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I N N O V A T I V E • C O M P R E H E N S I V E • H A N D S - O N
INTENSIVE UPDATE & BOARD REVIEW
Rosemont, IL
Lindsay Tjiattas-Saleski, DO, MBA, FACOEP
8/13/2018
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Lindsay Saleski DO, MBA, FACOEP Family Medicine/Emergency Medicine
65 yo female presents with shortness of breath, palpitations and generalized weakness for the last 3 weeks. Denies associated chest pain.
Pmhx: CAD
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a. Synchronized cardioversion
d. Massage the carotid arteries
e. Treat the patient with IV Adenosine
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a. Synchronized cardioversion
d. Massage the carotid arteries
e. Treat the patient with IV Adenosine
Several characteristic electrocardiogram (ECG) changes define AF: Presence of low-amplitude fibrillatory waves on ECG
without defined P-waves “Irregularly irregular” ventricular rhythm Fibrillatory waves typically have a rate of > 300 beats per
minute Ventricular rate is typically between 100 and 160 beats
per minute
B-blockers or Calcium channel blockers Resting rate goal ≤ 110bpm
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Patients with chronic atrial fibrillation are at increased risk for which of the following conditions?
a. Acute MI
b. Ventricular tachycardia
d. Cerebrovascular accident
e. Ventricular fibrillation
Patients with chronic atrial fibrillation are at increased risk for which of the following conditions?
a. Acute MI
b. Ventricular tachycardia
CHA2DS2-VASc score – predicts stroke risk
Warfarin for score of ≥ 2
Warfarin is superior to ASA/Plavix combo
If risk of embolization exceeds the risk of bleeding, patient is candidate for long-term antithrombotic therapy
• dabigatran (Pradaxa)
• rivaroxaban (Xarelto)
• apixaban (Eliquis)
68 yo female presents to the ED with intermittent palpitations, lightheadedness and shortness of breath. Symptoms worsened at church this morning. Patient did not feel well, walked to the bathroom and syncopized.
Pmhx: DM, HTN, CAD with stent placement
VS: HR 200, BP 135/100, RR 20, Pox 100%, T 98.6
Current: Patient is awake, alert and providing history.
The patients EKG is as follows:
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What is the antiarrhythmic of choice in management of stable ventricular tachycardia?
a. Adenosine 6mg IV push
b. B-blockers for rate control
c. Digoxin load the patient
d. Amiodarone 150mg IV
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What is the antiarrhythmic of choice in management of stable ventricular tachycardia?
a. Adenosine 6mg IV push
b. B-blockers for rate control
c. Digoxin load the patient
d. Amiodarone 150mg IV
https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-7-adult-advanced-cardiovascular-life-support/
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Just prior to floor transfer to the patient arrests. The rhythm strip reveals (see below). CPR is initiated. What is the next step in treatment according to ACLS?
a. Administer epinephrine 1mg IV
b. Administer calcium chloride
c. Administer sodium bicarbonate
e. Continue CPR – do not administer medications
Just prior to floor transfer to the patient arrests. The rhythm strip reveals (see below). CPR is initiated. What is the next step in treatment according to ACLS?
a. Administer epinephrine 1mg IV
b. Administer calcium chloride
c. Administer sodium bicarbonate
• >3 consecutive ectopic ventricular beats Widened QRS (>120msec) Regular rhythm Rate >100 bpm
• MC causes are ischemic heart disease and AMI
ALL wide complex ventricular rhythms treated as Vtach until proven otherwise
Stable – no evidence of hemodynamic compromise despite a sustained rapid heart rate, can be awake with a pulse
Unstable – evidence of hemodynamic compromise
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STABLE with pulse Amiodarone 150mg IV over 10 minutes, repeat as needed to
max dose of 2.2g/24 hours Prepare for elective synchronized cardioversion
UNSTABLE with pulse Immediate synchronized cardioversion IV access and sedation, but don’t delay tx
Pulseless arrest IV, O2, monitor, CPR Biphasic 200J/Monophasic 360J/AED devise specific CPR 5 cycles Check pulse and rhythm Epinephrine 1mg IV/IO whenever initially available and
redose every 3-5 minutes
55 yo male suddenly became unresponsive at home. Wife is a nurse and CPR was started immediately. The patient regained a pulse. And is responsive at this time. On ED arrival the cardiac monitor has the following rhythm:
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a. Magnesium 2 gram IV bolus
b. Cardioversion
What is the first line medical therapy?
a. Magnesium 2 gram IV bolus
b. Cardioversion
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Ventricular rate >200bpm
QRS structure with undulating axis, polarity of complexes appearing to shift about the baseline
Causes: QT Prolongation
Congenital - female
P – Phenothiazines
N – No known, Idiopathic)
E - Electrolyte abnormalities
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Overdrive pacing to ventricular rate of 100-120 bpm
Correct electrolyte imbalances
ICD for patients with congenital long QT syndrome
41 yo female presents to the FP office as a new patient with acute onset substernal, non- radiating chest pain that started while she was out working in the yard 15 minutes prior to her appointment. She states the pain is currently 10/10. She has associated SOB and nausea. No pmhx but has not seen a PCP in 5 years.
