ACLS Bradycardia Case
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| Define First Degree AV block. | Every P has a QRS but the PR interval is longer than 5 small boxes or > 0.2 seconds
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| Define Second Degree AV block Type 1 Wenckebach/Mobitz1. | The PR interval gets progressively longer until a QRS beat is dropped, then the cycle starts again.
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| Define Second Degree AV block Type II (Mobitz II). | The PR interval remains constant, but a beat is dropped
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| Define third degree block. | the p waves and QRS waves are firing independently of one another
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| Discuss the primary vs the secondary goal in bradycardia. | The primary goal is identifying symptomatic bradycardia. The secondary goal is defining the type of AV block present.
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| Why is it so important to be able to identify 3rd degree heart block? | This the kind most likely to cause cardiovascular collapse and require immediate pacing
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| What are the signs and symptoms of symptomatic bradycardia? | chest discomfort, SOB, decreased level of consciousness, weakness, fatigue, light headedness, dizziness, syncope, hypotension, diaphoresis, pulmonary congestion/edema, CHF, PVC, VT
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| What is the first step in treating bradycardia with a pulse? | First determine if its clinically appropriate. Is the heart rate less than 50bpm and inadequate for the patient’s condition
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| What is the second step in the Bradycardia case? | Identify and treat underlying cause, maintain patent airway, Assist with breathing as necessary, Oxygen if hypoxemic, Cardiac Monitor for Rhythm, Monitor BP and O2sat, IV access, 12 lead ECG
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| What is the third step in the bradycardia case? | Decide if treatment is indicated. Is the bradycardia causing hypotension, altered mental status, signs of shock, ischemic chest pain, acute heart failure
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| What is the course of action if the bradycardic patient is asymptomatic/stable? | Monitor and observe
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| What is the course of action if the bradycardic patient is not adequately perfused? | Give Atropine 0.5mg bolus and repeat q 3-5 minutes to a maximum of 3mg. If atropine is ineffective, transcutaneous pacing OR Dopamine IV infusion at 2-10mcg/kg per minute OR Epinephrine infusion at 2-10 mcg per minute
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| What is the final step in the bradycardia case? | Consider expert consultation, Transvenous Pacing
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| Why is caution advised for the use of atropine if the patient has acute coronary ischemia or MI? | Atropine would increase the workload of the heart, the increased demand for oxygen could worsen ischemia or increase the size of the infarct
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| Under what circumstances would it be inappropriate to rely on atropine? | Mobitz type II second or third degree AV block or in patients with third-degree AV block with new wide QRS complex.
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| Can ACLS providers perform TCP? | yes
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| When should immediate TCP be considered? | in unstable patients with high degree heart block when IV access is not available and when patients do not respond to atropine
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| What steps should follow the initiation of pacing? | confirm electrical and mechanical capture, reassess for symptom improvement and hemodynamic stability, give analgesics and sedation for pain control, try to find and correct cause of bradycardia
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| What do we need to think about when giving analgesics and sedation with TCP? | Sedative effects may further decrease BP and affect patient’s mental status
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| What do you do if TCP doesn’t work? | begin an infusion of dopamine or epinephrine and prepare for possible transvenous pacing by obtaining expert consultation.
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| Most patients should receive sedation before TCP. When might it be necessary to provide pacing without sedation? | If the patient is in cardiovascular collapse or rapidly deteriorating, particularly if the drugs are not readily available
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| Define cardiovascular collapse. | Sudden loss of effective blood flow to the heart and periphery
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| What is the general approach for the use of drugs for sedation/pain relief and TCP? | parenteral benzodiazepine for anxiety and muscle contractions, parenteral narcotic for analgesia, chronotropic infusion once available, expert consultation
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| How does transcutaneous pacing work? | by delivering an electrical stimulus through the skin via electrodes to the heart causing electrical depolarization and subsequent cardiac contraction
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| What are the indications for transcutaneous pacing? | bradycardia resulting in unstable clinical condition: symptomatic sinus bradycardia, Mobitz type II second-degree AV block, Third degree AV block, New BBB or bifasicular block, bradycardia with symptomatic ventricular escape rhythms
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| What are the signs and symptoms of unstable bradycardia? | hypotension, acutely altered mental status, signs of shock, ischemic chest discomfort, acute heart failure hypotension
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| What are the precautions for transcutaneous pacing? | contraindicated for severe hypothermia, not recommended for asystole, requires analgesia for conscious patients if patient condition allows, carotid pulse not good indication of capture because muscular jerking may be misinterpreted as pulse
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| What are the four steps to transcutaneous pacing? | place electrodes on chest per directions, turn pacer on, set the demand rate to approximately 60/min (adjust to clinical condition once pacing is established), Set mA 2 above the dose at which consistent capture is observed.
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| What is the target heart rate for transcutaneous pacing? | Whatever rate resolves clinical status – for most patients improvement is noted at a rate of 60 to 70
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| What is the target heart rate for with transcutaneous pacing if the patient has ACS? Why? | the lowest heart rate that allows clinical stability in order to avoid increasing oxygen demand and thus worsening ischemic damage
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| What is the alternative to transcutaneous pacing if atropine is ineffective? | A chronotropic drug to stimulate heart rate
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| Which chronotropic drugs are recommend for symptomatic bradycardia other than Atropine? What are the recommended infusion rates? | Epinephrine: initiate at 2-10mcg/min and titrate to patient response; Dopamine 2-10 mcg/Kg/minute and titrate to patient response
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| Explain how bradycardia may lead to ventricular escape rhythms. | an electrically unstable ventricular area which may normally be suppressed by the higher and faster pacemaker/SA node, may begin to fire in bradycardia especially in the presence of ischemia
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| What is the danger connected with ventricular escape beats especially in cases of severe bradycardia? | It can precipitate VT or VF
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| How does pacing work to prevent bradycardia dependent escape rhythms? | It takes the place of the pacemaker, superseding the unstable ventricular area.
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| Discuss the use of Transcutaneous pacing and accelerated idioventricular rhythm. | AVIR may occur in the setting of inferior wall MI. The rhythm is usually stable and does not require pacing.
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| Discuss the role of transcutaneous pacing if the heart is healthy but suffering from conduction problems related to electrolyte abnormalities or acidosis. | After correction of the imbalance, rapid pacing can stimulate effective myocardial contractions until the conduction system recovers. (like using a generator till the electricity comes back on)
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| Describe standby pacing. | Having electrodes placed in anticipation of clinical deterioration in patients with acute myocardial ischemia or infarction.
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| Why might a patient need standby pacing? | Several bradycardia rhythms are due to ischemic malfunction of conduction/pacing cells. These arrhythmias may decompensate into total block and cardiovascular collapse.
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| What rhythms would cause you to initiate standby pacing? | sinus node dysfunction resulting in severe and symptomatic bradycardia, Asymptomatic Mobitz type II second degree, Asymptomatic third degree, new BBB or bifasicular block
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| What are the criteria for identifying Mobitz type II second degree AV block on an ECG? | rate: slow to normal, rhythm: irregular (QRS complexes are dropped), QRS’s are usually wide, Pwaves are upright, more p waves than QRS’s but PR interval is fixed and usually normal duration
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| What are the criteria for identifying 3rd degree AV block on an ECG? | There are usually more p waves than QRS’s. There is usually arterial and ventricular regularity, but they are independent of one another. Pwaves QRS’s are doing their own thing.
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