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Medical Series: Essential Arrythmias Part 1: Going Fast DClinical Fellow in medicineSocial Medias Aims & objectives • Refresh the very basic physiology of cardiac electrical conduction • Consider a framework for organising arrythmias • Be confident to identify key tachyarrhythmias and understand their basic pathology • Appreciate an overview of arrythmia management What we will not cover; • Basic life support ie VF, Pulseless VT, Asystole, PEA. Case 1 Basic cardiac conduction Which part of cardiac conduction is the fastest? A. Atrial muscle B. AV node C. Ventricular muscle D. Bundle of his E. Purkinje fibres Case 1 Basic cardiac conduction Which part of cardiac conduction is the fastest? A. Atrial muscle B. AV node C. Ventricular muscle D. Bundle of his E. Purkinje fibresKey to understanding arrythmias Helps with ECG understanding Appreciate how drugs work Often tested in finals! Case 2 A 68 year old lady is seen in ED with palpitations, a severe pulsating headache examination she is breathless with crackles bilaterally at the bases. Admission bloods sent urgently come back with a TNI of 103. Obs are as follows; Hr 160, BP 80/58, 99% air, RR22, temp 36.7. Which following term does NOT describe instability ? A. Shock B. Myocardial Ischemia C. Heart failure D. Syncope E. Severe pulsatile headache Case 2 A 68 year old lady is seen in ED with palpitations, a severe pulsating headache examination she is breathless with crackles bilaterally at the bases. Admission bloods sent urgently come back with a TNI of 103. Obs are as follows; Hr 160, BP 80/58, 99% air, RR22, temp 36.7. Which following term does NOT describe instability ? A. Shock B. Myocardial Ischemia C. Heart failure D. Syncope E. Severe pulsatile headache Case 2 Whilst performing your A to E the nurses kindly give you the patients ECG. What arrythmia does this ECG represent? A. Ventricular fibrillation B. Monomorphic VT C. Torsades De point D. Supraventricular tachycardia E. Don’t know Case 2 Whilst performing your A to E the nurses kindly give you the patients ECG. What arrythmia does this ECG represent? A. Ventricular fibrillation B. Monomorphic VT C. Torsades De point D. Supraventricular tachycardia E. Don’t know Case 2 Ventricular Tachycardia Fundamentals; Physiology • Ventricular arrythmia causing rapid Most commonly due to a rentry circuit (usually due to scarring from (unsustainable) heart rate previousischaemia) Can be due to triggered activity from congenital defects or drug toxicity • Can be stable or unstable (digitalis) • Termed ‘non sustained’ (NSVT) if self terminates in <30 seconds Types Monomorphic Polymorphic (Torsadesde point) ECG features Rapid Broad complex Regular Large complexes Narrow QRS Broad QRS Framework Ventricular tachycardia l (VT) R l I Case 2 You correctly identify the ECG and given the patients instability proceed to correct the rhythm disturbance. What is the first line management? A. Defibrillation B. Synchronised Direct current cardioversion C. Load with amiodarone D. Adenosine STAT E. Don’t know Case 2 You correctly identify the ECG and given the patients instability proceed to correct the rhythm disturbance. What is the first line management? A. Defibrillation B. Synchronised Direct current cardioversion C. Load with amiodarone D. Adenosine STAT E. Don’t know Case 3 A 29 year old gentleman is seen in ED with palpitations and dizziness after a night out. He admits to using cocaine. He is usually fit and well. An ECG is performed in the emergency department. Which term most accurately describes the most prominent ECG finding? A. Atrial Flutter B. Atrial Fibrillation C. Supraventricular tachycardia D. Torsades de point E. Don’t know Case 3 A 29 year old gentleman is seen in ED with palpitations and dizziness after a night out. He admits to using cocaine. He is usually fit and well. An ECG is performed in the emergency department. Which term most accurately describes the most prominent ECG finding? A. Atrial Flutter B. Atrial Fibrillation C. Supraventricular tachycardia D. Torsades de point E. Don’t know Case 3 Atrial Fibrillation Fundamentals; Management includes • Disordered atrial ECG features electrical activity • Rate control • Irregularly irregular • Rhythm control • Irregular ventricular • No P Waves conduction • Wandering isoelectric baseline • Reducing stroke risk • Narrow complex • VeryCommmon • Variable ventricular rate • Stroke risk • May see ‘fibrillatory waves’ Narrow QRS Broad QRS Framework Ventricular tachycardia l (VT) R Atrial Fibrillation l I Case 4 A 50 year old nurse is brought to ED from the wards after a very busy day and stressful night shift, she has used her Ventolin inhaler 3 times through the night due to chest tightness after accidentally breathing in deodorant. She describes feeling very light headed with a racing pulse and mild chest discomfort. You are shown the following ECG; How would you describe this patients arrythmia? A. Supraventricular tachycardia B. Atrial fibrillation C. Ventricular tachycardia D. Atrial Flutter E. Don’t know Case 4 A 50 year old nurse is brought to ED from the wards after a very busy day and stressful night shift, she has used her Ventolin inhaler 3 times through the night due to chest tightness after accidentally breathing in deodorant. She describes feeling very light headed with a racing pulse and mild chest discomfort. You are shown the following ECG; How would you describe this patients arrythmia? A. Supraventricular tachycardia B. Atrial fibrillation C. Ventricular tachycardia D. Atrial Flutter E. Don’t know Case 4 A 50 year old nurse is brought to ED from the wards after a very busy day and stressful night shift, she has used her Ventolin inhaler 3 times through the night due to chest tightness after accidentally breathing in deodorant. She describes feeling very light headed with a racing pulse and mild chest discomfort. You are shown the following ECG; What is the first line management? A. Adenosine STAT B. Amiodarone loading STAT C. Oral Bisoprolol STAT D. Flecainide oral STAT E. Vagal manouvers Case 4 A 50 year old nurse is brought to ED from the wards after a very busy day and stressful night shift, she has used her Ventolin inhaler 3 times through the night due to chest tightness after accidentally breathing in deodorant. She describes feeling very light headed with a racing pulse and mild chest discomfort. You are shown the following ECG; What is the first line management? A. Adenosine STAT B. Amiodarone loading STAT C. Oral Bisoprolol STAT D. Flecainide oral STAT E. Vagal manouvers Case 4 What is SVT? Regular Atrioventricular Regular atrial • Atrioventricular reentrant tachycardia (AVRT) • Sinus tachycardia • AV nodal re -entrant tachycardia (AVNRT) • Atrial flutter • Junctional tachycardia • Inappropriate sinus tachycardia Irregular atrial • Atrial fibrillation • Atrial flutter with variable block • Multifocal atrial tachycardia (MAT) AV NODAL RE-ENTRANT TACHYCARDIA (AKA AVNRT) Fundamentals • Commonest cause of palpitations in structurally normal hearts • Rarely life threatening • Usually physiologically stable but unwell • Can occur spontaneously or on provocation with drugs Symptoms Palpitations Presyncope Anxiety Usually well tolerated and physiologically stable ECG features Rapid Physiology Narrow complex Regular - Micro re-entrant circuit Physiology Atrial flutter • Can have a clockwise, or anticlockwise (90%) re –entry (resulting in different ECG changes) Fundamentals; Idiots guide to spotting Flutter • Type of SVT To compare withAfib– check R-R intervals (AF will not • Can be stable or unstable have any pattern!) • Can have variable ventricular conduction Inverting yourecgmay make flutter waves easier to find • Form of re-entry circuit into right atrium (Macro) Be suspicious if the HR is exactly 150! • Predictable heart rates Be suspicious if vagal maneuvers unsuccessful • Can deteriorate to VF ECG features Note revealing an underlying flutter rhythm may be more obvious after adenosine or vagal maneuvers, but will not terminate flutter • Narrow complex • Tachycardia • Can be regular or irregular • Rates 150,300 typical • Loss of isoelectric baseline Narrow QRS Broad QRS Framework AVNRT Ventricular tachycardia l Atrial flutter (VT) R Atrial Fibrillation Atrial flutter l I Case 4 A 50 year old nurse is brought to ED from the wards after a very busy day and stressful night shift, she has used her Ventolin inhaler 