Cardio review

Dhafer Alshehri Meshari Almutari

PGY4
Cardio review
• Cardio review 1
Quiz + Approach to Bradyarrhythmia

• Cardio review 2
Quiz + Approach to Tachyarrhythmia
Cardio review I
 1- A 45-year-old male discharged from the hospital five days ago for ST
elevation myocardial infarction presents to the emergency department
with acute onset shortness of breath. Physical exam reveals a new
holosystolic murmur heard best at the lower left sternal border as well
as at the right lower sternal border. EKG shows deep q waves in V1 and
V2. What is the most appropriate pharmacotherapy for this patient’s
condition?

• A. Afterload reduction
• B. Inotropic medication
• C. Preload reduction
• D. Vasoconstriction
Surgical Complications of MI
• Occur days after MI (pt may not be aware they had MI)
• Flash pulmonary edema and shock
1- If free wall rupture
• Large effusion on POCUS
2- If ventricular wall rupture → new murmur
3- If mitral valve blow out → new murmur
• Treatment
• Fluids/pressors
• Emergent CV surgery consult
2- A 70-year-old man is brought to the emergency department by
ambulance after a by-stander called 911 because she saw him faint
while walking his dog 30 minutes ago. The patient states that he feels
short of breath, and does not recall what happened. He denies any
past medical history, but states that he has experienced chest pain and
shortness of breath in the past, particularly with exercising. Blood
pressure is 160/130 mmHg and O2 saturation is 100%. Physical
examination shows a grade IV/VI crescendo-decrescendo systolic
murmur best heard over the second intercostal space at the right
border of the sternum. An electrocardiogram shows left bundle branch
block. Which of the following is the most appropriate next step in
management?
A. Administer nitroglycerin 0.4 mg sublingual
B. Administer systemic thrombolytics
C. Consult cardiothoracic surgery
D. Order computed tomography pulmonary angiography
Aortic stenosis
Aortic stenosis
3- A 56yo man with history of porcine mitral valve presents with
lethargy, fever and chest discomfort. His exam is notable for a new 4/6
murmur heard best over the apex of the heart, new bilateral lower
extremity edema, mild bilateral basilar crackles and rare retinal
hemorrhages. His vital signs are T 102F (38.9 C), HR 112, BP 142/78, RR
28, Sat 96% on room air. What is the best initial management?

A. Start Vancomycin IV and admission

B. Admission and echocardiography
C. Call Cardiothoracic surgery and prepare the patient for the OR
D. Obtain a detailed social history including alcohol and drug abuse
Infective endocarditis
• Classic presentation = acute fever, CHF, and valvular failure
• Can present as undifferentiated subacute, flu-like illness
• Usually involves mitral valve, with left-sided failure
• Caused by Strep or mouth organisms
• Increasing incidence of right-sided form
• If indwelling lines or IVDU
• Caused by Staph
• Imaging
• Xray could look like multiple pneumonias
• Septic emboli from right-sided valve vegetations
• Management
• Blood cultures - 3 sets
• Empiric IV antibiotics
• Cardiac echo
• High risk dental and GI/GU procedures need antibiotic prophylaxis
Infective endocarditis
4- A 45-year-old male with a history of congenital long QT syndrome
and no recent hospitalizations presents to the ER with cough and fever
for one week. Chest radiograph reveals a right lower lobe pneumonia.
What is the most appropriate outpatient medication for this patient’s
condition?

A. Azithromycin
B. Clarithromycin
C. Doxycycline
D. Levofloxacin
long QT syndrome
long QT syndrome
5- A 45-year-old female with a history of lupus presents to the
emergency department with a chief complaint of chest pain, shortness
of breath, and fever for 4 hours. The pain is sharp, constant,
exacerbated by lying down and relieved by leaning forward. EKG shows
diffuse ST elevations as well as PR depression. Chest radiograph is
remarkable for an enlarged cardiac silhouette. Two sets of troponins 4
hours apart are negative. Vital signs are: HR 110 bpm, RR 24 bpm, BP
145/90 mmHg, O2 sat 98% on room air, and temperature 98.6F (37C).
Which of the following is the most appropriate next step in
management?

