100 ECG’s
Ventricular: (8 questions)

Questions

• 1
  A 51 year old gentleman on the coronary care unit one day after primary angioplasty due to an anterior MI develops sustained tachycardia. His BP is 121/81, HR is 150, he denies shortness of breath, chest pain or dizziness, but does report the feeling of palpitations. He has a history of hypertension and is an ex-smoker of 20 pack year history. His ECG is shown. What is the most appropriate course of action?
  
  Difficulty: Medium     Topic: Ventricular arrhythmias
  a

  IV Amiodarone

  b

  Synchronized DC Cardioversion

  c

  Defibrillation

  d

  IV Adenosine

  e

  Watch and wait
  Explanation: The ECG shows a broad complex tachycardia most consistent with Ventricular Tachycardia as a complication of myocardial infarction. The patient however is haemodynamically stable and has no signs of circulatory compromise (eg: hypotension, chest pain, pulmonary oedema, or decreased cerebral perfusion). This means that he is in Stable VT, which is managed medically with IV Amiodarone. DC Cardioversion is reserved for haemodynamically unstable VT patients who have a pulse, whereas pulseless VT is managed using the ALS algorithm and includes Defibrillation (non-synchronised shock). Watch and wait would be inappropriate in this scenario as VT could possibly degenerate into VF.
• 2
  A 62 year old lady is admitted to the A&E department with loss of consciousness of a few minutes duration. She reports feeling palpitations and dizziness prior to collapse. She has a history of myocardial infarction 2 years ago and is a current smoker. Whilst you are examining her, she starts complaining of shortness of breath and palpitations. Her pulse is regular at a rate of 200 per minute and her BP is 74/38. Her ECG is shown. What is the most appropriate course of action?
  
  Difficulty: Medium     Topic: Ventricular arrhythmias
  a

  IV Amiodarone

  b

  Synchronized DC Cardioversion

  c

  Defibrillation

  d

  IV Adenosine

  e

  Watch and wait
  Explanation: The ECG shows a broad complex tachycardia most consistent with Ventricular Tachycardia (most likely scar-related from a previous MI). The patient is haemodynamically unstable as she is demonstrating signs of circulatory compromise (eg: hypotension, chest pain, pulmonary oedema, or decreased cerebral perfusion). This means that she is in Unstable VT, which is managed with immediate DC cardioversion to restore sinus rhythm and maintain adequate cardiac output. IV Amiodarone is reserved for haemodynamically stable VT patients. If the patient was pulseless, then her "pulseless VT" should be managed using the ALS algorithm and includes Defibrillation (non-synchronised shock). Watch and wait would be inappropriate in this scenario as her circulation is compromised.
• 3
  A 74 year old man with a history of triple vessel disease collapses while crossing the street in a busy city cetnre. A passer by phones the ambulance which arrives promptly. The paramedics perform an ECG on the patient (shown). He is unconscious and has no pulse. What is the best course of action by the paramedics ?
  
  Difficulty: Easy     Topic: Ventricular arrhythmias
  a

  IV Amiodarone

  b

  Synchronized DC Cardioversion

  c

  Defibrillation

  d

  IV Adenosine

  e

  Watch and wait
  Explanation: The ECG shows a broad complex tachycardia most consistent with Ventricular Tachycardia (most likely ischaemic or scar-related from previous ischaemic heart disease). The patient therefore has "pulseless VT" which is managed using the ALS algorithm and includes Defibrillation (non-synchronised shock). IV Amiodarone is reserved for haemodynamically stable VT patients, whereas Synchronized DC cardioversion is used in patients with unstable VT (signs of haemodynamic compromise, eg: chest pain, shortness of breath and hypotension) who HAVE a PULSE. Watch and wait would be inappropriate in this scenario as his circulation is compromised.
• 4
  During a busy night shift, the crash team is called to see an unconscious patient. You are the first person to arrive on scene. You assess the 66 year old patient and find that he is not breathing and has no pulse. His ECG is shown. You proceed with CPR and is then handed a cardiac defibrillator. You give the patient two shocks but his ECG rhythm remains unchanged and is still pulseless. What is the next best step to take ?
  
