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ACMSEducate UKMLA Lecture Series Slides By Yasimin Nankya (KCL ACMS Secretary) Presented By Akua Asare (KCL ACMS President)Conditions Respiratory Conditions 01 Cardiovascular 02 Pneumonia Atrial Fibrillation Neurological Conditions 03 MeningitisStructure of Lecture Topic Recap A Recap of important aspects of the disease B Questions & Answers & Reasoning Practise questions 01a Atrial Fibrillation Topic Recap (Cardiovascular) Atrial Fibrillation - Recap Types of AF Paroxysmal Persistent Permanent Spontaneous episodes Arrhythmia is not self- Continuous Atrial last less than 7 days terminating – lasts >7 Fibrillation which cannot (Typically (<24 Hours) days (can be be cardioverted cardioverted)Atrial Fibrillation - Recap Presentation Symptoms Signs ● Chest Pain (Angina) ● Irregularly Irregular Pulse ● Narrow QRS Complex Tachycardia ● Dyspnoea (Shortness of Breath) ● No visible P waves on ECG ● Palpitations ● Irregularly spaced QRS complexes (varying RR intervals) Atrial Fibrillation - Recap ECG Signs ● Irregularly Irregular Ventricular Rhythm ● Narrow QRS Complex Tachycardia ● No visible P waves* on ECG *P Waves represent the electrical depolarisationof the atria of the heart Atrial Fibrillation - Recap Common Causes ● S - Sepsis ● M - Mitral Stenosis or Regurgitation ● I - Ischaemic Heart Disease ● T - Thyrotoxicosis ● H - Hypertension REMEMBER: AF is one of the key risk factors for Ischaemic Stroke Lifestyle Causes Alcohol and Caffeine Atrial Fibrillation - Recap Principles of Management -Rate or Rhythm Control -Anticoagulation First Line All patients with AF should have Rate control unless there is ● A reversible cause for their AF ● New onset atrial fibrillation (within the last 48 hours) ● Heart failure caused by atrial fibrillation ● Symptoms despite being effectively rate controlled Atrial Fibrillation - Recap Principles of Management Rate Control Beta Blocker First line => Atenolol or Bisoprolol Calcium Channel Blocker => Diltiazem or Verapamil (Not preferred in HF) Digoxin (Sedentary people with persistent AF requires monitoring and risk of toxicity) Aims to bring HR back down to normal Atrial Fibrillation - Recap Principles of Management Rhythm Control Can be offered in patients with ● A reversible cause for their AF ● New onset atrial fibrillation (within the last 48 hours) ● Heart failure caused by atrial fibrillation ● Symptoms despite being effectively rate controlled Aims to return patient to Normal Sinus Rhythm Atrial Fibrillation - Recap Rhythm Control Two types: Cardioversion => Immediate Cardioversion,Delayed Cardioversion Long Term Rhythm Control Cardioversion - Immediate (Pharmacological & Electrical) Used if AF : Present <48 Hours , Hemodynamically Unstable Pharmacological Cardioversion Flecainide Amiodarone Electrical Cardioversion Shocks heart back into sinus rhythm using a cardiac defibrillator Done with sedation or general anaesthesia - Delayed Electrical cardioversion used AF has been present for more than 48 hours and stable Patient should be anticoagulated for at least 3 Weeks beforehand Atrial Fibrillation - Recap Long term Rhythm Control ● Beta blockers first-line ● Dronedarone second-line for maintaining normal rhythm where patients have had successful cardioversion ● Amiodarone is useful in patients with heart failure or left ventricular dysfunction Anticoagulation Patients with any history of AF should be considered for Anticoagulants CHA 2DS 2-VASc determines the most appropriate strategy / Weigh up with HASBLED/ORBIT Atrial Fibrillation - Recap The following DOACs are recommended by NICE for reducing stroke risk in AF: ● apixaban ● dabigatran ● edoxaban ● rivaroxaban Second Line is Warfarin if DOAC is contraindicated Requires close monitoring o the INR => AF target range is INR 2-3 01b Atrial Fibrillation - Practise Questions (Cardiovascular)Acute onset of AF Rate Control (Bisoprolol) offered if >48 hours or uncertain onset of symptomsCHA 2DS 2-VASc score, due to the risk of recurrence. This patient's score is 3 (+1 for age 65- 74 years, 1 for female sex, 1 for