Arrhythmia Tutorial

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					Arrhythmia Tutorial
Sarah A. Stahmer MD

1A. A 72 year old diabetic woman with a history of hypertension
treated with diltiazem and coronary artery disease presents with
fatigue, but no syncopal episodes. An EKG is obtained (EKG 1).
What is her underlying rhythm?
    A. Sinus Bradycardia
    B. Junctional rhythm
    C. 2nd degree type 1 AV block
    D. 2nd degree type 2 AV block
    E. 2 to 1 AV block

1B. The most likely location of her block is:
  A. Above the AV node
  B. Bundle branch
  C. This EKG provides no clues that localize the block above or
     below the AV node

1C. The next best step in management of this patient is:
Emergent cardiac catheterization
  A. Administration of digoxin-specific Fab fragments (Digibind ®)
  B. Administration of isoproterenol
  C. Temporary transvenous pacing
  D. Cessation of diltiazem

2. An 83 yo f with a history of CHF presents with nausea and DOE.
Her initial EKG is shown in tracing 2a.

2B. EKG 2b is obtained 20 minutes later. What should you do now?
  A. Check serum electrolytes
  B. Temporary pacing
  C. Administer IV lidocaine
  D. Send cardiac enzymes, start IV nitroglycerin, and transfer to the
2C. 60 minutes later EKG 2c is obtained. The best treatment at this
point is:
   A. Cardiac catheterization with angioplasty
   B. Amiodarone 150 mg bolus
   C. Overdrive pacing
   D. Digoxin-specific Fab fragments (Digibind ®) and CCU
   E. IV esmolol bolus and infusion

3A. An 80 yo f with HTN and diabetes presents with fatigue, exercise
intolerance, and dyspnea. EKG 3a is obtained. What is her underlying
rhythm? What is the probable location of the conduction abnormality?
   A. Sinus node
   B. AV node
   C. Below the AV node
   D. The rhythm is idioventricular

3B. The next day, the patient develops the rhythm seen in EKG 3b.
What is the rhythm?
  A. Sinus bradycardia
  B. Complete heart block
  C. High grade incomplete heart block
  D. 2 to 1 AV block

4A. A 64 year old man complains of dizziness with head turns, and
when he wears tight shirts. EKG 4 is obtained. What is the rhythm?
  A. Mobitz type I block
  B. Mobitz type II block
  C. Complete heart block
  D. Sinus arrest

4B. Is a pacemaker indicated for this patient?
  A. Yes
  B. No

5. You are called to put in a transvenous pacer in an asymptomatic
patient for “complete heart block.” EKG 5 is recorded. What is the
underlying rhythm?
   A. Complete heart block
   B. Sinus rhythm with accelerated junctional rhythm
   C. Atrial fibrillation
   D. Atrial tachycardia
   E. Ventricular tachycardia

6. A 42 year old man presents to the emergency department with
chest pain. EKG 6a is obtained. What is the rhythm?
   A. Sinus tachycardia
   B. Ectopic atrial tachycardia
   C. Atrial flutter
   D. Multifocal atrial tachycardia

6B. The patient is treated, his pain resolves, and he is admitted to the
intensive care unit. Shortly thereafter, he becomes hypotensive, and
EKG 6b is obtained. What is the underlying rhythm?
   A. Complete heart block
   B. High degree incomplete heart block
   C. Accelerated junctional rhythm without heart block
   D. Accelerated idioventricular rhythm

6C. Should atropine be given to this patient?
  A. No, because it is ineffective with infranodal block
  B. No, because it is contraindicated in anterior MI
  C. No, because isoproterenol is more appropriate
  D. Yes, because pacing is contraindicated
  E. Yes, it is frequently effective in the first 6 hours of an inferior MI

6D. Will this patient likely require permanent pacing?
  A. Yes, complete heart block with an acute MI always requires
     permanent pacing
  B. Yes, because the ventricular escape rhythm implies infranodal
     conduction disease
  C. No, because most patients with inferior MI recover AV
     conduction after the acute phase
  D. No, because, pacing does not impact survival after acute MI