3 times through the night due to chest tightness after accidentally breathing in deodorant. She describes feeling very light headed with a racing pulse and mild chest discomfort. You proceed to initiate a vagal manouevre Which of the following is the ALS recommended vagal maneuver? A. Carotid sinus massage B. Modified Valsalva C. Patient breath holding D. Dunking into cold water/ice bath E. Don’t know Case 4 A 50 year old nurse is brought to ED from the wards after a very busy day and stressful night shift, she has used her Ventolin inhaler 3 times through the night due to chest tightness after accidentally breathing in deodorant. She describes feeling very light headed with a racing pulse and mild chest discomfort. You proceed to initiate a vagal manouevre Which of the following is the ALS recommended vagal maneuver? A. Carotid sinus massage B. Modified Valsalva C. Patient breath holding D. Dunking into cold water/ice bath E. Don’t know Case 5 You are working on AMU and the nursing team bring you an admission ECG they are worried about. You look over the patients notes; years ago with 1xDES and known bundle branch block. Otherwise fit and well’’. Background of NSTEMI 10 much the same as previously and is not sure what all the fuss is about, you feel an irregular radial pulse. Which of the following is the most appropriate first line management? A. Direct current cardioversion B. Modified Valsalva C. Oral flecainide D. Adenosine stat E. Oral Bisoprolol Case 5 You are working on AMU and the nursing team bring you an admission ECG they are worried about. You look over the patients notes; years ago with 1xDES and known bundle branch block. Otherwise fit and well’’. Background of NSTEMI 10 much the same as previously and is not sure what all the fuss is about, you feel an irregular radial pulse. Which of the following is the most appropriate first line management? A. Direct current cardioversion B. Modified Valsalva C. Oral flecainide D. Adenosine stat E. Oral BisoprololLeft bundle branch block Idiots guide • Broad Fundamentals • Feature of abnormal conduction usually secondary • V in V1(SRS pattern!) to; • (Possibly M in v6) • IHD, HTN, DCM, Aortic stenosisetc • LAD • out LBBB considered STEMI equivalent until ruled • Unusual looking ECG • Brugadacriteria ECG findings (criteria) • Broad (>120ms) • Dominant S wave in V1 • Broad monophasic R wave in v5/v6 • Left axis deviationRight bundle branch block Idiots guide • Broad Fundamentals • Feature of abnormal conduction • Mostly dominant R wav‘ SR”in v1 • Can be congenital and asymptomatic or new • (Possibly W in v6) secondary to other pathology • Normal axis • and in context of chest paine concerning if new • Unusual looking ECG ECG findings (criteria) • Broad (>120ms) • Dominant R wave in V1 • Broad S wave in v5/v6 • ‘Always’ normal axis Narrow QRS Broad QRS Framework AVNRT Ventricular tachycardia l Atrial flutter (VT) R Atrial AF with BBB Fibrillation (AF) l Atrial flutter I Case 6 You are working on CCU when a patient becomes unstable, the patient is 49 hospital with syncopal episodes. They are being worked up for possible devices or ablative therapy the nurses attach the defib and the following rhythm strip is seen; What electrolyte abnormality should be urgently checked? A. Sodium B. Magnesium C. Potassium D. TSH E. Calcium Case 6 You are working on CCU when a patient becomes unstable, the patient is 49 hospital with syncopal episodes. They are being worked up for possible devices or ablative therapy the nurses attach the defib and the following rhythm strip is seen; What electrolyte abnormality should be urgently checked? A. Sodium B. Magnesium C. Potassium D. TSH E. CalciumInvestigating arrythmias INITIALLY LATER • History • Bloods • Drugs (Caffeine, iatrogenic, cocaine) • Electrolytes (inc Mg, Ca) • Prev cardiac history? Eg IHD • TSH, drug levels (digoxin?) • Examine • Echo • Stable or unstable? • ECG • Structural heart disease? • Consider • Broad/narrow , regular/irregular • Underlying disease, eg Angiography, inherited cardiac diseases (WPW) O O F Feedback & Instagram + 3C N O Please complete feedback to receive slides and cheat sheet!Follow our In3tagram pa e for MCQs! NH O Cl CH 3 CH3 OH CH 3 CH OH 3 3HC CH3 3HC O