A. Bedside echocardiogram
B. CT pulmonary angiography
C. C. Discharge home with NSAIDS and close follow-up
D. NSAIDS and admission for observation
Pericarditis
• Inflammation of outside of heart
• Usually viral but can also be
secondary to
• Uremia
• Lupus
• Malignancy
• Fungal
• Classic symptom is chest pain that
improves when sitting up and leaning
forward
• May hear “rub” on auscultation
Pericarditis
• ECG changes
• Diffuse ST elevations except aVR and V1
• Changes are split into stages (can take weeks to
months to years to progress through stages)
• PR depression and ST segment elevation
• ECG normalizes
• T wave inversion phase
• ECG normalizes
• Check troponin to rule out myocarditis
• Imaging
• Ultrasound to look for effusion and tamponade
• Treatment
• Usually discharge home if stable
• NSAIDs
• Colchicine can prevent sequelae
Pericarditis VS MI ?
Pericarditis VS MI
• Steps to distinguish pericarditis from STEMI:
• Is there ST depression in a lead other than AVR or V1? This is a
STEMI
• Is there convex up or horizontal ST elevation? This is a STEMI
• Is there ST elevation greater in III than II? This is a STEMI
• Now look for PR depression in multiple leads… this suggests
pericarditis (especially if there is a friction rub!)
6- A 55-year-old male with COPD is brought in to the emergency
department complaining of acute onset of palpitations. His
medications include theophylline. Vital signs are stable except for
heart rate of approximately 140. ECG is shown. What is the most
appropriate next step in management?

A. Amiodarone
B. Esmolol
C. Lidocaine
D. Synchronized cardioversion
SVT
SVT
SVT
7- A 45-year old male presents to the emergency department with
three hours of substernal chest pain and shortness of breath. On exam
he is diaphoretic but his vital signs are otherwise stable. EKG is shown
below and is unchanged on repeat. Initial troponin is elevated at 0.8
ng/dL. The remainder of his initial labs including a chemistry panel and
CBC are normal. What is the most likely underlying cause of this
patient’s presentation?

A. Angina secondary to new plaque

formation without cell death
B. Non-transmural myocardial
infarction
C. Pulmonary embolism
D. Transmural myocardial infarction
Ischemic ECG
Ischemic ECG
8- A 72-year-old male with type 2 diabetes, hypertension, and a
history of aortic stenosis requiring valve replacement one month prior
presents to the emergency department with fever and fatigue of 3
days’ duration. Vital signs are: BP 145/87 mmHg, P 107 bpm, RR 20
bpm, O2 Sat 94%, and T101.4F (38.2C). Physical examination is
remarkable for a 3/6 decrescendo diastolic murmur at the right upper
sternal border and faint crackles present at both lung bases. Which of
the following is the most likely causative organism?

A. Aspergillus
B. Staph aureus
C. Strep pneumoniae
D. Strep viridians
Infective endocarditis
9- A 65-year old male with a history of Paget’s disease of the bone
presents to the Emergency Department with gradually progressive
shortness of breath. He has no other past medical history and has
always been active and healthy. Physical exam is significant for an S3
on cardiac ausculatation, as well as bilateral rales. EKG is remarkable
for low grade tachycardia but is otherwise normal, with no ST changes
or q waves. Which of the following is the likely precipitating cause of
this patient’s symptoms?

A. Arteriovenous connections in the new bone

B. Atherosclerotic calcification
C. Chronic hypercalcemia
D. Myocardial hypertrophy
High output Heart frailer
 High output Heart failure
• Heart can’t generate enough output to meet demands despite working
over-time
• Classic causes
• AV shunts
• Anemia (simple profound anemia)
• Hyperthyroidism
• Generalized peripheral vasodilation
• Erythroderma from drug reaction
• Burns
• Beri Beri - vitamin B1 deficiency
• Provide supportive care and treat underlying cause
• Can cause cardiomyopathy
10. A 45-year old male presents to the Emergency Department with
acute onset chest pain and shortness of breath less than 1 hour ago
while mowing his lawn. Initial EKG is shown below. Which coronary
artery is most likely to be occluded?

