Updated: 12/21/2019

Ventricular Arrhythmia

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Snapshot
  • A 57-year-old man presents to the emergency department after fainting. He was accompanied by his wife who witnessed the event. Prior to the event, he experienced lightheadedness and palpitations. When he fainted, cardiopulmonary resuscitation was performed. Defibrillator pads were placed on the patient, which demonstrates pulseless ventricular tachycardia. He is defibrillated with 200 Joules (biphasic.)
Introduction
  • A group of ventricular arrhythmias that include
    • ventricular premature beats 
      • action potentials are ectopically generated within the ventricles
      • typically benign and asymptomatic
    • ventricular tachycardia
      • if sustained ventricular tachycardia is not managed, it can result in ventricular fibrillation
      • can occur secondary to blunt chest trauma
        • consider commotio cordis (blunt trauma during ventricular repolarization) with focal trauma to the chest over the heart followed by ventricular tachycardia 
    • ventricular fibrillation
      • life-threatening, if not immediately managed
      • most common cause of cardiac arrest after a STEMI
  • Epidemiology
    • risk factors
      • myocardial ischemia and infarction
      • ventricular hypertrophy
      • long QT syndromes
      • valvular heart disease
      • congenital cardiac abnormalities
  • Symptoms
    • palpitations
    • symptoms of heart failure, which include
      • shortness of breath
      • chest discomfort
      • syncope
    • cardiac arrest

Ventricular Arrhythmias
Type
Electrocardiogram Findings
Treatment
Ventricular premature beats (VPBs)
  • Widened QRS complex with abnormal morphology 
  • Typically with reassurance or a β-blocker in healthy patients
Ventricular tachycardia
  • 3 or more consecutive VPBs, displaying a broad QRS complex tachyarrhythmia
  • Stable 
    • amiodarone  
    • lidocaine
    • procainamide
  • Unstable
    • synchronized cardioversion
  • Pulseless ventricular tachycardia
    • defibrillation
Ventricular fibrillation
  • Erratic rhythm with no discernable waves (P, QRS, or T waves)
  • Defibrillation for all patients
 
 

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.CV.15.114) A 75-year-old man presents to the emergency department with a sensation of a flutter in his chest. He has a past medical history of diabetes and hypertension but is generally not compliant with his medications. His temperature is 98.0°F (36.7°C), blood pressure is 122/78 mm Hg, pulse is 130/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for an obese man who is not confused, moving all extremities spontaneously, and has a rapid heart rate. An ECG is obtained as seen in Figure A. The patient is asked to bear down while he is laid flat and his legs are elevated resulting in no change in his symptoms or rhythm strip. Which of the following is the best next step in management? Review Topic | Tested Concept

QID: 104120
FIGURES:
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Adenosine

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Amiodarone

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Aspirin and cardiac catheterization

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Cardioversion

50%

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Defibrillation

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