1 Quiz 4 Arrhythmias summary statistics and question answers The correct answers to questions are indicated by *. All students were awarded 2 points for question #2 due to no appropriate responses for treatment of bradycardia. All students were awarded 2 points for question #3 due to poor answer discrimination. The correct answer was listed as e. All the above are appropriate recommendations. Quiz 4 score stats all students (n=163). 8.0±1.9,mean±sd 8.0, median 0.0-10.0, range n=163 (TC: 109, Duluth: 54) Frequency 0 20 40 60 80 100 4 1 3 18 91 46 0 2 4 6 8 10 Quiz 4 Arrthymias scores (n=163)
2 1. Vasopressin and epinephrine have been shown to have similar survival and discharge rates when used in patients with pulseless arrest. Which of the following statements best express the potential advantages to vasopressin over epinephrine? a. When compared to epinephrine, vasopressin does not directly stimulate myocardial beta receptors. b. When compared to epinephrine, vasopressin effects are not blunted in the presence of acidosis. c. When compared to vasopressin, epinephrine effects may include increasing myocardial oxygen demand. d. Vasopressin is given as a one time IV dose in contrast to epinephrine which may need repeat IV bolus administered every 3-5 minutes. *e. All of the above.
3 2. A 69 year old male arrives to the hospital emergency room (ER) unconscious. En route, he was conscious in the ambulance but became confused, disorientated and short of breath when his blood pressure suddenly dropped to 78/42 mmhg from 120/80 mmhg and pulse to 45 bpm (beats per minute) from 69 bpm. Vitals (now in ER): Blood pressure: 60/30 mmhg Heart rate: 35 bpm EKG (now in ER): Irregular chaotic beat, non-distingusible QRS complexes and no p-waves. He has a peripheral IV line already started in the ambulance. What is the most appropriate action for this patient while CPR is in progress? *a. Immediately transport the patient to the operating room for catheter ablation of chaotic atrial ectopic foci. *b. Initiate rapid IV bolus dose of adenosine STAT per emergency room protocol to convert to NSR. *c. Start IV amiodarone STAT per emergency room protocol followed by five cycles of CPR. *d. Suggest having the nurse recheck EKG leads during the remaining five cycles of CPR. *e. Provide direct-current cardioversion followed by five cycles of CPR.
4 3. A 69 year old male with height 5'11' and weight of 70 kg comes in to the clinic for a routine checkup. He is clinically stable with no complaints at this time. His chart indicates a history of atrial fibrillation (AF) with 3 successful direct-current cardioversions to NSR in the past month. Medical history: atrial fibrillation (one month ago) hypertension (14 years ago) Labs (today): Na: 140 meq/l (normal level: 135-145 meq/l) K: 4.0 meq/l (normal level: 3.5-5.0 meq/l) Cl: 101 meq/l (normal level: 95-110 meq/l) CO2: 27 meq/l (normal level: 20-30 meq/l) Glucose: 85 mg/dl (normal level: 80-120 mg/dl) Creatinine: 0.8 mg/dl (normal level: 0.5-1.2 mg/dl) TSH (thyroid function): within normal limits. Medications: No known drug allergies hydrochlorothiazide 12.5 mg po daily diltiazem ER 240mg po daily enalapril 10 mg po daily simvastatin 20 mg po daily aspirin 81 mg po daily Vitals (today): blood pressure: 121/75 mmhg heart rate 69 bpm. EKG (today): atrial fibrillation (AF) QRS complex: 110 ms QTc: 390 ms Transesophageal echocardiography (today): No thrombi present in left atrium
5 Which of the following interventions could be considered for treatment of AF if the physician has determined the patient has a low proarrhythmic risk? *a. Initiate oral flecainide on an out-patient basis to convert to normal sinus rhythm and prevent AF from occurring while considering anticoagulation therapy with warfarin. * b. Begin oral dofetilide on an in-patient basis to help restore normal sinus rhythm and consider warfarin to prevent thrombi formation during conversion to NSR. * c. Start oral propafenone to pharmacologically convert and maintain normal sinus rhythm while considering adequate anticoagulation with warfarin. *d. Continue to monitor rate control of AF since patient is asymptomatic ("no complaints") and consider anticoagulation therapy with warfarin. *e. All the above are appropriate recommendations.
6 4. A 60 year old male with height 6'0" and weight 83 kg arrives to the hospital emergency room with complaints of palpitations. He has no complaints of confusion, lightheadedness or chest pain. Medical history: None, otherwise healthy. Vitals (today): blood pressure: 159/97 mmhg heart rate: 185 bpm Labs (today): Na: 142 meq/l (normal level: 135-145 meq/l) K: 4.5 meq/l (normal level: 3.5-5.0 meq/l) Cl: 103 meq/l (normal level: 95-110 meq/l) CO2: 25 meq/l (normal level: 20-30 meq/l) Glucose: 90 mg/dl (normal level: 80-120 mg/dl) Creatinine: 0.9 mg/dl (normal level: 0.5-1.2 mg/dl) TSH (thyroid function): within normal limits. EKG (today): Regular R-R intervals with narrow QRS complexes (<0.12 seconds). Medications: No known drug allergies aspirin 325 mg po daily.
7 Which of the following is the most appropriate emergent step in management of the patient? *a. Rapid IV bolus dose of adenosine STAT per emergency room protocol to convert to NSR. b. Start IV bolus of epinephrine or vasopressin STAT per emergency room protocol followed by five cycles of CPR. c. Begin an atropine IV drip per hospital protocol to convert to NSR. d. Rapid IV bolus dose of lidocaine per emergency room protocol to convert to NSR. e. Provide direct-current cardioversion followed by five cycles of CPR.
8 5. A 68 year old male is in the emergency room with complains of palpitations for the last 3 hours. Medical history: dyslipidemia (8 years ago) hypertension (17 years ago) severe asthma (20 years ago) structural heart disease (1 year ago): left ventricular hypertrophy and ejection fraction 36%. Vitals (now in ER): Blood pressure: 148/93 mmhg Heart rate: 180 mmhg EKG (now in ER): atrial fibrillation Medications: No known drug allergies fluticasone and salmeterol (Advair Diskus ) 500mcg/50mcg one inhalation twice daily for asthma albuterol 2 puffs q4h as needed for asthma Montelukast (Singulair ) 10mg po every evening for asthma atorvastatin 80 mg po daily for dyslipidemia lisinopril 20 mg po daily for hypertension digoxin 0.125 mg daily aspirin 325 mg po daily
9 Which of the following IV medications is the most appropriate drug therapy to emergently control heart rate if direct-current conversion to NSR has failed the patient? *a. diltiazem. b. amiodarone. c. ibutilide. d. metoprolol. e. digoxin.