A. Left Anterior Descending

B. Left Circumflex Artery
C. Right Coronary Artery
D. Sinoatrial artery
11- A 55-year old male with a history of recently diagnosed and
untreated small cell lung cancer presents with acute on chronic
shortness of breath for 1-2 hours. He is speaking 4-5 word sentences
and is diaphoretic. BP 78/45, P 121, RR 29, T99.0F (37.2C), O2Sat 99%
room air. Lung auscultation demonstrates minimal bibasilar crackles,
and cardiac auscultation reveals muffled heart sounds. The patient
demonstrates 6cm jugular venous distention. ECG is shown. Which of
the following is the most appropriate initial step in management of
this patient?

A. Dobutamine
B. Pericardiocentesis
C. Normal saline IV bolus
D. Rapid Sequence Intubation
11
Pericardial Tamponade
ECG changes
• Causes Tachycardia
• Traumatic
• Pericarditis Low voltages
• Uremia Electrical alternans (large and small QRS beat
• Lupus to beat)
• Viral
• Malignancy Imaging
• Look for Beck’s Triad U/S shows RV collapsing under pressure from
• Low BP, JVD and muffled effusion
heart sounds Treatment
• Might not see JVD in trauma IV fluids and
due to hypovolemia
If trauma → thoracotomy
If non-trauma → pericardiocentesis
12- A 65-year-old male patient presents to the emergency room with
the chief complaint of crushing substernal chest pain for one hour. Past
medical history includes atrial fibrillation, hypertension, diabetes, and
ischemic stroke 2 months prior (after undergoing left hip replacement).
Home medications include insulin, lipitor, atenolol, aspirin, and
warfarin. Vital signs are: BP 190/100 mmHg, HR 65 bpm, RR 12 bpm,
and O2sat 98% on RA. EKG is shown. Which of the following is an
absolute contraindication in this patient to administering
thrombolytics?
A. Anticoagulant use
B. Elevated blood pressure
C. Hip replacement surgery 2 months ago
D. Ischemic stroke 2 months ago
13-Paramedics brought in a 34-year-old man for fever and cough. He
denies any medical problems but has a history of drug abuse. He has
been having weight loss, dry cough and fever over the past 3 weeks,
with decreased appetite and malaise. On exam, vital signs are BP
95/62, HR 132, Temp 102.1°F, RR 22, and O2 saturation of 95% on RA.
There is no jugular venous distention present, but you note a 3 out of
6 systolic murmur that is heard best on the left sternal border, with
diffuse crackles on pulmonary exam. Chest x-ray is obtained (see
figure). What is the most LIKELY diagnosis?

A. Acute pulmonary hypertension

B. Pulmonary metastasis
C. Primary tuberculosis
D. Septic emboli
14- A 30-year-old female with no past medical history is brought in by
ambulance for loss of consciousness. She was walking to work when
she suddenly fainted. She was unconscious for an unknown amount of
time, but is now alert and oriented to person, place and time, and has
no neurologic deficits. The patient reports feeling palpitations and
lightheadedness before losing consciousness. Chest radiography is
within normal limits and EKG is as shown. Based on these findings,
what is the next best step in management for this patient?

A. Activation of cardiac catheterization laboratory for

emergent percutaneous coronary intervention
B. Admission for echocardiography
C. Admission for evaluation for automatic implantable
defibrillator device
D. Observation for serial troponins and ECGs, with
same-day treadmill stress testing
15- A 24-year-old man presents to the ED with intermittent
palpitations. He has had two prior visits for supraventricular
tachycardia that resolved with vagal maneuvers. He is currently
asymptomatic and hemodynamically stable. His ECG is shown. Which
of the following is the most appropriate next step?

A. 24-hour Holter monitor

B. Referral to electrophysiologist
C. Serial troponins
D. Stress echocardiogram
WBW
16- An 76-year-old previously healthy woman presents with severe
shortness of breath and respiratory distress. Her partner of 50 years
died unexpectedly two days prior. A complete evaluation, including an
echocardiogram, is consistent with Takotsubo syndrome. Which of the
following statements regarding this syndrome is most accurate?