  Difficulty: Medium     Topic: Ventricular arrhythmias
  a

  Give IV Amiodarone and continue CPR

  b

  Give IV Adrenaline and continue CPR

  c

  Shock for a third time and continue CPR

  d

  IV Adenosine

  e

  Watch and wait
  Explanation: The ALS sequence in pulseless VT or VF is shock, shock, shock, then drug, shock, drug, shock. Therefore, it is appropriate to attempt a third shock, and if that fails to give IV Adrenaline between shocks whilst maintaining CPR.
• 5
  A student nurse is asked to do an ECG on a patient who is being assessed for chest pain in the acute medical admissions ward. They get the below ECG and is unsure on what to do next. They come to ask for your help, which of the following do you suggest as the most appropriate course of action ?
  
  Difficulty: Easy     Topic: Ventricular arrhythmias
  a

  Perform CPR while the nurse contacts the arrest team

  b

  Sound the cardiac arrest alarm and await the team's arrival

  c

  Ask her for a repeat ECG

  d

  Perform an arterial blood gas to check the potassium

  e

  Start the patient on naproxen
  Explanation: This unfortunate patient was having his ECG taken when he went into ventricular fibrilliation. Ventricular fibrillation is not compatible with cardiac output necessary for life so requires input from the cardiac arrest team as well as the attending clinicians. The best course of action would be to start CPR immediately while awaiting help to arrive.
• 6
  A 35 year old man is admitted to the acute medical unit for episodes of collapse. He is feeling lightheaded and drowsy. His ECG is shown. What is the diagnosis?
  
  Difficulty: Easy     Topic: Ventricular arrhythmias
  a

  Atrioventricular nodal rentry tachycardia (AVNRT)

  b

  Atrioventricular reciprocating tachycardia (AVRT)

  c

  Atrial fibrillation

  d

  Ventricular tachycardia

  e

  Sinus tachycardia
  Explanation: A broad complex tachycardia in this scenario is likely to be Ventricular tachycardia. All other options are narrow complex tachycardias.
• 7
  A 52 year old male with a past medical history of ischaemic cardiomyopathy and myocardial infarction presents to the emergency department with palpitations. An ECG is done (shown) and a decision to start him on Amiodarone is made. What is the main class of anti-arrhythmics that Amiodarone falls in ?
  
  Difficulty: Medium     Topic: Ventricular arrhythmias
  a

  Sodium Channel Blockers

  b

  Beta Blockers

  c

  Potassium Channel Blockers

  d

  Calcium Channel Blockers

  e

  Digitalis derivative
  Explanation: The ECG here shows a broad complex tachycardia, most likely to be ventricular tachycardia (VT). This is probably a complication of ischaemic cardiomyopathy in this patient. The management of VT depends on the clinical status of the patient. In the haemodynamically stable patient, Amiodarone is generally the treatment of choice. Amiodarone has multiple mechanisms of anti-arrhythmic actions, but it is generally recognised as a potassium channel blocker (Class III anti-arrhythmic).
• 8
  A 69 year old woman with a past medical history of ischaemic cardiomyopathy and myocardial infarction presents to the emergency department with palpitations. An ECG is done (shown) and a decision to start her on Amiodarone is made. Which of the following need monitoring as part of ongoing care for patients on Amiodarone ?
  
  Difficulty: Medium     Topic: Ventricular arrhythmias
  a

  Thyroid function, Liver function and Renal function

  b

  Thyroid function, Pulmonary function and Renal function

  c

  Liver function, Pulmonary function and Full blood count

  d

  Thyroid Function, Full Blood Count and Renal function

  e

  Thyroid Function, Liver Function and Pulmonary function
  Explanation: A Class III anti-arrhythmic agent, Amiodarone is commonly used in patients with arrhythmias for long term rhythm control. In this patient, it was started due to Ventricular Tachycardia (Broad Complex Tachycardia on ECG). It has many side effects, the most notable of which are Thyroid sideeffects, Liver toxicity and Pulmonary fibrosis. It is therefore essentail to monitor for these side effects regularly by doing Liver function tests, Pulmonary function tests and Thyroid function tests.