Medicine Marrow Pg No 407-416 (ECG)
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Questions and Answers

What is the initial energy level used for Atrial fibrillation?

  • 200 J
  • 300 J
  • 100 J
  • 50 J (correct)

    • An unsynchronized procedure requires connecting the electrode to the patient.

    False

    Where should the paddles be placed for the cardioverter/defibrillator procedure?

    Right side of the upper sternum, below the clavicle and apex of the heart (left of the nipple)

    The starting energy level for Polymorphic Ventricular Tachycardia is ______ J.

    <p>200</p> Signup and view all the answers

    Match the arrhythmias with their corresponding starting energy levels:

    <p>Atrial fibrillation = 50 J Atrial flutter = 50 J Monomorphic Ventricular Tachycardia = 100 J Polymorphic Ventricular Tachycardia = 200 J</p> Signup and view all the answers

    What is a characteristic feature on an ECG for WPW syndrome?

    <p>Short PR interval</p> Signup and view all the answers

    The prognosis for atrial fibrillation in manifest WPW syndrome is considered good.

    <p>False</p> Signup and view all the answers

    What are delta waves associated with in the context of WPW syndrome?

    <p>Pre-excitation of the ventricle</p> Signup and view all the answers

    In concealed WPW syndrome, the 12-lead ECG appears __________.

    <p>normal</p> Signup and view all the answers

    Match the type of WPW syndrome with its characteristic feature:

    <p>Concealed = Good prognosis for A.fib Manifest = Bad prognosis for A.fib</p> Signup and view all the answers

    Which of the following are risk factors for plaque formation? (Select all that apply)

    <p>Hypertension</p> Signup and view all the answers

    Obstructive sleep apnea syndrome is a risk factor for large vessel coronary artery disease.

    <p>True</p> Signup and view all the answers

    What is the most crucial preventable cause of plaque formation?

    <p>Smoking</p> Signup and view all the answers

    The presence of __________ is significant when stenosis is ≥ 60-70%.

    <p>plaque</p> Signup and view all the answers

    Match the following determinants of oxygen supply and demand:

    <p>Systemic blood pressure = O₂ Demand Heart rate = Both O₂ Supply and Demand Coronary artery resistance = O₂ Supply Myocardial wall stress = O₂ Demand</p> Signup and view all the answers

    What is the characteristic feature of polymorphic VT?

    <p>Multiple different complexes with changing polarities</p> Signup and view all the answers

    Low potassium levels can lead to Torsades de pointes.

    <p>True</p> Signup and view all the answers

    What is the primary treatment for congenital Torsades de pointes?

    <p>β-blockers</p> Signup and view all the answers

    Immediate __________ is a critical management step for acquired Torsades de pointes.

    <p>defibrillation</p> Signup and view all the answers

    Which of the following is not a warning sign of ventricular arrhythmias?

    <p>Exercise-induced</p> Signup and view all the answers

    Match the following causes of Torsades de pointes with their category (Acquired or Congenital):

    <p>Low Magnesium = Acquired Long QT Syndrome = Congenital Antiarrhythmics = Acquired Hypothermia = Acquired</p> Signup and view all the answers

    Sustained monomorphic VT is characterized by a heart rate greater than 200 bpm.

    <p>True</p> Signup and view all the answers

    What is the duration for a sustained monomorphic VT episode?

    <p>30 seconds</p> Signup and view all the answers

    In ventricular tachycardia (VT), the QRS duration is wider than _____ seconds.

    <p>0.16</p> Signup and view all the answers

    Match the following characteristics to their appropriate types of ventricular tachycardia:

    <p>Monomorphic VT = All complexes look alike Wide QRS tachycardia = Duration &gt; 0.16 s Non-sustained VT = Episodes &lt; 30s Sustained VT = Episodes ≥ 30s</p> Signup and view all the answers

    What is the typical rate of Accelerated Idioventricular Tachycardia (AIVT)?

    <p>40 - 100 bpm</p> Signup and view all the answers

    Ventricular Premature Complexes (VPC) can be preceded by a P wave.

    <p>False</p> Signup and view all the answers

    What is the mechanism responsible for Ventricular Premature Complexes (VPC)?

    <p>Extrasystole</p> Signup and view all the answers

    The distance between the VPC and the preceding QRS complex is called the ______.

