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Ok, I think we'll go, we'll give it a start. Um Once again, thanks for everyone. Joining in today, our lecture today is gonna be done by doctor and doctor Lee. It's gonna be on tachycardia and G readings. So I'll give, I'll hand over the phone to both of these lovely doctors and hopefully they'll be able to uh teach you a lot more than I would I to my. Um Right. Hopefully you can all see. Um our, this session is the third session of me and Lauren's the BCG and acute medicines. Um This one's about tachycardia. So what is tachycardia? So this is obviously a fast heart rate, anything more than about 100 and 50 minutes and typically notice um that it's at rest. Um and it's normal for anybody to have a fast heart rate if they're doing something like exercise, this can be physiological sinus tachycardia or a normal tachyrhythmia. So you're gonna feel the pulse on if it's regular or it's irregular. And so it can cause anemia, hyperthyroidism, infection, hypokalemia and exercise. So, so this will just be going through the guidelines in the, from the Research Council in the UK um obviously, I don't know if everybody's gonna be working in the UK, but I think they're pretty simple guidelines and they help split all the T cards into different sections and how we treat these sections. So, first step of the guideline is we assess with an A to approach. And so obviously, when you go to anybody unwell, you're gonna start airway, breathing circulation, um disability and everything else. And so the fact that you're gonna need oxygen, if they've got low oxygen and you're gonna put Cannulas in, you take blood and you're gonna do an EKG of the, all the rest of the observation, BP, oxygen saturations, et cetera. And we're also looking to identify and treat reversible causes. So obviously, as part of your observations and your assessment, you think they're in shock or they've got hypokalemia, they've got low BP, fast heart rate, you can treat them with fluids. Um And if you do like a blood gas, for example, you see the range of electrolytes in the treatment. Um So the next step, you're gonna look for any life threating features. So this is shock, syncope, myocardial anemia and severe heart failure. So, are they, have they fainted, have they collapsed? Um They're unconscious. Um Are they struggling to breathe? You've got a chest x of the lungs are full of fluid or something um or is on the EKG, they look like they've got a lot of, they've got, which Laura went through last time. So if, yeah, obviously for the semi and semi lament for the treatment for that, but if they're really, really poorly, they unstable. That treatments always synchronized these shock. This isn't something that we're gonna do. Um And it needs a lot of a big team and a lot of help. Um If the patient's conscious, they'll need sedation. You need anesthetics there. Um And regardless if they're conscious or unconscious, if they need to do these shots, you need senior help and you need a lot of information. Um If that's unsuccessful, then amiodarone 300 mg IV. And then we repeat it, they repeat the shot. Um So I thought we do a couple of cases in this um, session, make a bit more effective. So Missus A, she was in the A&E waiting room. She was with her husband, her husband was waiting to be. So she's not the patient. We don't know anything about her, why she's coming. She collapsed, basically. Um, and he called to see her. She's in her, a three, she's maintaining her airway. Her breathing is fine. Her heart rate's really fast. 100 and 90 each minute and her BP is low. It's 8, 5/60. She looks really pale. She feels really clammy. Everything else is fine. E CG done says T ti haven't gone to or anything at the moment. Don't worry about that. Basically, it's just that um, you put her on oxygen. You've got two large in start it, you put out at two T two or whatever the valent is a medical emergency call. What's your first line treatment according to the guidelines? Hopefully you can put it in the chart. Um What are you thinking? It's quite a simple question as if anything more power to guidelines. OK. I actually can't see the sac because I know my full skin, but hopefully these will be in the and everyone's agreed synchronized CC shot. Um Like is a quite an easy question because that was the only treatment we talk about so far from the guidelines. So I wasn't gonna see anything like that. Um This is because she was unstable and she had one of the life and have a couple and so she had, she was unconscious of before and she also seems a bit unstable given her how fast her heart is and how low her BP is. Obviously, we don't know the cause of that, but she could be hyperemic, she might be bleeding somewhere, not, but she seems unstable. So this is not going to call for help. Um So when you see SVT patients in general, we'll go to later um but they can be quite stable. So it might not require a shock. Um You just have to go through those guidelines and think that they seem stable as you have any threat. So the next bit is really when you get into the tachycardia. Um And as you can see here, the first step of classifying tachycardia is, is the QR S broad on our end. Um I hopefully everyone came to the session one where we look at normal EKG S and but if not, I've got the card. So QR which basically QRF should be less than two or three small squares. Um and therefore white is more than 100% correct Narrow complexes. Basically, things like atrial blood cell fibrillation, atrial fibrillation is the more common one or even and complex could be the bundle blocks, hyperkalemia BC or VF and four. So another question if you chat um is this PR S border and what? OK, I would chat. So I'll shout