1. what is the normal PR interval?
    3-5 small squares
  2. what is the width of a normal QRS complex?
    less than 3 small squares
  3. what does one small square represent?
  4. what does one large square represent?
  5. if there is an irregular rhythm, how do you work out the rate?
    count the number of QRS complexes in 30 large squares (i.e. 6 seconds) and times by 10
  6. what are the p and t waves like in VT?
    there are no P or T waves in VT
  7. describe the rhythm of mobitz 1?
    regularly irregular
  8. describe the PR interval of mobitz1
    PR interval is progressively prolonged until an impulse fails to be conducted to the ventricles and the cycle then repeats
  9. which are the septal leads?
    V1, V2
  10. which are the inferior leads?
    II, III, aVF
  11. which are the lateral leads?
    i, aVL, V5, V6
  12. which are the anterior leads?
    V3, V4
  13. what are the 3 disease processes for acute coronary syndrome?
    • rupture of atherosclerotic plaque
    • smooth muscle constriction
    • thrombus formation
  14. what is ST Segment Depression a sign of?
    myocardial ischaemia
  15. what is T wave inversion a sign of
    myocardial ischaemia, but very non specific
  16. what is acute ST elevation a sign of?
    possible acute MI
  17. what is Resolving ST elevation with Q wave formation a sign of?
    usually a subsequent sign of a full thickness infarction
  18. describe cardiac chest pain - symptoms
    • central crushing
    • radiating to left side, jaw
    • associated with sweaty, nausea, vomiting, SOB
    • vice like pain
    • sudden and severe
    • gradually gets worse
  19. what are the physical signs of a patient suffering from cardiac chest pain?
    • collapse
    • nausea
    • vomit
    • sweaty/clammy
    • altered vital signs
    • irreg. heart beats/palps
    • SOB
  20. how does unstable angina present? 3 ways
    • angina of effort with growing frequency over days, provoked by less exertion
    • angina occurring recurrently and UNPREDICTABLY - not specific to exercise
    • unprovoked and prolonged episode of chest pain
  21. what are the ECG findings of unstable angina?
    • normal
    • ST depression = high risk
  22. what are the chemical findings of unstable angina?
    • cardiac enzymes: usually normal
    • troponin: minor release suggests high risk
  23. what is the initial treatment for all ACS?
    • Oxygen
    • Aspirin 300 mg orally (crush/chew)
    • Nitroglycerine (GTN spray or tablet)
    • Morphine (or diamorphine)
    • call expert help!
  24. what is the definitive treatment for unstable angina?
    • MONA
    • LMW heparin
    • beta blocker
    • if high risk: glycoprotein IIb/IIIa inhibitor
    • clopidogrel
    • iv/buccal nitrate for ongoing chest pain
  25. what are the ECG findings of NSTEMI?
    • non specific
    • ST depression
    • T wave inversion
  26. what are the chemical findings of NSTEMI?
    • raised troponin release
    • and elevated CKMB
  27. what are the ECG findings of STEMI?
    • acute ST elevation
    • with Q waves likely to develop later
  28. what are the chemical findings of STEMI?
    • raised troponin release
    • and elevated CKMB
  29. what is the definitive treatment for NSTEMI?
    • MONA
    • LMW heparin
    • beta blocker
    • if high risk:
    • glycoprotein IIb/IIIa inhibitor
    • clopidogrel
    • iv or buccal nitrates for ongoing chest pain
  30. what is the definitive treatment for STEMI?
    • after MONA
    • early repercussion therapy: PCI (percutaneous coronary intervention) or thrombolysis
  31. which blood tests need to be done if ACS is suspected?
    • FBC
    • U&E
    • clotting screen
    • troponin
  32. what is the differential diagnosis for narrow complex tachycardia?
    • 1. sinus tachycardia: normal P wave followed by normal QRS
    • 2. atrial tachyarrhythmias including:
    • a) atrial fibrillation: absent P wave, irreg. QRS
    • b) atrial flutter: atrial rate usually 300bpm giving flutter/sawtooth baseline and ventricular rate 150bpm so 2:1 block
    • c) atrial tachy: ban shape P waves, may outnumber QRS
    • d) multifocal atrial tacky: 3or more P wave morphologies, irreg QRS
    • supraventricular tachycardia: P wave absent or inverted after QRS
    • 3. junctional tachycardia: rate 150-250bpm, P wave either buried in QRS or occurring after QRS
    • a) AV nodal re-entry tachycardia
    • b) AV re-entry tachycardia, includes access path e.g. WPW
  33. what is the initial treatment for SVT?
    • O2, iv access
    • check if rhythm is regular or irregular
    • if irregular treat as AF
    • if regular: vagal manoeuvres e.g. carotid sinus massage or valsalva manoeuvre
  34. if vagal manoeuvres are unsuccessful what should be given, how much? why? what is half life and MOA?
    • adenosine 6mg bolus first: causes transient AV block
    • half life: short 10s!
    • MOA: 2 ways
    • 1. transiently slowing ventricles to show underlying atrial rhythm
    • 2. cardioverting junctional tachycardia to sinus rhythm
  35. why are CSM or valsalva used?
    transiently INCREASE AV block to unmask underlying atrial rhythm
  36. what are the SE of adenosine?
    • transient chest tightness
    • dyspnoea
    • headache
    • flushing
  37. what are the 3 relative CI to adenosine?
    • asthma
    • 2nd/3rd degree AV block
    • sinoatrial disease (unless pacemaker)
  38. what is adenosine potentiated by?
  39. what is adenosine antagonised by?
  40. if adenosine is not effective in SVT what can be used? what does it depend on?
    • pt stable: amiodarone
    • pt unstable: sedation and DC cardioversion
  41. how can it be checked if a patient is stable?
    • BP < 90
    • HR > 200
    • impaired consciousness
    • heart failure
  42. what are the features of Mobitz II?
    • intermittent failure of AV conduction
    • get occasional missed QRS complexes after normal atrial contraction
  43. what is motibz II caused by?
    • anterior wall MI
    • degenerative changes in conduction system
    • severe coronary artery diseae
  44. in mobitz II where is the problem?
    • bundle of His
    • bundle branches
  45. if a patient is uncompromised with motibz II what should be given and why?
    • up to max 3mg atropine
    • because higher risk of developing complete AV block or systole
    • may need cardiac pacing
  46. once initial treatment for ACS has happened, which other investigations need to be done?
    • stress test
    • angiogram
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