Cardiology Exam 2 - Lecture Notes: Treating Adult Bradycardia

Wednesday, December 5, 2018
Cardiology Exam 2 - Lecture Notes

Treating Adult Bradycardia
- By Definition: Bradycardia is anything less than 60 bpm. Sheet says 50 // Patients tend to be
symptomatic at 50 bpm or less.
1. Assess appropriateness for clinical condition
2. Identify and treat underlying cause
• Maintain patent airway; assist breathing as necessary
• O2 (if hypoxic)
• Cardiac monitor to identify rhythm; monitor blood pressure and oximetry
• IV access
• 12-lead ECG if available - Don’t delay therapy
3. Persistent bradyarrhythmia causing:
• Hypotension?
• Acutely altered mental status?
• Signs of shock?
• Ischemic chest discomfort?
• Acute heart failure? (Auscultation, etc)
4. If NO - Monitor and Observe
5. If YES - Atropine // If Atropine ineffective: Try transcutaneous pacing; Dopamine infusion;

Epinephrine infusion
6. Consider: Expert consultation or trans-venous pacing
Contraindications for Atropine: 3rd degree heart-block or higher pacemaking heart blocks.
Functions: Dopamine increases cardiac contractility with positive chronotropic effects - Wide
dosage of dopamine… 2-5 mcg (renal dose); 5-10 mcg (chronotropic); 10-20 mcg (systemic
effects). Titrate to patient response.
Negative Effects of Dopamine: Longer half-life, takes long to take effect, inside the body longer.
1
Epinephrine: Increases preload, increases starlings-law, increases stroke volume and cardiac
output. Also: Positive chronotropic effects. Epinephrine can cause increased ischemia to the
heart since it is pure adrenaline.
Depending on Protocol: Typically administered with an 1000 mL bag of saline.
TCP (Transcutaneous Pacing): *TRUMP CARD* If patient base-line altered, immediately go to

TCP. In theory, the electricity should work 100% of the time. Electricity is the last treatment,
must stick through entire transport.
- Majority of patients resorting to TCP are sick enough to need it before any medications
• TCP Pre-Treatment: Relaxation drugs ~ 2-5 mg Versed (Adjust to patient response); 1-2
mcg/kg (or 50-100 mcg) Fentanyl; 1-5 mg Morphine
Concluding: 3rd Degree-HB or Mobitz Type 2 Second-Degree HB… Go straight to pacing. Most
difficult part of treating bradycardia is heart-blocks.
Drug Card on Slides in Canvas for Reference
Treating Adult Tachycardia:

1. Assess appropriateness for clinical condition. HR typically greater than or equal to 150
bpm if tachyarrhythmia.
2. Identify and treat underlying causes:
• Maintain patient airway; assist breathing as necessary
• O2 (if hypoxic)
• Cardiac monitor to identify rhythm; monitor blood pressure and oximetry
3. Persistent tachyarrhythmia causing:
• Hypotension?
• Acutely altered mental status?
• Signs of shock?
• Ischemic chest discomfort?
• Acute heart failure?
4. If YES - Synchronized Cardioversion ~ Consider sedation, regular narrow complex consider

adenosine
2
5. If NO - Wide QRS? Greater than or equal to 0.12 seconds —> If YES to wide QRS: IV
access and 12-lead, consider adenosine only if regular and monomorphic, consider anti
arrhythmic infusion, consider expert consultation.
7. If NO to Wide QRS: IV and 12-lead access, vagal maneuvers, adenosine (if regular), beta
blockers or calcium channel blockers, expert consultation.
Adenosine: Liquid pacing medication that contains a VERY short half-life, requiring an IV push
of 6 seconds or less. Print strip entirety of IV push. Requires higher gauge needle.
Dosages: 6 mg rapid IV push follow with NS flush ~ wait 2-5 min ~ 12 mg rapid IV push if
required ~ wait 2-4 min ~ 12 mg rapid IV push
Consider Adenosine before Amioderone
Amioderone: 150 mg over 10 minutes (VERY slow IV push), repeat if needed.
- Synchronized Cardioversion: Consider sedation… Generally patient is so altered that it

doesn’t really matter.
SVT Regular-Narrow:
• 50 J
• 100 J
• 150 J
• 200 J
V-Tach Regular-Wide:
• 100 J
• 150 J
• 200 J
Atrial Irregular-Narrow:
• 120 J
• 150 J ; lastly 200 J
Adult Cardiac Arrest:

Refer to Handout Sheet for Walk-Through
3
Additional Notes: Only two true shockable rhythms ~ VT and pVT… Anything else is to be
treated as Asystole
- Directly after shock delivered, begin CPR without a thought

- Paramedics are the only one who will check a pulse - BLS healthcare providers not able to
actively check for pulse
- Once IO or IV obtained begin medication administration:

Epinephrine 1:10000, 1 mg IV/IO push. Given every 3-5 minutes. * CONTINUED DURING
ENTIRE ARREST * Start considering advanced airways - Intubation preferable and King-
Airways as rescue airway.
- Recheck rhythm… Defibrillate, continue CPR.