out if anything pops up. So don't worry about it. Excellent. I'll just get an excellent and if not, then we'll carry on. OK. So hopefully everyone agrees if they're thinking in their head or anything. Um But this is a narrow pr s because obviously this is, I don't know if you can count it. Hopefully it says quite well, but it's less than two or 345. Correct. Um This looks like it's uh it's got the really typical salty shape to the P wave. Um It doesn't often look that but um so narrow complex is like I said, they, they come from a potential or super to that they can be from the sign of a node. Um So this would be a normal P wave that you'd see. And that's the only thing that was generated from the SA node, the ATRIA. And you've got abnormal P waves, flu wave. Look at below three waves, for example. And then the aging node or junction is that no P wave or normal P wave would sort of less um in young people marathon are really well tolerated. Um They could only, they could just, only have palpitations, they could come in and out of it. Um Or they could stay in it for a while. If they stay in it for more than a, a few weeks, then you have to think about, obviously, we have to treat it because it could lead to something about heart failure. This is obviously because the heart's working really hard and quite a long time. Um elderly patients, 60 days of heart disease in the past. Um they can be quite unwell with it and that's because if the heart's pumping really fast, it's not really getting any time to fill the ventricles for the blood and the output is reduced and they found they don't really have the um they don't really have the ability to cope with that like each other. So types of my complex tachycardia again, we split that into regular, irregular um so regular spinus tachycardia or flusher with something like a 21 block. Um So it's just a six pattern block AV block is obviously how many P waves are per every service and ventricular node reentry tachy charges a reentry pas um and irregular ones are a fibrillation and atrial or tachycardia with variable block. So sometimes a block can be a 21312131, for example, and that would show like a, a regular test. So I said earlier anyway, this causes a sinus tachycardia. I don't know why I repeat myself here, but to not as um BP involved pulmonary embolism. And this is a really, really, really important one. If you see a patient in A&E or the ward, of course, to see them, they've got a fast heart rate. Um, obviously you look at other symptoms like blood in the, um, when they're coughing, chest pain, um, shortness of breath, all of those things. But, uh it's really important to rule out, think about doing other tests and looking for causes of that. So, um, calf swelling or redness or anything like that. Obviously, if they're prone to period, they've got um surgery if they've been on a long flight, something like this because coronary embolisms, um, they can obviously and everything else, but they can just be a little bit hard to that. So, atrial fleer versus atrial fibrillation. Atrial fleer is less common in atrial fibrillation. But everybody's heard of af probably everyone's already seen af um on and met probably thousands of patients with af um, it has similar symptoms they both present quite similarly similarly because that obviously fast heart rate. Um, it usually about it, but the kind of filters that down, um, with the conduction before and they're probably sitting more about 100 and six. Um, this obviously some people to be more like and not, not. Uh plus it's got the typical pattern that we still use. Um And like I said before, you can get 1 to 1 conduction that you could be running at 300 minutes. That's really only, I've never seen it, but it's only when you give someone like someone with like who's got this accessory pathway and give them uh a blocking drug or something like that. I could be blockage or something. Um It's just a little bit of a note because then it can become he, but I've never seen um A is more irregular. You have no P waves. So look at the RR interval, you can feel the pulse off the plate. Is it regular or irregular? But I think most people agree there's no P waves. And um um, so ad RTM RTI don't think you get too bogged down on it. Um Yeah, I just, it's not something I've ever seen written on the TV when someone's signed it. Um, both re and Tachycardia. So this is one of the abnormal circuits. So when the electrical um, activity is going from the sound, the node, um instead of kind of the direct pathway there. It's been a bit of a weird circle for them. Um They're both pouches so you can come in and out of it and usually regular about 100 and 50 ft. They can start and stop quickly. Passenger, right. D NRC is entirely within the node. That's what the N is for a and proximal to it. D RT have one within the node and one room outside of it. So if you want to run the, go through the anus for them, OK. Um Anyone who we r um has anyone that it would um will Parkinson's like, I think everybody knows or has heard of W Parkinson's like, it's probably one of the more common, weird and wonderful things to learn for an exam question. Um So it's a congenital affirmation um with some separation of the atria, not a ventricles are not very well. Um Patients of this often present when they're quite young into the teenage years. Um Sometimes they can come in with some fast heart rate, sometimes they collapse when they're out playing sport or something and some people could remain asymptomatic their whole lives. But I think people use different within the earlier years. Um They can be in also, they can be in either a or, or a and they, the rest in have the features that are listed below. A few of them are obviously