diabetes)CHA 2DS 2-VASc score is 5 1 Congestive HF 1 Hypertension 2 Over 75 1 Vascular Disease Therefore Anticoagulant has to be offeredCardioversion is ONLY considered in New onset AF if it presents within 48 hours of presentations 02a Pneumonia -RecapPneumonia - Recap Pneumonia is an infection that inflames the air sacs in one or both lungs Symptoms Signs ● Cough ● Fever ● Sputum ● Tachycardia ● Dyspnoea ● Reduced O2 Sat ● Chest Pain (Which may be pleuritic)ced Breath Sounds ● Fever ● Bronchial BreathingPneumonia - Recap Types of Pneumonia (Red currant jelly sputum) Pneumonia - Recap Investigations • U&Es ● Chest X Ray • Check for Dehydration ● Consolidation • Also other changes seen with some atypical ● FBC pneumonia ● Neutrophilia • CRP • Raised in response to infection Pneumonia - Recap Normal X Ray Investigations Pneumonia ● Chest X Ray Consolidation Pneumonia - Recap Management Determined by CURB-65 Score or CRB - 65 in primary care settings ● C (Confusion) => abbreviated mental test score Score of less than or equal to 8 gives a score of 1 ● U (Urea) ● R (Respiratory Rate) => Less than or equal to 30 gives a score of 1 ● B (Blood Pressure) => Systolic less than or equal to 90 and diastolic less than and/or equal to 60 gives a score of 1 ● 65 (Aged 65 or older) ALWAYS REMEMBER: SYSTOLIC READING AND DIASTOLIC READING SCORES ARE SEPARATE => Patient could have normal systolic and diastolic of 55 they would score 1 Patient could have systolic of 85 and a normal diastolic they would score 1 Patient has systolic of 85 and a diastolic of 55 they would score 2 Pneumonia - Recap Management Antibiotics like Amoxicillin or Erythromycin is used Erythromycin can be used in children when Mycoplasma is present/suspected or chlamydia trachomatis Supportive care => O2 therapy if hypoxaemic IV Fluids if hypotensive or shows signs of dehydration CURB 65 Score of 0 Home based care with oral amoxicillin Score of 2 or more Hospital assessment 02b Pneumonia - Questions & AnswersKlebsiella Pneumoniae is also characterised by red currant sputum so that alongside history of alcohol use should indicate KlebsiellaAlcoholic -> Think KlebsiellaPeripheral blood smear showing red blood cell agglutination => Haemolytic Anemia which is found in mycoplasma PneumoniaeErythromycin is used in children when Mycoplasma is present ! 03a Meningitis -RecapMeningitis - Recap Meningitis is an inflammation of the meninges Complications of Meningitis include: ● Hearing Loss!!! E.g. sensorineural ● Encephalitis Meningitis - Recap Signs/Symptoms ● Headache ● Fever ● Neck stiffness ● Photophobia ● Nausea and vomiting ● Focal neurology ● Seizures ● Reduced conscious level ● Non-Blanching petechial rash ● (meningococcal septacemia)Meningitis - Recap Investigations Diagnostic investigations for suspected meningitis include: - Blood tests - FBC,U&Es, Clotting, Glucose - ABG - Blood cultures - Imaging: CT Head - Lumbar puncture for Cerebrospinal Fluid (CSF) analysis (CI in high ICP)Meningitis - Recap Lumbar puncture for Cerebrospinal Fluid (CSF) analysis FindingsMeningitis - Recap Management ● 2g of IV ceftriaxone (OR Cefotaxime) twice daily - to ensure CNS penetration ● IV amoxicillin (Contains Penicillin) - added in patients at age extremes for listeria* coverage. *Listeria is a bacteria and is also a common cause of meningitis in Neonates and the elderly ● In cases of suspected viral encephalitis (Brain inflammation) - IV Acyclovir should also be administered. ● Patients allergic to penicillin => Chloramphenicol administered instead Any person who has been in contact with a patient diagnosed with Meningitis should receive Ciprofloxacin as prophylaxis - 500 mg orally daily is recommended 03b Meningitis - Questions & AnswersTB and HIV co-infection are common, especially in sub-Saharan Africa and should always be considered !!!The End – Thank you – Questions? Respiratory Conditions 01 Cardiovascular 02 Pneumonia Atrial Fibrillation Neurological Conditions 03 Meningitis ACMSEducate UKMLA Lecture Series Slides By Yasimin Nankya (KCL ACMS Secretary) Presented By Akua Asare (KCL ACMS President)