    <p>coupling interval</p> Signup and view all the answers

    Match the following terminology with their definitions:

    <p>Monomorphic VT = Same morphology QRS complexes Polymorphic VT = Variable morphology QRS complexes Compensatory pause = Distance between two sinus impulses across VPC R on T phenomena = VPC occurs on preceding wave</p> Signup and view all the answers

    What characterizes Acute Coronary Syndrome (ACS)?

    <p>Plaque formation in epicardial arteries</p> Signup and view all the answers

    Syndrome X is typically found in young male smokers.

    <p>False</p> Signup and view all the answers

    What type of thrombi is critical in ST elevation myocardial infarction (STEMI)?

    <p>Fibrin rich thrombi</p> Signup and view all the answers

    In Syndrome X, the patient's response to treatment is generally considered ______.

    <p>benign</p> Signup and view all the answers

    Match the following features with their corresponding syndromes:

    <p>Post menopausal female = Syndrome X Young male smokers = Syndrome Y Exertional angina = Syndrome X Sudden cardiac death = Syndrome Y</p> Signup and view all the answers

    What is defined as two VPCs occurring in succession?

    <p>Couplet</p> Signup and view all the answers

    Parasystole is characterized by VPCs that have different coupling intervals.

    <p>True</p> Signup and view all the answers

    What heart rate is classified as Ventricular Tachycardia (VT)?

    <p>greater than 100 bpm</p> Signup and view all the answers

    A __________ is defined as isolated VPCs that occur after every sinus beat.

    <p>Ventricular Bigeminy</p> Signup and view all the answers

    Match the types of VPC patterns with their definitions:

    <p>Ventricular Bigeminy = Isolated VPCs after every sinus beat Ventricular Trigeminy = Isolated VPCs after every two sinus beats Couplet = Two VPCs occurring in succession VT = Three or more VPCs in a row with high heart rate</p> Signup and view all the answers

    Which feature is characteristic of ventricular tachycardia (VT)?

    <p>Widened QRS complexes</p> Signup and view all the answers

    Capture beats originate from the abnormal conduction pathway.

    <p>False</p> Signup and view all the answers

    What is the management for hemodynamically unstable VT?

    <p>Synchronized DC Cardioversion</p> Signup and view all the answers

    A characteristic feature measured in Brugada Sign is a time interval longer than _____ ms.

    <p>100</p> Signup and view all the answers

    Match the following signs with their descriptions:

    <p>Brugada Sign = Distance from QRS onset to S wave nadir &gt; 100 ms Josephson's Sign = Notching at S-wave nadir Concordance = Direction of QRS complexes in leads Fusion Beats = Characteristics of sinus rhythm and VT</p> Signup and view all the answers

    Which medication is used for stable VT with structural heart disease?

    <p>Amiodarone</p> Signup and view all the answers

    Polymorphic VT requires immediate defibrillation in all cases.

    <p>False</p> Signup and view all the answers

    What is the key characteristic of conduction abnormalities noted in ventricular tachycardia?

    <p>Absent RS Complex</p> Signup and view all the answers

    What characterizes Type A Left Sided WPW?

    <p>Tall positive R wave and delta wave</p> Signup and view all the answers

    The delta wave on an ECG indicates delayed impulse transmission.

    <p>False</p> Signup and view all the answers

    What is the role of the SA Node in the heart?

    <p>Starting point of the electrical impulse</p> Signup and view all the answers

    In manifest WPW, early diagnosis leads to __________ treatment for managing the condition.

    <p>catheter ablation</p> Signup and view all the answers

    Which medication is used to treat Atrial Ventricular Reentrant Tachycardia (AVRT)?

    <p>Adenosine</p> Signup and view all the answers

    Match the manifestations of WPW with their definitions:

    <p>Pre-excitation = Atria and ventricles contract before normal conduction Delta Wave = Characteristic early upstroke on the ECG Short PR Interval = Interval between P wave and QRS complex is too short Bundle of Kent = Abnormal accessory pathway between atria and ventricles</p> Signup and view all the answers

    Sinus rhythm always indicates the absence of delta waves in WPW.

    <p>False</p> Signup and view all the answers

    What is the primary goal of catheter ablation in WPW syndrome?