the really common exam question features. So the short pr interval less than 100 and 20 mills, the slurred 52 s which is the delta wave. And obviously the other ones are prolonged and they could also 70% apparently have this. So they've got some depression which could look a little bit less. But yeah, it's just because of the other stuff. Um So this is just a diagram um just to kind of show the, the accessory pathways um and what it looks like in an E CG. And obviously, there's that secondary ST depression that I was saying that it's not from ischemia, it's because of the, the depolarization on the weight. And that, um so obviously, in a normal one, it goes to electrons from the, to the V and then in this one, you've got one leg of it doing that, what should do and another leg is kind of bypassing that going around the excessive pathway. It should be five. So three things. Um This is another snapshot of the guidelines we're talking about. So we've decided it's narrow and then we've decided whether it's regular or irregular, obviously, every time or as a member eight, are they stable? Have you got any life range features? If they have, we'll put now make appointment, getting some help, they might need a shot. So if they're stable and I've got a regular vision and there's lots of ba on maneuvers that you can try. Uh There's, there's like modified B to, you can get like a string um, they can blow on that, you can put their leg back a little bit of warning that. Um, also, I think there's some like blowing on balloon doing this thing where you plug your nose and blow it. Lots of people weird, uh, sinus massage. Um, I've never seen or done one. but obviously it's quite factory rubbing on the clotted. Uh, you don't need both clutter and you, it says just need to be careful with people with something like something like that. So I'm not sure you will be running to check with an ultrasound scan before you do that. If they, if I'm not sure that happen, but just night, uh if this doesn't work IV azine, uh if you have severe asthma, it's a constant. So you're using something like the instead if the first line fails, that's how the IV. And if all of that fails, then you come to the six, obviously, basically the whole time. If you're an F one or something like that, this is not gonna be, you know what player gonna go. Um And if it's irregular, then so with a beta blocker, something like or something like that and they might already be taking oral, you can give them an IV as well. Um And option if doesn't help. So, additional information is I think a bit but um if the failure to terminate the SVT with just like basal stimulation, so without having or course of ma or with drug treatment, then it could suggest that it's atrial origin. Um um And if, and the aging blockers should be avoided in people with all kind of in atrial fibrillation of. Um this is obviously because this could lead to them in a being in a 1 to 1 block again, then they go to 300 each minute and they could go into V which obviously, um so use these drugs, which other than flecainide, I've not heard of before. Ok. So case two mister B 85 year old male who called an ambulance testing, that was heart was racing, not breathless. No vomiting, no um, ulcer are listed there. Heart rate is 100 and 50 BP is 100 and 3070 oxygen, 96% on temperature, 36.7 and do here. Um If we have a look at it, uh what is it and what you start? So obviously you feel narrow or more. Um Is it regular or irregular? No, if someone feels right, just try to make that. It's not just that you think in your head. So this interview will hopefully everybody agrees. There's no wa um this is probably one of the that we use for. And so it's obviously got the narrow together as well and it's also got uh basically, so you sometimes you see it called A with RVR so to move on. Um So they're not rate controlled at the moment. So you wanna give them a beer and either all depends on the person. Um, is he hemody hemodynamic stable? With no life e features? Yes, because his obligations are fine. He, I mean, he had a bit of chest pain. He's gonna investigate anyway. But, um, he looked, well and he's fine as well. Um, and then the chest pain needs full investigation. Even if you see something that you think, well, that's probably causing the chest pain and you still need to investigate in case of nausea. So you wanna do, you wanna do, do EKG in this case, it depends of hours of onset of pain. Um That um when it just start low, even if you having a myocardial injury, so wide complex tachycardia is mixed. Um The causes are benefits of tachycardia, which would be the thing that's on your mind as the diagnosis. Otherwise, other than the ones where you're turning up in a less I um this is the one that's probably gonna get you um, two tachycardia such as atrial tachycardia and ADP O from the front, um or an accessory pathway or induced by drugs or um and paste also and with paste, I actually look that up. Um But you'll see a lot of patients sometimes a bit more but it's a straight line. Um So otherwise, obviously, other than when you sign up in the patients that um it can lead to the service, uh they usually all of these patients usually have previous heart disease. Um, they might be quite old. Um, they might have had previous cardiac arrest, they might have had previous heart attacks. Um, they might just have a cardiomyopathy. I don't know what they, um, is the surface is what causes the wide and the, the electrical signal doesn't travel very fast so it start doing it quite slow, which is what causing the cell issue. And then this can also put another round of each other. Um It can be difficult to distinguish the same over a wide complex that out. So the features are a