A. Caused by ingestion of infected shellfish

B. Caused by a lesion in the left main coronary artery
C. Palliative management is appropriate
D. Supportive management is appropriate
Takotsubo syndrome
Takotsubo syndrome
• Takotsubo syndrome
• “Broken heart disease” - clear coronaries, no
vasospasm
• Reversible but often fatal
• Related to acute stress with huge catecholamine
outburst
• Symptoms/signs
• STEMI/CHF
• Troponin bump
• Characteristic echo

Take home point

Takotsubo syndrome is a non-ischemic cardiomyopathy that is
often reversible and associated with emotional stress.
• 17- A 42-year-old woman with an AICD presents to the ED after
experiencing multiple shocks over the past few hours. For which of
the following conditions may the application of a magnet be
indicated?

A. Electrolyte disturbance
B. Lead displacement
C. Lead fracture
D. Recurrent SVT
ICD
• 18- A 35-year-old woman with systemic lupus erythematosus
presents to the ED with dyspnea and weakness. She has a history of
pleuritis and pericarditis. A point of care echocardiogram reveals a
large pericardial effusion. Vitals are: HR 105, BP 110/70, RR 28 and
SpO2 96% on room air. Which of the following clinical findings would
increase the likelihood of this patient requiring a pericardiocentesis?

A. Systolic BP of 110 mmHg on expiration and 105 mmHg on inspiration

B. Systolic BP of 95 mmHg on expiration and 110 mmHg on inspiration
C. Systolic BP of 105 mmHg on expiration and 110 mmHg on inspiration
D. Systolic BP of 110 mmHg on expiration and 95 mmHg on inspiration
19-A 55-year-old woman presents to the ED with acute chest pain for
one hour. Her ECG is shown. Which of the following is the most
optimal management?

A. Low molecular weight heparin (LMWH) and admission

B. Referral for urgent PCI or surgery
C. Serial ECG and troponin measurement
D. Sublingual nitroglycerin
19
STE:AVR
20- A 44-year-old man presents to the ED with an inferior and right
ventricular MI seen on 12-lead ECG. Upon arrival to the ED, his rhythm
strip is obtained and shown below. Which of the following is the most
likely mechanism for this?

A. AV nodal artery ischemia

B. Decreased vagal tone
C. SA nodal artery ischemia
D. Sino-atrial exit block
Bradycardia
?
?
?
?
Easy way to identify AV block
1 2
RR PR
1st Fixed Fixed

2ed Mob1 Ø
2ed Mob2
Ø Fixed

3th Fixed
Ø
 Cardio review II
Dhafer Alsheri Meshari Almutari
PGY4
1- A 34 year female presents to the Emergency Room with a chief
complaint of fever and fatigue for several days. Past medical history is
significant for "some type of heart valve problem". Vitals are: BP
100/70 HR 110 RR 12 O2sat 100% T 101.7F (38.7C). Exam is significant
for tender lesions on the tips of her fingers. Which of the following is
the correct term for these lesions?

A. Erythema marginatum
B. Janeway lesions
C. Osler's nodes
D. Subcutaneous nodules
Infective endocarditis
Who need prophylaxis?
2- An 18-year-old male is brought by ambulance to the Emergency
Department after a sudden cardiac arrest during football practice. His
line coach witnessed this event and immediately placed an automatic
external defibrillator on him, shocking him with immediate return of
spontaneous circulation. In the Emergency Department, the patient
regains consciousness and endorses feeling palpitations immediately
before his syncopal episode. Physical examination reveals normal vital
signs and is otherwise unremarkable. An emergent formal
transthoracic echocardiogram shows normal ejection fraction, normal
anatomy and no wall motion abnormalities. Which of the following
EKG findings is consistent with this patient's likely underlying
pathology?
A. Needle-like Q waves in all leads.
B. Shortened PR-interval and slurred upstroke in the QRS complex
C. S1Q3T3
D. Electrical alternans
WBW
3- A 55-year old male with a history of diabetes, hypertension, COPD
and coronary artery disease with two drug eluting stents placed in the
past, presents to the Emergency Department with chest pressure and
shortness of breath. Physical exam is significant for an irregular heart
rhythm and wheezes in all fields as well as 1+ pitting edema to the mid
shins bilaterally. Initial cardiac monitor rhythm strip is shown below. In
addition to oxygen therapy as needed, what is the most appropriate
initial treatment of this patient’s condition?

