Wednesday, November 30, 2011

ACLS review: Acute Coronary Syndromes Part 1

Acute Coronary Syndromes

Primary goals of therapy for patients with ACS
·         Reduce the amount of myocardial necrosis
·         Prevent major adverse cardiac events
·         Treat acute, life-threatening complications of ACS

AMI Symptoms
·         Pain that is more intense than angina and that persists for longer periods of time (eg, longer than 15–20 minutes)
·         Chest discomfort, discomfort in other areas of the upper body, shortness of breath, sweating, nausea, vomiting, and dizziness
·         Atypical symptoms are more common in women, the elderly and diabetic patients.


Initial Evaluation
·         Obtain vital signs and oxygen saturation
·         Obtain IV access
·         Obtain 12 lead EKG
·         Perform target history
·         Obtain serum cardiac enzymes, CBC chemistries, and coagulation studies
·         Portable CXR

Note:  Ideally within 10 minutes of ED arrival providers should obtain a targeted history while a monitor is attached to the patient and a 12-lead ECG is obtained (if not done in the prehospital setting). The evaluation should focus on chest discomfort, associated signs and symptoms, prior cardiac history, risk factors for ACS, and historical features that may preclude the use of fibrinolytics or other therapies

Initial General Treatment
(MONA greets all patients)
·         Morphine 2-4mg IV if pain unrelieved by nitroglycerine
·         Oxygen 4L/min
·         Nitroglycerine SL or spray
·         Aspirin 160-325mg

Tuesday, November 29, 2011

EKG Rhythm Strips 21: Fast rhythms

Identify the following rhythms
1.

2.


3.



4.


5.



Answers

Identify the following rhythms
1.
Multifocal Atrial Tachycardia
 Multifocal Atrial Tachycardia.  The rate is 149.   The rhythm is irregular.  There is an upright P wave before each QRS complex.   The QRS complex is narrow, < .12 sec.   Because the rate is over 100 and there are at least three different P waves of differing morphology, this qualifies the rhythm as a mulifocal atrial tachycardia.  Since this rhythm is ectopic in nature, it probably would not respond to either adenosine or cardioversion.  
2.
Atrial Fibrillation with RVR
Atrial Fibrillation with RVR.  The rate is 150.  The rhythm is irregular.  There are really no identifiable P waves before each QRS complex.  Fibrillatory waves are clearly seen.  The QRS complex is narrow. Because the rate is over 100/min, this rhythm is identified as atrial fibrillation with a rapid ventricular rate.   This rhythm will not usually be converted by adensoine but will slow down so that it can be identified more clearly.  If the rhythm is of new onset, < 24 hours and the patient is unstable, emergent cardioversion may be attempted. 
3.
Atrial Tachycardia
Atrial Tachycardia.  The rate is about 210.   The rhythm is regular.  There are faint, identifiable P waves present. Examine the T waves of the preceeding complexes and you can make out the P waves which are superimposed on the T waves.  The QRS is narrow.  

4.

Junctional Tachycardia
 Junctional Tachycardia.  The rarte is 150.  The rhythm is regular.  There are inverted P waves before each narrow QRS complex.  The inverted P waves are characteristic of a junctional rhythm.  Because the rate is > 100, this makes it a junctional tachycardia. 
5.
Ventricular Tachycardia

Ventricular Tachycardia.   The rate is 187.  The rhythm is regular.  There are no P wave present.  The QRS is wide, > .12 sec.  If the patient had a pulse but was unstable, what would be the treatment of choice?    a.  Amiodarone 300mg IV push.   b.   Defibrillation with 360 J (monophasic)   c. Cardioversion with 100J   d.  Lidocaine 1.5mg/kg.  IV?      If a patient with VT had a pulse but was unstable, the provider would cardiovert the patient at 100 J and increase the joule setting stepwise on subsequent cardioversion attempts.   On the other hand, if the patient were pulseless, then you would defibrillate the patient at 360 J (monophasic).   Lidocaine 1.5mg/kg is indicated for the patient with VT who has a pulse but is only symptomatic.   Amiodarone is the first antiarrhytmic used in a pulseless arrest with VT displayed on the monitor.  But it is used in refractory VT after initial defibrillation attempts and vasoconstrictors have failed to convert the rhythm.  



Reviewed on 3/1/16

Sunday, November 27, 2011

EKG Rhythm Strips 20: Ventricular Ectopy 3

Identify the following rhythms

1.

2.
3.

4.

5.