7. A 35 yo m is brought to the ED after having been found
unresponsive in his backyard. Wife thinks he had being doing heroin.
He has minimal response to Narcan, head CT is neg. An ECG (7) is
obtained. The next step is to:
   A. Give NaHCO3, hyperventilate
   B. Notify the cath lab immediately
   C. Obtain a core temperature
   D. Give calcium chloride, D50 and insulin

8. A 41 year old man with no previous medical history is admitted to
the hospital with syncope. While walking in the hall, he has a near-
syncopal episode, and EKG 8 is obtained. What is the most likely
cause of his dizziness?
   A. Severe AV nodal disease
   B. Sick sinus syndrome
   C. Severe situational vagally mediated syncope
   D. Telemetry does not suggest any specific etiology

9. A 33 year old man presents with exertional dyspnea and is noted
to be bradycardic. EKG 9 is obtained. What is the rhythm?
   A. Complete heart block
   B. Incomplete heart block
   C. Mobitz type II AV block
   D. Vagally mediated bradycardia

9B. What treatment is indicated?
  A. Atropine
  B. Isoproterenol
  C. Chronic therapy with oral  agonists
  D. Referral for permanent pacing

10. The rhythm strip seen in EKG 10 is obtained from a patient with a
pacemaker. Which intervention is most appropriate?
   A. Place a magnet over the pacemaker
   B. Increase the pacemaker output
   C. Increase the pacemaker rate
   D. Increase the pacemaker sensitivity (lower the sensing
   E. Decrease the pacemaker sensitivity (increase the sensing
11A. An 86 year old woman with a history of CHF is admitted
because of acutely worsening dyspnea. Her blood pressure is
108/62, and she has bibasilar crackles and elevated jugular venous
pressure. The rhythm strip shown in EKG 11a is obtained.
What is the EKG diagnosis?
What intervention is most appropriate?
   A. Lidocaine, 1 mg/kg IV bolus, then 2 mg/min
   B. Verapamil 5 mg IV
   C. Diltiazem 20 mg IV
   D. Digoxin 0.25 mg IV
   E. Adenosine 6 mg IV

11B. The next day, she is breathing comfortably with a BP of 100/60
mm Hg. Her labs include a BUN of 40 mg/dL, a Cr of 2.3 mg/dL, and
K+ of 3.2 mmol/L. EKG 12b is obtained. What intervention is most
  A. Temporary pacing
  B. Intravenous amiodarone
  C. Potassium chloride 40 mmol IV over 2 hours
  D. Digoxin immune antibody fragments IV
  E. Dopamine 5 g/kg/min IV

13. A 32 year old woman presents with palpitations. EKG 13a is
obtained. She is treated with adenosine, and EKG 13b is obtained.
What is the most likely cause of this tachycardia?
   A. AV reentry using an accessory pathway
   B. AV nodal reentrant tachycardia
   C. Atrial tachycardia
   D. Sinus tachycardia

13. A 45 year old man presents with severe hypotension and hypoxia.
He is intubated, and EKG 13 is obtained. Your next step should be to:
   A. Call the catheterization laboratory for emergent balloon pump
      placement and angioplasty
   B. Begin lidocaine infusion
   C. Begin amiodarone infusion
   D. Perform emergent electrical cardioversion
   E. Give intravenous metoprolol
14a. A 71 yo man presents to the ED with 3 mm of ST segment
elevation in leads V1 to V3. His BP is 120/80 mm Hg, and he is
complaining of chest discomfort. The rhythm shown in EKG 15a is
noted. What is the EKG diagnosis? What immediate intervention is
most appropriate?
   A. Carotid sinus massage
   B. Intravenous beta blockade
   C. Intravenous amiodarone
   D. Electrical cardioversion
   E. Intravenous procainamide