A. Adenosine
B. Albuterol and Atrovent
C. Cardioversion
D. Diltiazem
MAT
4- A 56-year-old male presents to a rural emergency department with
the chief complaint of chest pain for the past 20 minutes. Past medical
history is significant for hypertension and high cholesterol. Vital signs
are: BP 172/91 mmHg, HR 80 bpm, RR 16 bpm, O2sat 97%. On exam,
the patient is diaphoretic and clutching his chest. ECG is shown. The
nearest facility with cardiac catheterization capability is more than 2
hours away by transport. Which of the following is the next best step
in management of this patient?

A. Administer calcium gluconate and consult renal

B. Administer fibrinolytics
C. Administer unfractionated heparin while pending cardiology
consultation
D. Emergent transfer to outside facility for percutaneous
coronary intervention
4
STEMI Therapy
• Know coronary artery territories
• Treatment
• Initial treatment is same as for NSTEMI
• O2 PRN
• ASA
• Nitroglycerin
• Heparin
• +/- additional platelet inhibitors (clopidogrel, ticagrelor)
• Thrombolytics vs primary percutaneous intervention (PCI)
• Indications for thrombolytics
• ST elevations of 1-2 mm in ≥ 2 anatomically contiguous leads
• Pain < 12 hours
5- A 55-year-old male presents to the emergency department 3 weeks
after undergoing cardiac catheterization for an ST elevation myocardial
infarction. He complains of 2 days of substernal chest pain worsened
by inspiration. Electrocardiogram (ECG) reveals diffuse ST elevations.
He does not have a copy of his previous ECG. Given the timing of his
symptoms, what is the most likely diagnosis?

A. Dressler's Syndrome
B. Left ventricle aneurysm
C. Myocarditis
D. Papillary muscle rupture
Dressler's Syndrome
Differential Diagnosis for Diffuse ST-Elevation
1- Large Acute STEMI
Has reciprocal ST-segment depression
Evolving changes (especially with tx)
2- Pericarditis/Myocarditis
No reciprocal ST-segment depression
PR-segment depression (not specific)
3- Ventricular aneurysm
• No reciprocal ST-segment depression
• + Q-waves
4- Early repolarization
No reciprocal ST-segment
depression
No PR-segment depression
Fishhook j-point elevation
5- Vasospasm
No reciprocal ST-segment
depression
May evolve with treatment
6- A 63 year old male presents to the Emergency Department (ED)
complaining of fatigue for the last several weeks. Past medical history
is significant for diabetes, hypertension, and high cholesterol. He had a
dental root canal procedure performed 3 weeks prior to his ED
presentation. Vitals sign are: BP 148/90, P 94, RR 14, O2sat 97%RA. He
complains of subjective fevers at home but is afebrile on presentation.
Laboratory testing is significant for a Hemoglobin 9.7g/dl, MCV 84.
Exam is notable for a faint diastolic murmur heard best at the apex.
Which of the following is the most likely organism causing his disease
process?
A. Clostridium botulinum
B. Staphylococcus aureus
C. Staphylococcus epidermidis
D. Streptococcus viridans
Key

Streptococcus viridans is the most common etiologic bacterial agent

responsible for causing infective endocarditis secondary to
odontogenic procedures.
7- A 58-year-old man with no past medical history presents with
several 20 minute episodes of heaviness in his chest for one day.
These episodes are triggered with even minimal exertion and are
associated with lightheadedness, nausea and diaphoresis. His ECG is
shown. His vital signs and exam are normal and he is currently
symptom free. Cardiac troponin is negative. What is the most
appropriate disposition?

A. Coronary care unit

B. Home with aspirin
C. Observation unit for trending of troponins
D. Telemetry unit for stress testing
8- A 76-year-old woman presents to the ED with chest pain. A 12-lead
ECG reveals ST elevation in leads I and aVL. Which of the following
additional findings increases the likelihood of an occlusive myocardial
infarction?

A. ST depression absent in all other leads

B. ST depression in III and aVF
C. ST depression in V5 and V6
D. ST depression present in all other leads
9
9- A 70-year-old man presents to the ED with abrupt onset chest pain,
weakness and dyspnea. Examination reveals a new diastolic murmur
and point of care ultrasound is positive for pericardial fluid. Which of
the following is most likely responsible for the murmur?

