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25/03/2017 EKG Findings and Arrhythmias - USMLE Step 2 CK exam

EKG Findings and Arrhythmias USMLE Step 2


CK exam

BYPAUL CIURYSEK, MD / TUESDAY, 08 JUNE 2010 / PUBLISHED ININTERNAL MEDICINE

EKG ndings and Arrhythmias


Heart Blocks:
First-degree AV block normal sinus rhythm with PR interval 0.2ms
Second-degree, type 1 (Weckenbach) block PR interval elongates from beat to beat until a PR is dropped
Second-degree, type 2 (Mobitz) block PR interval xed but there are regular non-conducted P-waves leading to dropped beats
Third-degree block no relationship between P waves and QRS complexes. Presents with junctional escape rhythms or ventricular escape
rhythm

Atrial Fibrillation

The most common chronic arrhythmia


From ischemia, atrial dilatation, surgical history, pulmonary diseases, toxic syndromes
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Classically, the pulse is irregularly irregular 1/3
25/03/2017 EKG Findings and Arrhythmias - USMLE Step 2 CK exam

Signs and Symptoms:

Chest discomfort
Palpitations
Tachycardia,
Hypotension + syncope

Treatment:

Control rate with b-blockers, CCBs, and digoxin (not acutely)


If brillations last >24hr then should anticoagulate with warfarin for at least 3 weeks before cardioversion (prevents embolisms)
If you cannot convert to normal sinus rhythm, the patient will require long-term anticoagulation. 1stline is warfarin, 2ndline is aspirin

Cardioversion to convert to normal rhythm:


1stline IV procainamide, sotalol, amiodarone
Electrical shock of 100-200J followed by 360J

Atrial Flutter

Less stable than Ab


The rate is slower than that of atrial brillation (approximately 250-350bpm)
Ventricular rate in atrial utter is at risk of going too fast, thus atrial utter is considered to be more dangerous (medically slowing this
rate can cause a paradoxical increase in ventricular rates)
Classic rhythm is an atrial utter rate of 300bpm with a 2:1 block resulting in a ventricular rate of 150bpm
Signs and symptoms similar to those of atrial brillation
Complications include syncope, embolization, ischemia, heart failure

Classic EKG nding is a sawtooth pattern:


Treatment:

If patient is stable, slow the ventricular rate with CCBs or b-blockers (avoid procainamide because it can result in increased ventricular
rate as the atrial rate slows down)
If cardioversion is going to take place be sure to anticoagulate for 3 weeks
If patient is unstable must cardiovert start at only 50J because is easier to convert to normal sinus rhythm than atrial brillation


Multifocal Atrial Tachycardia (MFAT)

An irregularly irregular rhythm where there are multiple concurrent pacemakers in the atria.
Commonly found in pts with COPD

EKG shows tachycardia with 3 distinct P waves


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25/03/2017 EKG Findings and Arrhythmias - USMLE Step 2 CK exam
Treatment:

Verapamil
Treat any underlying condition


Supraventricular Tachycardia

Many tachyarrhythmias originating above the ventricle


Pacemaker may be in atrium or AV junction, having multiple pacemakers active at any one time
Differentiating from ventricular arrhythmia may be difcult if there is also the presence of a bundle branch block

Treatment:

Very dependent on etiology


May need to correct electrolyte imbalance
May need to correct ventricular rate [digoxin, CCB, b-blockers, adenosine (breaks 90% of SVT)]
If unstable requires cardioversion
Carotid massage if patient has paroxysmal SVT


Ventricular Tachycardia

VTach is dened as 3 consecutive premature ventricular contractions


If sustained, the tachycardic periods last a minimum of 30s.
Sustained tachycardia requires immediate cardioversion due to risk of going into ventricular brillation

Treatment:

If hypotensive or no pulse existent do emergency debrillation (200, then 300, then 360J)
If patient is asymptomatic and not hypotensive, the rst line treatment is amiodarone or lidocaine because it can convert rhythm back to
normal


Ventricular Fibrillation

Erratic ventricular rhythm is a fatal condition.


Has no rhyme or rhythm


Signs and Symptoms:

Syncope
Severe hypotension
Sudden death


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