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okay? How? We started dating people in guys yet people aren't learn. I'm gonna share the rent. Ipil. Be interesting to see how many people, Um, how many people have come from the last season's? Well, um What do you see, You guys? Do you see the president? Yeah. It's come up just now. Yeah, Yeah. Fantastic on tastic. Okay, that's gonna be fun on. Hey, guys. Thanks for joining. I'm able one of one part of 60 of Syria's. Obviously, this your hair is another one of the co founders. We got really another one important committee members as well. We're just waiting for people to join. And while we're waiting, we've got this poor called menti where we figure out where people from. What's the question? Asked today Share, actually. Yeah. So we're just asking where you people where everyone's from. So, guys, welcome, welcome, super super excited. It's been a really, really good academic year. We're very happy to see some old some new faces. Lilly is obviously going to be a big new face. Ah ah, for this year. So we're very excited for that on. We hope you enjoy the year. If anyone is in God's go give you, give it, Give a shout. I mean, does go for my course surgical training. So ah, happy doing the teaching if anyone's around. Other than that, let's get involved with wait for people to come in and probably start a little bit later today, guys. But, um, hopefully, hopefully we'll get some people coming in. We're mindful that some of you many of you just started University on may not really be inversion nude remind set yet, but it's it's designed to be a very chill but very informative session on the CDs is something that we can definitely Uh uh, yeah, James, Once James back. I'm not surprised. Uh, I'm really confused because I've made us people can change their name. So is that actually James trolling us? Or is that that's actually James? Yeah. James Watt. Shame. Not surprised. Yeah, This electric guys will be very useful for people who are in going into clinical years for people that will be going into F one. Um, are graduating soon. We hoped the stuff that we covered today is ah, about evil. If you questions, put it in the chat. If you don't know about feedback and how that works. We'll put the feedback in the lecture, but we'll also have in the chart so you can click on Twitter. The feedback certificate will give you the feedback certificate. Uh, will be done. Will be given out after you complete the feedback. I'm sure you can tell I'm jumping up. I haven't done that for a while. I'll get sicker soon. Hopefully, um and then we're going to do some more focused lectures. A swell. This year, I'm going to try and do some mskube. Oka stops slightly more advanced stuff, but it will definitely stuff that you can tune into if your medical students as well um, there they say, if you're happy, we can start going soon. Um, I'm going to go to the 20 board here. So if you guys don't know how to use menti, go on. Www dot meant you dot com. Type in the code. 90733131. And then you should be able to get involved. We only got 19 people involved so far. We have 100 people here so love to get more people involved. Uh, London, Romania. Exeter, Enbrel. Very very, very, uh, mixed. So we always enjoy having people from all parts of the country on outside. Let's see. Yeah, height. It keeps an accident. Anybody from cool? I graduated from extra nam working insurers. So if you see me on the Detrol LA just say hi. Got someone from Inverness. That's like, way up north. I was there. I was there for my surgical boot counts. Amazing place. Actually, the hospital there're ignore the consultants there. If there If the consultants that there are like because you have the boot camp, it's probably a super awesome hospital. Um, I don't actually have a message through capacity has reached Max. That shouldn't be right. Maybe we'll look. She 500? Um, no, it's fine. We We shouldn't be a capacity at the numbers we're at right now. Well, look, yeah, I have a look in case there's something up there that's six test minute. There are copy to think and post on the chart. What? So if anyone still wants to get involved, we'll give a couple of moments, guys, because we're in mind for the fine. But there's some people still trying to get on, just hoping that just Yeah, there's loads, and that's just coming through. Some guys will have to look into that while we're doing the lecture problem about capacity. Just starting it now. You should have been 500 I think. Yeah. There's more than 100 being admitted now. Yeah, A Well, there we go. Big storm coming in. Uh, yeah. Do you want to get there? Yeah. Yeah, we'll give it. We'll give it another apologies. Nice. Uh, whoever didn't get in earlier and for whoever that's still waking. So if you weren't in for the start, if some of you watched the lectures before my name is she here? I'm one of the co founders with you. Was also one of the co founders. We Someone new this year, Lily, who is an F one based in London. She's going to be running a lot of the surgical teaching. Very excited, So yeah, Basildon. Well, fine, but ah ah, yeah, yeah. Graduate from London Imperial. So, uh, we're excited for the new year ahead. If you have any questions or anything you want to ask added to the chapter If you want to contact anyone of us A You, me or really You can contact directly on the chat. If there's anything else that you want to do, I'm happy for people to reach out as well. Uh, a couple of things and projects that will be doing is well, and we'll be doing some mskube. Okay. Teaching this year, Uh, that I would be very, very excited about. So if you're interested, not do that. You know, when I could give you updates on that, Um, I think that they were We should probably get started. Yeah, that's fine. Let