- Try for anti-dysrhythmic:
Amioderone: Slow IV bolus IV/IO - 300 mg. Can be repeated at 150 mg 3-5 min for a max dose
of 450 mg. Patient has to be refractory in order to administer second dose.
Magnesium Sulfate: 2 grams Mag for polymorphic rhythms.
Refractory Definition: Patient is sustained in the rhythm regardless of treatment
Refractory VF: If patient slips into PEA (or not shockable rhythm) and then back to VF, requires
3 shocks to reset timer to allow patient to go back into refractory period.
* CHECK PATIENT PULSE BEFORE EVERY DEFIBRILLATION *
- Asystole/PEA is treated the exact same EXCEPT for no defibrillation and no anti-
dysrhythmias.
5 H’s and 5 T’s ~ The Causes of Cardiac Arrest
1. Hypovolemia (Loss of volume) - Normal Saline, plasma-line, Lactated-Ringers (burns and

blood loss). Goal: Increasing fluid
2. Hypoxia (Low O2) - Administer O2, manual BVM, intubation, king-tube, LMA.
Capnography, End-Tidal CO2. (Note: Acidosis treat with sodium bicarbonate).
3. Hypokalemia (Low Potassium) - Nausea, vomiting, diarrhea.
4. Hyperkalemia (High Potassium) - Renal failure, skipped dialysis. Sodium Bicarb; Calcium
Chloride; Albuterol. Medications: Playing hide and seek with Potassium.
4
5. Hypothermia (Cold) - Cover them up, shock management, patients become hypothermic
easily.
6. Tension Pneumothorax: Needle decompression or chest tube.
7. Tamponade (Cardiac): Fluid inside the sac of the heart. Pericardial synthesis ~ Needle inside
the sac of the heart to draw out fluids.
8. Toxins: “To Narcan or not to Narcan?” NO Narcan during cardiac arrest.
9. Thrombosis (Pulmonary): MI, symptomatic treatment
10. Thrombosis (Coronary): PE, symptomatic treatment
Procedures:
Precordial Thump: Used for unstable tachyarrhythmias when a defibrillator is not readily
available. Can stimulate depolarization within the heart to aid the ventricles.
Pit-Crew CPR (High-Performance CPR):
- “First in the Door” - Position One… Assuring the person is dead, imitates compressions,
goes to the righthand side
- Position-Two ~ AED, alternate compressions with position 1 on 2 minute intervals

- Position-Three ~ Initiate airway management, alternate with positions 1 and 2.
- Position-Four ~ First arriving paramedic
- Position-Five ~ Quality assurance, recording, documenting, communication
- Position-Six ~ Liaison -> Speaking with family
Double-Sequential Defibrillation: Two monitors, two sets of pads. Front and back. Asynchronis
defibrillation - At the same time. Hits more myocytes in the heart (about 90).

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Wednesday, December 5, 2018

Cardiology Exam 2 - Lecture Notes

1. Assess appropriateness for clinical condition

2. Identify and treat underlying cause

• Maintain patent airway; assist breathing as necessary

• Cardiac monitor to identify rhythm; monitor blood pressure and oximetry

• 12-lead ECG if available - Don’t delay therapy

3. Persistent bradyarrhythmia causing:

• Acutely altered mental status?

• Ischemic chest discomfort?

• Acute heart failure? (Auscultation, etc)

4. If NO - Monitor and Observe

5. If YES - Atropine // If Atropine ineffective: Try transcutaneous pacing; Dopamine infusion;

6. Consider: Expert consultation or trans-venous pacing

Depending on Protocol: Typically administered with an 1000 mL bag of saline.

TCP (Transcutaneous Pacing): *TRUMP CARD* If patient base-line altered, immediately go to

Drug Card on Slides in Canvas for Reference

Treating Adult Tachycardia:

2. Identify and treat underlying causes:

• Maintain patient airway; assist breathing as necessary

• Cardiac monitor to identify rhythm; monitor blood pressure and oximetry

3. Persistent tachyarrhythmia causing:

• Acutely altered mental status?

• Ischemic chest discomfort?

• Acute heart failure?

4. If YES - Synchronized Cardioversion ~ Consider sedation, regular narrow complex consider

Consider Adenosine before Amioderone

Amioderone: 150 mg over 10 minutes (VERY slow IV push), repeat if needed.

- Synchronized Cardioversion: Consider sedation… Generally patient is so altered that it

• 150 J ; lastly 200 J

Adult Cardiac Arrest:

- Directly after shock delivered, begin CPR without a thought

- Once IO or IV obtained begin medication administration:

- Recheck rhythm… Defibrillate, continue CPR.

Magnesium Sulfate: 2 grams Mag for polymorphic rhythms.

Refractory Definition: Patient is sustained in the rhythm regardless of treatment

* CHECK PATIENT PULSE BEFORE EVERY DEFIBRILLATION *

5 H’s and 5 T’s ~ The Causes of Cardiac Arrest

1. Hypovolemia (Loss of volume) - Normal Saline, plasma-line, Lactated-Ringers (burns and

3. Hypokalemia (Low Potassium) - Nausea, vomiting, diarrhea.

6. Tension Pneumothorax: Needle decompression or chest tube.

8. Toxins: “To Narcan or not to Narcan?” NO Narcan during cardiac arrest.

9. Thrombosis (Pulmonary): MI, symptomatic treatment

10. Thrombosis (Coronary): PE, symptomatic treatment

Pit-Crew CPR (High-Performance CPR):

- Position-Two ~ AED, alternate compressions with position 1 on 2 minute intervals

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TCP (Transcutaneous Pacing): TRUMP CARD If patient base-line altered, immediately go to