

1mg IV/IO q 3-5 minutes

Front 67

Dose of Vasopressin

Back 67

40 units IV/IO

Front 68

PEA/Asystole

Back 68

1. not shockable
2. CPR is essential
3. give epi 1mg q3-5 minutes

Front 69

Dosing of Atropine if perfusion is inadequate

Back 69

0.5mg IV, may repeat up to 3 mg total

Front 70

Dosing for Amiodarone in refractory VF/VT

Back 70

300mg IV/IO once, may repeat with 150mg IV/IO

Front 71

Symptomatic bradycardia

Back 71

1. HR < 50bpm
2. Symptoms = altered mental status, ischemic chest pain, hypotension

Front 72

Management of Symptomatic bradycardia

Back 72

1. ensure adequate airway and breathing
2. establish IV access
3. If perfusion is inadequate - Atropine 0.5mg IV, repeat up to 3mg total

Front 73

Symptoms of symptomatic tachycardia

Back 73

1. hypotension
2. ischemic chest pain
3. altered mental status
4. other signs of shock

Front 74

Sinus Tachycardia

Back 74

1. HR > 100 bpm
2. causes - anemia, shock, fever
3. Management - drug therapy usually not necessary

Front 75

Supraventricular tachycardia

Back 75

1. HR > 120bpm
2. Management - vagal manuevers (1st line), adenosine 6mg IV via rapid push

Front 76

Vagal Manuevers for treatment of SVT

Back 76

1. holding breath
2. dipping face in cold water
3. coughing
4. "bearing down"
5. carotid sinus massage

Front 77

Management of Irregular narrow-complex tachycardia (atrial fibrillation and flutter)

Back 77

1. Diltiazem
2. Beta Blockers

Front 78

Wide-Complex tachycardia

Back 78

1. Unstable - cardiovert
2. Stable - Amiodarone 150mg IV given over 10 minutes followed by IV infusion of 1mg/min for 6 hours OR procainamide OR sotalol