    <p>To eliminate the accessory pathway</p> Signup and view all the answers

    Study Notes

    Cardioversion/Defibrillation Procedures

    • Synchronized: Cardioverter/defibrillator is synchronized with the patient's rhythm.
    • Unsynchronized: No need to connect the electrode to the patient.
    • Paddle Placement:
      • Right side of the upper sternum, below the clavicle.
      • Apex of the heart (left of the nipple).
    • Energy Levels:
      • Atrial fibrillation (A.Fib): Start with 50 J, then 100-200 J.
      • Atrial flutter (A.Flutter): Start with 50 J.
      • Polymorphic Ventricular Tachycardia (Polymorphic VT): Start with 200 J.
      • Monomorphic Ventricular Tachycardia (monomorphic VT): Start with 100 J.

    WPW Syndrome

    • ECG Features:
      • Normal P wave.
      • Short PR interval.
      • Delta waves.
      • Near normal QRS.
      • 2° ST & T wave changes.
    • Mechanism:
      • SA Node: Starting point of the electrical impulse in the heart.
      • Bundle of Kent: Abnormal accessory pathway between the atria and ventricles.
      • Pre-excitation: The atria and ventricles contract before the normal conduction.
    • Types:
      • Concealed: Normal ECG, conduction via AV node.
      • Manifest: Abnormal ECG, conduction via Bundle of Kent (BOK), A.fib.
    • Management:
      • Concealed: Adenosine for AVRT, referral to Electrophysiologist.
      • Manifest: Early diagnosis, Catheter Ablation is definitive treatment.

    Ventricular Arrhythmias

    Warning Signs

    • Increased frequency of episodes.
    • Multifocal.
    • Bigeminy/couplet.
    • First episode > 40 years.

    Ventricular Tachycardia (VT)

    • Monomorphic VT:
      • ECG features:
        • Wide QRS tachycardia (> 0.16 s).
        • Rate > 200 bpm.
        • All complexes look alike (monomorphic VT).
        • Sustained monomorphic VT: Sustained ≥ 30s.
      • Not affected by: Exercise, parasystole, LV dysfunction.

    Polymorphic VT

    • Multiple different complexes with changing polarities.
    • Usually associated with prolonged QT: Torsades de pointes (TdP).

    Causes of TdP

    • Acquired: MI, Low K+, Low Ca2+, Low Mg2+, Hypothermia, Drugs (Antiarrhythmics, Macrolides, Antihistaminics)
    • Congenital: Long QT Syndrome

    Management of TdP

    • Acquired: Immediate defibrillation, IV MgSO4, Rhythm stabilization, Rx of Cause.
    • Congenital: β-blockers.

    Cardioversion vs. Defibrillation

    • Cardioversion: Current discharged at the same time as the patient's QRS.
    • Defibrillation: Current discharged through defibrillator machine.
    • Risk of V.Fib: If current discharged at the vulnerable period of the T wave.

    Broad QRS Tachyarrhythmias

    • Pathophysiology:
      • Source: Ventricle.
      • Mechanism: Cell-to-cell transmission → Broad QRS.
      • Rhythm:
        • Idioventricular Tachycardia (IVT)
        • Accelerated Idioventricular Tachycardia (AIVT)
      • Rate:
        • IVT: 15 - 40 bpm.
        • AIVT: 40 - 100 bpm.
        • VT: > 100 bpm.
      • Causes: Monomorphic VT, Polymorphic VT, QRS > 0.165; Supraventricular Tachycardia (SVT) with bundle branch block (BBB), Antidromic AVRT (WPW syndrome).

    Ventricular Premature Complexes (VPC)

    • Mechanism: Extrasystole, premature discharge from ventricle.
    • Criteria for VPC:
      • Not preceded by a P wave.
      • Very wide QRS complex.
      • ST/T changes in opposite direction.
      • Coupling interval: Always constant.
      • Compensatory pause: Distance between two sinus impulses across VPC/ distance between two sinus impulses across normal beat.
      • R on T phenomena: VPC lies on previous wave.

    Introduction to ACS

    • Pathophysiology:
      • Plaque formation in large epicardial arteries (>400µm).
      • Rupture, erosion, occlusion.
      • Critical with fibrin rich thrombi.
      • ST elevation MI (STEMI).
    • Types of plaque: Vulnerable, Non-vulnerable.
    • Cardiac syndromes: Syndrome X (post menopausal female, exertional angina, no cardiac diseases, good with antianginals, poor with vasodilators), Syndrome Y (young male smoker, rest angina, sudden cardiac death/arrhythmias).

