Cardiology quiz

Welcome to your Cardiology quiz

Name

22-year-old female presents to the Urgent Care Clinic with a “fast heart rate” and palpitations. She has experienced this before, but she came today because the current episode is lasting longer than usual. She is slightly dizzy but otherwise asymptomatic. She is in no apparent distress, is breathing comfortably, and has 2+ peripheral pulses. Her vitals are within normal limits except a heart rate of 162. Her ECG is shown below:

1. What would be your initial management of this patient?

Perform a vagal maneuver, such as Valsalva or carotid sinus massage

Immediately insert a 16G intravenous cannula and commence a sotalol infusion

Slow IV push 12mg IV Adenosine followed by IV Verapamil

Rapid push bolus of 6mg IV Adenosine

2. Vagal maneuvers effectively achieve cardioversion in approximately 28% of patients [5]. However, the efficacy drastically increases when using the “modified Valsalva” technique described in the REVERT trial.

In order to complete the maneuver:

Place the patient supine, and then have him blow into a 10cc syringe for 15 seconds. Quickly sit the patient up.

Place the patient at a 30 degree angle, and then have him blow into a 50cc syringe for 5 seconds. Quickly lay the patient flat, and raise his legs to 90 degrees for 5 seconds. Lastly, sit the patient fully upright for 10 seconds

Place the patient at a 90 degree angle, and then have him blow into a 10cc syringe. Then lie patient flat for 30 s

Place the patient at a 30 degree angle, and then have him blow into a 5cc syringe for 60 seconds. Quickly lay the patient flat, and raise his legs to 45 degrees for 15 seconds.

Place the patient at a 30 degree angle, and then have him blow into a 10cc syringe for 15 seconds. Quickly lay the patient flat, and raise his legs to 45 degrees for 15 seconds. Lastly, sit the patient fully upright for 30 seconds

3. If vagal manoeuvres fail, what is your next course of action?

Administer Adenosine as a 6 mg as a slow push over 5 min

Administer Adenosine 6 mg and Verapamil 5 mg as IV rapid push bolus

Administer Adenosine as a 12 mg IV rapid-push bolus, followed by a normal saline flush.

Administer Adenosine as a 6 mg IV rapid-push bolus, followed by a normal saline flush.

4. With regards to the use of Adenosine, which of the following statements is INCORRECT ?

One of the most significant relative contraindications to adenosine is its high side-effect profile. Many patients find the medication to be so intolerable that they may prefer alternate options.

Dosing should be reduced in patients with heart transplants or if the medication is provided via central access

Although asthma is not a contraindication to adenosine use, it may be reasonable to avoid its use in asthmatic patients, due to its bronchoconstrictive effects

adenosine use should be avoided in patients with recent dipyridamole use, as dipyridamole inhibits the metabolism of adenosine and prolongs its effects.

It is relatively safe to administer Adenosine in patients with Long QT syndrome