dissociation. So the P wave is not even related to the PR s. Um There's just, some of them may be, some of them might be a fire attack, there's no relationship to and they can have cap be so they can have a normal way. And, but then obviously, the rest of like, um they also can have less deviation in the first session. Um And that was ad and one but that um they may also have bundle branch block. Um So this might also this might be coexisting. So you might come in there and they've had it for years or they could only have it within the year, it might be back to normal. So the same is that can have a run of and, and um the, not the same b I've only really seen them on 24 hour and stuff like that. Obviously, if it's gonna spontaneously stop after 30 seconds by, that can help you do it, then they're probably not any more stage. It um unless they're on something like a continuous cardiac monitor with an A CD or right on the. But I think um so the cause of increase in age, this is probably just because they've got all of the things below uh the or and eye artery disease, cardiomyopathy, heart failure, heart disease, which could also be caused by electrolyte, hyperkalemia, hyper, over the dosage drugs, anything. So it points but I put some of those um this is probably more expensive. Um It's kind of twisting around the base of G, sometimes I find it quite hard to, to t and sometimes it really easy. Um But I feel it and they may start terminate and they can, so they can be dangerous any other. Remember once stabilized, you have to set that im we're looking for the cord, go back into it. So, and also in our history over. Um so the lead to point and this might be something you do and there's lots of common drugs that can cause that. And we had a exam that I also, well, and there's a lot more common drugs as well. Um This is a, so these are the interviews, the bottom is the kind of normal of tachycardia. It's quite regular both r if you touch in a way and the point is the top one and it's got the on the baseline that I don't know if you can say right now or not, but you can kind of say, say it these little. Yeah. Yeah, it's not actually the height of the, which is my fault, but at first you can have them kind of all the, but they got the question. It is really hard to say, but it usually, um the is actually safe treatment of wide complex tachycardia. So, again, back to the guidelines. Is it regular? Because if that is narrow, just the regular or regular. First of all, remember at the very top of the guidelines is, are they stable? Have they got step regardless of course. Um But we're human though, stable, irregular um facilities are like um so atrial fibrillation was on the is one of the things and you can, you should treat that as an irregular narrow test. So you atrial fibrillation we're giving people. Um But for 20 more points with magnesium over 10 minutes. So that stabilizes. And we also need to say, like I said before, we need to look at the electrolytes um all the cores and that if they're regular or we don't know, then we're gonna give amiodarone. Maybe this is more often the case. Um The amiodarone 20 mg IV is a 10 to 60 minutes. Um All the way II, I've never prescribed amiodarone or given it. I'm not sure who can if it's a specific level of what you have to give it. But you see me around and they will, it's quite a nasty drug patient can feel really terrible. Um, I think it's quite specific, can figure as well. Um, so case free Mr, he came and seen in rubbish was, he's got, he's got a really big guy, he's got everything, got a family cage, you know, he's had it. Um, what does it do? Um So, no. Ok, so this is, um, it's kind of BT looks a little bit funny but if you look at these two for the, um, it looks quite regular. I think we all look really, quite good. Um It's almost like maybe eight or nine little squares, so it's quite good. We can't see any key waves. Um And, and you can see the skin around this person. Um So your tachycardia, it's a wide complex tachycardia the likely because it's fast. Um And the whole time and it's regular, uh the previous cardiac more likely to have these observation 280 heart rate, BP, hearing over 60 on oxygen, I think. Um, his and his back how he, but II think so. I want that 115, like I said, um, and so I don't think anyone you, uh and it, that you could either really ar really either way, but he is obviously not collapsed and he is not in stock periphery has not shut down um and his BP is ok. Ok. So II milligrams um set a week ago, elderly patients with uh heart problems in the past and so and everything they can deteriorate quite quickly. Um So even if you feel confident, always, yeah. Um and also I walk in on the um you wanna feel so in here now um you might need to. Um so I think I ran through that really, really quickly. Any questions I feel I'm happy to go back to anything II can see. Ok, lovely. And thank you Alex for that lovely session. I doctor um she will be doing another session alongside doctor Lee as well on the 25th of May. But please do fill in the bed that forms today a after the and it will be automatically emailed to you. It's very important for the lecture as well as for us as well to make sure that we're meeting your expectations and future events, how to coordinate them and you will be getting a certificate of at and consultation. But please do join us again on the 25th of July on a session on Friday Cardia. And at the end, there will be a quiz on what has been done over the last four session. Well, four sessions at the end. Ok. Is that, that's all right? Any questions in the meantime? Ok. Yes. No, I think um we can leave it at that for today. Thank you. So much for joining us and hopefully we see you again soon.