Answers

1.
1st degree AV block with ventricular trigeminey

2.
2nd Degree AV Block Type II with couplet of PVCs
3.
Sinus Arrhythmia with unifocal PVC

4.
Sinus Tachycardia with multifocal PVCs

5.
Atrial Fibrillation with RVR and multifocal PVCs



Reviewed on 3/1/16

Saturday, November 26, 2011

EKG Rhythm Strips 19: Ventricular Ectopy 2

Identify the following rhythms:

1.

2.

3.




4.
5.


Answers
1.
Sinus rhythm with ventricular trigeminy




2.
Sinus rhythm with ventricular bigeminy



3.
Sinus rhythm with ventricular Quadrigeminy





4.
Sinus rhythm with a four beat run of ventricular tachycardia




5.
Sinus rhythm with couplets of PVCs





Reviewed on 3/1/16

Friday, November 25, 2011

EKG Rhythm Strips 18: Ventricular Ectopy 1

1.

2.















Answers
1.
Sinus rhythm with a couplet of PVCs





2.
Sinus rhythm with multifocal PVCs


3.
Sinus rhythm with 6 beat run of VT

4.
Sinus rhythm with unifocal PVCs

5.
Sinus rhythm with ventricular bigeminy



Reviewed 2/28/16

Thursday, November 24, 2011

EKG Rhythm Strips: Slow rhythms 3

1.





2.


3.


4.

5.

6.

Answers
1.

Idioventricular Rhythm









Idioventricular Rhythm.   The rate is 33.  The rhythm is regular.  There are no P waves before the QRS complexes.   The QRS complex is wide, greater than .12 sec.  A slow rhythm with wide QRS complexes and absent P waves is characteristic of an idioventricular rhythm.  This might be a rhythm that you would see in a patient with PEA.   Recall that with PEA there is a rhythm on the monitor but the patient will be pulseless.   What is the immediate treatment for a patient that is pulseless and apenic?   How do you confirm true pulselessnes in a patient with PEA? What two drugs are indicated in the treatment of PEA?  What are some reversible causes?

2.
Bradycardia with Sinus Arrhythmia

Bradycardia with Sinus Arrhythmia.    The heart rate is 39.  The rhythm is irregular.   There are upright P waves before each QRS complexes.   The PR interval is .16 sec.   Because of the irregular rhythm this makes it a bradycardia with sinus arrhythmia.   If the patient experienced this rhythm during insertion of an NG tube and was becoming more symptomatic, what drug could you administer the patient?
3.
2nd Degree Heart Block Type II
2nd Degree Heart Block Type II.   The heart rate is 40. The rhythm is irregular. There are upright P waves before each QRS complexes and there are some extra, nonconducted P waves present. The PR interval is .16 sec. Because of the extra P waves and the conducted P waves that have a consistent PR interval this rhythm is a 2nd degree heart block type II or Mobitz II heart block.  This is a block that occurs below the level of the AV junction.  You might see this rhythm with anterior infarcts because the LAD perfuses the intraventricular septum.
4.
Sinus Bradycardia
Sinus Bradycardia.  The rate is 42. The rhythm is regular. There are upright P waves before each QRS complexes with a PR interval is .16 sec. The QRS complex is narrow, less than .12 sec.  Based on this information, the rhythm is correctly identified as sinus bradycardia.

5.
Junctional Rhythm
Junctional Rhythm. The rate is 39. The rhythm is regular. There are inverted P waves before the QRS complexes.  The PR interval is shortened.  The QRS complex is narrow, < .12 sec. A slow rhythm with narrow complexes and with absent or inverted P waves is characteristic of a junctional rhythm.   The patient's BP is 86/39.   He is alert but mildly confused and anxious.  He is holding his chest and is complaining of chest pain and is short of breath. His pulse oximetery is 92% on 2L/min via nasal cannula.   His capillary refill is delayed, < 3 sec.  His skin is cold and clammy.   Is this patient stable or unstable?   What is the recommended treatment for this patient?
6.
3rd Degree Heart Block
3rd Degree Heart Block.   The rate is 34.  The rhythm is regular.   The P waves are not associcated with the QRS complexes.   The QRS complexes are wide, > .12 sec.   A slow rhythm with complete AV dissociation is characteristic of a 3rd degree heart block or complete heart block.  You might see this rhythm with anterior infarcts because the LAD perfuses the intraventricular septum below the AV junction.   Two catecholamines that can be administered to this patient: Epinephrine  and dopamine



Reviewed on 2/28/16