VS: 160/100, HR: 92, RR: 22, Pox: 98%, T98.9
The patients EKG is as follows
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Which of the following time dependent interventions will most likely benefit this patient? a. CK-MB level b. Stress test c. Angioplasty d. Metoprolol IV e. Atorvastatin PO
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Which of the following time dependent interventions will most likely benefit this patient?
a. CK-MB level
b. Stress test
d. Metoprolol IV
e. Atorvastatin PO
EKG evolves through a typical sequence Hyperacute or peaked T wave Elevation of the J point and the ST segment retains its concavity ST segment elevation becomes more pronounced and convex ST segment may be indistinguishable from the T wave
The joint ESC/ACCF/AHA/WHF committee: definition of MI established specific ECG criteria for the diagnosis of STEMI: 2 mm of ST segment elevation in precordial leads for men and
1.5 mm for women in lead V2-V3 greater than 1 mm in 2 contiguous leads in other leads
ACS also = STEMI if: new left bundle branch block posterior MI
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90 minutes or less for patients transported to PCI-capable hospital
120 minutes to transfer to a PCI capable hospital
Fibrinolytic agents If within 12 hours of onset and no PCI available
Administer within 30 minutes of presentation
Aspirin (162-325mg)
Nitrates
β-Blockers
51 yo female presents with palpitations, nausea, and chest pain. The CP is substernal and non-radiating. She states she was having a nightmare and woke up with palpitations. She has had multiple prior episodes for which she has been seen in the ED. She has not obtained outpatient follow up.
PMHx: CAD, CHF, HTN, drug abuse
BP: 200/120, HR: 177, RR: 36, T: 98.9, Pox: 96% on RA
The patients EKG is as follows:
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In this patient ACLS Protocol states that you should immediately:
a. Administer Amiodarone 150mg IV
b. Administer Adenosine 6mg IV
c. Initiate CPR
d. Synchronized cardioversion
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In this patient ACLS Protocol states that you should immediately:
a. Administer Amiodarone 150mg IV
b. Administer Adenosine 6mg IV
c. Initiate CPR
d. Synchronized cardioversion
https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-7-adult-advanced-cardiovascular-life-support/
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Ventricular rate >100 bpm
AVRT (anatomical re-entry circuit)
Sx: Sudden onset regular palpitations, syncope, SOB, CP, HF
Tx: SVT that is not associated with severe symptoms or hemodynamic collapse
Vagal maneuvers
IV non-dihydropyridine calcium channel blocker or an IV beta blocker
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66 yo female with pmhx DMII presents with CC of intermittent dizzy spells and two episodes of near syncope over the last week. An EKG is done and she is found to have a heart block. She is sent to the ED for further evaluation.
VS: 146/78, 40, 20, 98.6, 100% on RA
The patients EKG is as follows:
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What are indications for permanent pacemaker placement in patients with 3rd degree heart block?
a. Symptom free patients with asystole > 3 seconds
b. Dizziness and near-syncope
c. Heart block during exercise in the absence of myocardial ischemia
d. Asymptomatic patients with asystole of 5 seconds or longer
e. Escape rate < 40bpm
What are indications for permanent pacemaker placement in patients with 3rd degree heart block?
a. Symptom free patients with asystole > 3 seconds
b. Dizziness and near-syncope
c. Heart block during exercise in the absence of myocardial ischemia
d. Asymptomatic patients with asystole of 5 seconds or longer
e. Escape rate < 40bpm
http://content.onlinejacc.org/article.aspx?articleid=1138927
Absent conduction of ALL atrial impulses resulting in complete electromechanical AV dissociation
P waves and QRS complexes are present but unrelated and occur at different rates
Multiple causes: Medications
Infectious causes (Lyme)
Post surgical causes
Stable or Unstable??