    ECG Interpretation and Management of VT

    • Cardinal Features of VT:
      • Wide QRS.
      • Fusion Beats.
      • Capture Beats.
    • Specific Signs:
      • Brugada Sign.
      • Josephson's Sign.
      • Concordance.
    • Conduction Abnormalities:
      • Positive or Negative Concordance.
      • Absent RS Complex.
      • No P Waves/A-V Dissociation.
    • Management of VT:
      • Stable VT: Amiodarone, Procainamide, Lignocaine, Sotalol.
      • Hemodynamically Unstable VT: Synchronized DC Cardioversion.
      • Pulseless VT: Immediate attention and potentially defibrillation.
      • Polymorphic VT: Further investigations may be necessary.
      • Ventricular Fibrillation: Emergent intervention is needed.

    ECG Analysis

    • Parasystole: VPCs with different coupling intervals.
    • Multifocal VPC: VPCs with different morphologies.
    • Interpolated VPC: VPC sandwiched between two sinus impulses.
    • Ventricular Bigeminy: Isolated VPCs after every sinus beat.
    • Ventricular Trigeminy: Isolated VPCs after every sinus beats.
    • Couplet: Two VPCs in a row.
    • VT: Three or more VPCs in a row and a heart rate (HR) greater than 100 bpm.

    ECG Analysis: Left vs. Right Sided WPW

    • Left Sided WPW:
      • Type A:
        • Lt -> Rt conduction.
        • Positive tall R wave and delta wave.
        • Tall positive R wave.
      • Type B:
        • Rt -> Lt conduction.
        • Negative R wave and delta wave.
        • Negative R wave.
    • Manifestations of WPW:
      • SA Node: Starting point of the electrical impulse in the heart.
      • Bundle of Kent: Abnormal accessory pathway between the atria and ventricles.
      • Pre-excitation: The atria and ventricles contract before the normal conduction.
      • Short PR Interval: Interval between the beginning of the P wave and the beginning of the QRS complex is too short.
      • Delta Wave: A characteristic early upstroke on the ECG, indicating pre-excitation.
      • QRS Complex: The complex of waves on an electrocardiogram.
    • Management:
      • Concealed WPW: AVRT (Adenosine), Electrophysiologist.
      • Manifest WPW: Early DX, Catheter Ablation, A.Fib, Synchronised DC Cardioversion, Sinus Rhythm + Delta Wave, Refer to Electrophysiologist.

    Determinants of Oxygen (O₂) Supply & Demand:

    • O₂ Demand:
      • Systemic blood pressure (SBP).
      • Heart rate (HR).
      • Myocardial contractility.
      • Myocardial wall stress.
    • O₂ Supply:
      • Coronary artery resistance/diameter.
      • Heart rate (HR).
      • Perfusion pressure.

    Causes for Large Vessel CAD:

    • Spasm (Prinzmetal angina).
    • Vasculitis (Takayasu/Kawasaki).
    • Septic.
    • Plaque Formation.
    • Emboli.
    • Other sources.

    Risk Factors for Plaque Formation:

    • Family history.
    • Degree of calcification.
    • Lifestyle (physical inactivity).
    • Smoking (most crucial preventable cause).
    • Hyperlipidemia.
      • High sensitivity C-reactive protein (hs-CRP).
      • Low-density lipoprotein (LDL) (small dense/oxidized LDL).
      • Low high-density lipoprotein (HDL).
      • Lipoprotein Lipase A2 (Lp(a)).
    • Hypertension (alters vessel architecture, endothelial dysfunction).
    • Diabetes (associated with central obesity and insulin resistance).
    • Age (40-50 years).
    • Gender (female > male).

    Left Ventricular Hypertrophy (LVH):

    • Increased O₂ demand.

    Syndrome 2:

    • Obstructive sleep apnea syndrome (OSAS).
    • Centripetal obesity.
    • Hyperlipidemia.
    • Insulin resistance.
    • Hypertension.

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    Description

    This quiz covers essential procedures for cardioversion and defibrillation, including the differences between synchronized and unsynchronized techniques, paddle placement, and energy levels for various arrhythmias. Additionally, it provides insight into WPW syndrome, including ECG features and mechanisms. Test your knowledge of these critical cardiac concepts.

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