14b. NSR is restored, he is given thrombolytic therapy, bolused with 1
mg/kg lidocaine, and started on a lidocaine infusion at 2 mg/min. The
rhythm shown in EKG 14b is noted.
What is the EKG diagnosis?
Which intervention is most appropriate?
   A. Discontinue the lidocaine
   B. Give additional lidocaine, 0.5 mg/kg IV bolus, and increase the
      lidocaine to 3 mg/ml
   C. Change the lidocaine to amiodarone
   D. Electrical cardioversion
   E. Observation

15. A 69 year old man has been undergoing evaluation for
palpitations. His resting EKG is EKG 15a. A previous ECHO and ETT
have been normal. He presents to the ED with palpitations, and EKG
16b is obtained. On 12-lead monitoring, the rhythm shown in EKG
16c is noted. Which of the following is true?
   A. This condition rarely results in sudden death
   B. This arrhythmia is sensitive to adenosine
   C. This arrhythmia usually responds to calcium channel blockers
      and beta blockers
   D. This arrhythmia is amenable to catheter ablation
   E. All of the above

16. A 50 yo smoker w chronic bronchitis treated with beta-2 agonists
and theophylline presents w/ dyspnea. His T is 102 F, BP 130/70 mm
Hg, RR is 32 breaths/min. There are diffuse wheezes, nail beds are
cyanotic, + JVD. EKG 18 is obtained. What is the EKG diagnosis?
Which intervention is most appropriate?
   A. Digitalization
   B. Electrical cardioversion
   C. Oxygen, acetaminophen, and discontinuation of theophylline
   D. Activated charcoal
   E. Verapamil, 1 mg/min IV

17. A 33 yo f is brought in after having taken “pills”. She is drowsy,
stable VS and an ECG is obtained 17a.

Your initial management is to administer:
  A. Normal Saline
  B. Digibind
  C. Calcium Chloride
  D. NG lavage/charcoal

18. A 27 yo man with no PMH presents with palpitations and EKG
18a. His blood pressure is 100/60 mm Hg. Which of the following is
   A. IV diltiazem should be started for rate control of
      supraventricular tachycardia
   B. IV procainamide should be started for stable ventricular
   C. IV diltiazem should be given for right ventricular outflow tract
   D. IV procainamide should be given for atrial fibrillation with WPW
   E. Digoxin should be given for rate control of atrial fibrillation

18b. The patient becomes diaphoretic, and blood pressure drops to
70/40 mm Hg. What is the appropriate next step?
   A. IV amiodarone
   B. IV procainamide
   C. IV lidocaine
  D. IV diltiazem
  E. Electrical cardioversion

18c. The patient is converted to sinus rhythm. The following ECG is
obtained. Which of the following is correct?
   a. The patient is not at increased risk for sudden death
   b. The patient should undergo catheter ablation
   c. The patient should have an implantable defibrillator placed
   d. The patient should have an ICD and a catheter ablation

18d. The patient has recurrent symptoms and EKG 18d is obtained.
What is the most likely etiology of the rhythm?
      A. Orthodromic reentrant tachycardia (AV reentrant
      B. AV nodal reentry tachycardia
      C. Atrial fibrillation
      D. Atrial tachycardia

19. A 66 year old presents with palpitations. Blood pressure is
100/70, and lungs are clear. EKG 19 is obtained. The best course of
action at this point would be to:
   A. Give diltiazem 10 mg IV
   B. Give lidocaine 100 mg IV
   C. Put a magnet over the chest
   D. Sedate and perform electrical cardioversion
   E. Give amiodarone 150 mg IV

20. A 57 year old woman has a seizure in the dentist’s office and is
transferred to the emergency department. EKG 21 is obtained. The
nurse asks which antiarrhythmic agent you wish to choose. What is
the best answer?

  A. Amiodarone
  B. Procainamide
  C. Flecainide
  D. Diltiazem
  E. None of the above