Temporary Cardiac pacing
Treat the cause
Pacemaker for those with associated symptoms, ventricular pauses ≥3 seconds, or a resting heart rate <40 beats/min while awake
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www.edoctoronline.com
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V4: apex
II, III, avF: inferior wall (possible RV)
http://www.nottingham.ac.uk/nursing/practice/resources/cardio logy/images/ecg_regions_old.gif
www.usfca.edu
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Rule of 300- Divide 300 by the number of boxes between each QRS = rate
Rate 60 – 100 Normal Rate < 60 Bradycardia Rate >100 Tachycardia
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The heart rhythm must be supraventricular in origin
The QRS duration must be ≥ 120 ms There should be a QS or rS complex in lead V1 There should be a RsR' wave in lead V6 The T wave should be deflected opposite the
terminal deflection of the QRS complex. This is known as appropriate T wave discordance with bundle branch block. A concordant T wave may suggest ischemia or myocardial infarction.
New onset LBBB in setting of chest pain considered a STEMI
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Not AVR or V1
Absence of reciprocal changes
Usually considered benign however some studies showing possible association with Vfib, sudden death, cardiac arrest. Must correlate clinically.
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Symtpoms: Pleuritic CP, improves when leaning forward, shortness of breath
EKG:
Absence of reciprocal changes
PR- segment depression
Normal Sinus Rhythm: Originating from SA node, P wave before every QRS, P wave in same direction as QRS
Sinus Bradycardia: stable vs unstable, atropine, prepare for transcutaneous pacing, consider epinephrine or dopamine
Sinus Tachycardia: determine etiology Atrial Fibrillation, “irregularly irregular”: stable vs unstable, control rate
vs cardioversion, diltiazem or beta-blockers, avoid AV nodal blocking agents (adenosine, digoxin, diltiazem, verapamil) in setting of AF + WPW
Atrial Flutter, “sawtooth pattern”: stable vs unstable, control rate vs cardioversion, diltiazem or beta-blockers
Supraventricular Tachycardia (SVT), “narrow complex tachycardia”: stable vs unstable, control rate vs cardioversion, vagal maneuvers, adenosine
Torsades de Pointes, “twisting of the points,”: magnesium Ventricular Tachycardia, “wide complex tachycardia,”: with or without a
pulse, without = defibrillation, with = amiodarone, synchronized cardioversion
Ventricular Fibrillation, “erratic tracing”: defibrillation http://www.heart.org/HEARTORG/CPRAndECC/HealthcareProviders/AdvancedCardiovascularLifeSupportACLS/Advanced- Cardiovascular-Life-Support-ACLS_UCM_001280_SubHomePage.jsp
Practice. February 2013. Volume 15, No 2. Antithrombotic Therapy in Atrial Fibrillation to Prevent Embolization. UTD. Accessed 6/2/2014. Atrial Fibrillation: Diagnosis and Treatment. Am Fam Physician. 2011 Jan 1;83(1):61-68.
Ventricular Tachycardia & Torsades Polymorphic Ventricular Tachycardia and Torsades de Pointes. Rosen’s Emergency Medicine.
Sixth Edition, Volume 2. pp1243-1244 Piktel JS. Piktel J.S. Chapter 22. Cardiac Rhythm Disturbances. In: Tintinalli JE, Stapczynski J, Ma
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Aquired Long QT Syndrome. UTD. Accessed 7/24/2014
STEMI Hollander JE, Diercks DB. Hollander J.E., Diercks D.B. Chapter 53. Acute Coronary Syndromes: Acute Myocardial
Infarction and Unstable Angina. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. Tintinalli J.E., Stapczynski J, Ma O, Cline D.M., Cydulka R.K., Meckler G.D., T eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011. http://accessmedicine.mhmedical.com/content.aspx?bookid=348&Sectionid=40381518. Accessed August 15, 2014.
O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(4):e78-e140. doi:10.1016/j.jacc.2012.11.019
Circulation. 2013; 127: 529-555 Published online before print December 2012, doi: 10.1161/CIR.0b013e3182742c84 ACC/AHA Guideline Update for the Management of ST-Segment Elevation Myocardial Infarction. American
Family Physician. 2009; 79 (12):1080-1086
SVT An Evidence-Based Approach to Supraventricular Tachydysrhythmias. Emergency Medicine Practice.
EBMedicine.net. April 2008. Volume 10 Number 4. Accessed Online 8/19/2014.
Heart Block `Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of
Cardiac Rhythm Abnormalities: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) Developed in Collaboration With the American Association for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;51(21):e1-e62. doi:10.1016/j.jacc.2008.02.032. Accessed online 7/13/2015.
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