A. Aortic regurgitation
B. Mitral stenosis
C. Pulmonic regurgitation
D. Tricuspid stenosis
Cardiac Valvular Disease
• Acute mitral regurgitation
• Look for in ACS
• Clinical signs
• Pulmonary edema without increase in heart size
• Drop in BP
• Pansystolic murmur
• Treatment
• Cath lab vs OR (need IABP)
• Acute aortic regurgitation
• Look for in aortic dissection
• Diastolic murmur and tearing chest pain
• Look for MI on ECG and effusion on U/S
10- A 78-year-old man is brought to the ED for progressive shortness of
breath and recent syncope. He is tachycardic but normotensive. He has
evidence of respiratory distress and rales on examination. Chest x-ray
shows pulmonary edema and his most recent echocardiogram reveals
an aortic valve area of 0.8 cm² (normal is 3 - 4 cm²). Which of the
following medication classes is likely the safest to use in stabilizing this
patient while awaiting definitive care?

A. Beta-blockers
B. Calcium channel blockers
C. Diuretics
D. Nitroglycerin
Take home point
The management of pulmonary edema in the setting of critical aortic
stenosis is challenging. All medical therapies can make these patients
worse but judicious use of diuretics are recommended for
symptomatic patients.
11- A 78-year-old woman with a history of coronary artery disease
presents to the ED with dyspnea. She denies chest pain or orthopnea.
Vitals are: HR 60, BP 105/80, RR 16 and SpO2 98% on room air.
Examination reveals crackles bilaterally in the chest and peripheral
pitting edema. There is no accessory muscle use. Her CXR shows
cardiomegaly and pulmonary venous congestion. Which of the
following is the most appropriate management?

A. Diuretics
B. NIPPV
C. Nitrates
D. Opiates
CHF
• Causes Treatment
• Ischemic heart disease, prior MI Oxygen only if hypoxic
• Cardiomyopathies BiPap/CPAP applied early
• EtOH Furosemide (if fluid overload)
• Cocaine Morphine is out! Nesiritide is out!
• Symptoms/signs Phlebotomy may help
• Left sided Decrease preload
• SOB, pulmonary edema, S3 Nitrates to vasodilate
• Right sided Not if hypotensive, RV MI, sildenafil
• JVD, hepatic congestion, peripheral edema Decrease afterload
• Right HF usually follows Left HF Nitrates at the higher dose range
• If not look for RV infarct or PE ACEIs
• Don’t be fooled by BNP To increase contractility
• If normal, then it isn’t CHF Bridge with vasopressors or IABP while waiting for stent/
• If elevated, could be causes other than CHF bypass
12- A 52-year-old man presents to the ED with pleuritic chest pain and
dyspnea on exertion for two weeks. His ECG is shown. He is otherwise
healthy, and this is his second episode in the last six months of the
same pain. Which of the following is the most appropriate
management?

A. Azathioprine
B. Colchicine
C. Dabigatran
D. Prednisone
12
13- A 72-year-old man presents to the ED with chest pain. His ECG is
shown. Transmural infarction of which ventricular wall is most
consistent with his ECG?

A. Anteroseptal
B. Inferior
C. Lateral
D. Posterior
.
13
14- A 22-year-old woman with a recent throat infection presents to the
ED with swelling and pain in her knees and ankles. Her throat culture
results are positive for group A streptococcus. Which of the following
additional findings would be required to make a diagnosis of acute
rheumatic fever?

A. Elevated CRP
B. Fever
C. Prolonged PR interval
D. Subcutaneous nodules
15- 66-year-old male patient presents with a 3-hour history of sudden onset left
sided chest pain, diaphoresis, and dyspnea. He notes a long-standing history of
hypercholesterolemia and cigarette smoking. Initial evaluation shows his vitals to
be HR 92 bpm, RR 22 bpm, and BP 92/64 mmHg. He is afebrile. He is noted to be in
obvious discomfort. His ECG confirms a sinus rhythm with a rate of 92 bpm. His PR
and QRS intervals are normal, and he has a normal QRS axis of 75 deg. He has
inverted T waves in leads III and V1-V3. He has ST segment elevation of 2.5 mm in
V1 as well as ST segment elevation of 1 mm in II, III, and aVF. Q waves are seen in II,
III, and aVF. After ECG review, you decide to add right precordial leads, which show
ST segment elevation of 2.5 mm in V4R. Of the following options, which of his ECG
findings is most sensitive and specific for right ventricular infarction?

A. Q waves in the inferior leads

B. ST segment elevation in V4R
C. ST segment elevation of V1
D. ST segment elevation of the inferior leads
RV infarct
16- When attempting transvenous pacing, which of the following is the
preferred site for access?

A. Right external jugular vein

B. Right femoral vein
C. Right internal jugular vein
D. Right subclavian vein
Transvenous pacing
17- A 31-year-old man presents after passing out while mowing his
lawn. He remembers feeling short of breath before he fainted but
currently denies shortness of breath, chest pain, and history of anxiety
Physical examination reveals a healthy-appearing man with a harsh
crescendo-decrescendo midsystolic murmur that increases with a
Valsalva maneuver. An ECG is obtained. Assuming basic laboratory test
results are normal, which of the following diagnostic studies should be
ordered?

A. Chest radiography
B. Head CT
C. Coronary CT angiography
D. Transthoracic echocardiography
18 - What is the diagnosis?
19- Unstable 60 years old male came this rhythm , How to manage?
Torsades de Pointes
Torsades de Pointes Managment
1- shock patient with defibrillation dose. If unstable
2- Give 1-2 gram magnesium then DON NOT FOFGET TO BUT HIM IN
INVUSIIN 1-2gram/h
3- If patient not respond or having on and off Torasad you have
tow options:
1- Overdrive pacing set the rat on 120
2- Give isoproterenol
 20- A 21-year-old man presents with sudden weakness and a rapid
heart rate. He is alert and oriented. Vital signs include BP 104/67, P
210 , R 22. The examination is remarkable for a very rapid and irregular
cardiac rhythm. He has a history of Wolff-Parkinson-White syndrome
but is otherwise healthy. Which of the following interventions is
correct for this patients condition?

A. Adenosine and synchronized cardioversion

B. Amiodarone and procainamide
C. Diltiazem and procainamide
D. Procainamide and synchronized cardioversion
20
Atrial Fibrillation
Tachyarrhythmias
• STEP 1: IV, O2, monitor, crash cart with airway equipment and
defibrillator to the bedside
• STEP 2: Is the patient stable or unstable?
• STEP 3: Are P waves present?
• STEP 4: Is it regular or irregular?
• STEP 5: Is it wide or narrow?
STEP 1: IV, O2, monitor, crash cart with airway
equipment and defibrillator to the bedside

• We must be prepared.
• All antiarrhythmic drugs are pro-arrhythmic and even electrical
cardioversion can result in lethal rhythms
STEP 2: Is the patient stable or unstable?

• Unstable patients = cardioversion.

• Ischemic chest pain.

• Altered mental status,
• Pulmonary edema
• Systolic BP < 90 mmHg
Are P waves present?
• P wave before each QRS complex

• P must look the same and be upright in leads II, inverted in avR.

• Many patients with sinus tachycardia will be unstable and in shock

due to an underlying cause (hemorrhage, sepsis, PE) - they need
blood or fluids or fibrinolytics, not cardioversion!

•
Are P waves present?
• special” P waves?
• Extremely fast, irregular, chaotic
= Atrial fibrillation (AFib)

• Regular sawtooth pattern at 300 bpm

= Atrial flutter (A-flutter)

• Distinct P waves of variable

morphology = Multifocal atrial
tachycardia (MAT)
STEP 4: Is it regular or irregular?
This is a key distinction:

• An irregular rhythm is not ventricular

tachycardia (e.g. the rhythm is coming
from above the AV node)

• Treatment of an irregular rhythm is thus

to block the AV node
STEP 5: Is it wide or narrow?
This is a key distinction:
• A narrow rhythm is not ventricular tachycardia (e.g. the rhythm is
coming from above the AV node)
• Treatment of an narrow rhythm is thus to block the AV node
• Narrow QRS is <0.12msec (3 small squares)