me Just remorseful routine. So Manchester wins today. Oh, but Manchester and brittle. Oh, sorry. It's all right. No, they're absolutely. Please go ahead. Okay. Know already? It's just once. All right. Hi. Everyone has to hear introduced May. My name is Lily. I'm currently a F one doing general surgery at Basildon Hospital on today. We're just gonna have a section on the C G interpretation on, but I'm going along. Please feel free to oppose any questions in the chat function. My co host you're here on, but you will try their best answer. All of the questions on bail be a small break during the middle. Just for a couple of minutes on feel free to again. Ask any questions. You can just, um you you're Mike. I won't mind that on. Do just before we begin. Can you just write in the chat function for me? Which clinical year you're in. So just so I can gauge into what amount of detail that we can go into for each case. Okay, so I think from the responses so far, we've got quite a mixture. Then that's fine. So I guess we can go from the very basics and if any If you would like to know anything in mawr Depth and breath, please. Just again. Yeah. Message on the chapped would just, you know, meet yourself and ask directly. So yes. So just these are all of our so for media's if you just start scan the bark heard feel free to follow any of them onda again. Um uh, the six PM series sponsored by MD You on, um, get started. So yes. So just some learning objectives before we start. So, um obviously the objective is to be able to understand a niece, e g trace the normal component off any CG to be able to present a 12 lead standard E C G. And be able to recognize some off the common arrhythmias that might come up in your house keys or paces on gum. So if you want to ask about any management about ECD abnormalities, feel free. But just because I'm I'm keeping this tutorial at a basic level, I'm not. I haven't got any much information on my slides in terms of the comprehensive management for some of the abnormalities. So I'm going to present in this session 10 CCGs and total. So after we have a look at each one, I just want you all to essentially write in the chart function. What do you think the E c G shows on? Um, yeah, and, yeah, there's no right or wrong answer. Please just be as interactive as you can. Um, So yep. So we got our first one if you just take a minute to have a look and then just write anything down in the chat. So even if you don't reach a conclusion off what the CD shows feel free. So just write any information that you've gained from the C. G itself. Okay, so I'm seeing a lot off people saying It's normally see GI Some people thinks in my ST elevation on D Someone has said Rug, you rhythm. 75 BPM. Sinus rhythm. Yeah, And some people have said that could be 10 to ti waves. And I'm guessing you, man probably hyperkalemic because of that. So, yeah, if we just go through that so essentially is a normal E c g. And the reason why I've put that up there, it's just because to be able to recognize any abnormalities on any CG or impact anything, you need to be able to recognize what a normal version of that thing looks like, eh? So let's just go through essentially the normal components and standard PCG tracing. So just in terms of very quickly and true, Your know this in terms of ECD physiology? Yes, sir. In the heart of the essay node is the natural pacemaker off the heart on gum, it sends signals bounces of mild cardio on it. This gets delayed at the AB node normally by northwestern One second. Then I think the impulse travels down the ventricle down the boundary of bundle of his underpants. Kinji fibers to cause the ventricular contraction. So, in terms of how that correlates to a B. C D. Tracing, um, you get a P wave a cure us on the T wave. So the P wave normally corresponds to atrial depolarizations, and then the cure s corresponds to ventricular depolarizations. So P wave essentially is when the atrial atrium contracts on Do the your ass is when the ventricles contract. And then, um, you have a essentially a isil electric segment in terms off to ST segment on. Then you have a T wave. Which chorus wants to trickle a report or is a shin? So that's when the potassium ions he flux out and it goes back to its normal resting potential. Ready, Teo depolarizing again for the next cycle. So in a normal standard, PCG trays you normally won't see atrial repolarization just because that's normally hidden in the cure s complex. Um, so yes, so that's a standard PCG trace there for you on d um in terms off components of an E c. G. So I've listed everything here on obviously, I know you care about exams. And so in terms off presenting easy G in your exams in the practical station. It's good to practice on a daily basis just with every CGC. Try to mention each of these components on because that's where you would get most of the marks. Because even if everything is normal just by mentioning these things, you would essentially get order marks along the way on Dive just risen a sort of a sample ECD presentation here on on day because you don't have to use this template. But it's just something there for your reference after this session on Do. If you do sometimes feel clueless, it's good to stick to a template that so that you know essentially where you're going. And sometimes it can get you back on on track off what you're looking at. Um, so if we just go through the basics off, how do you determine each of the components of the BCG? So essentially obviously named date on DA? Sometimes if you could give it indication for doing the C G before you present the each compact each of the component that be great, then in terms of determining the heart rate, um, this is it. Everyone just comment under attack, whether you're familiar with the equation off 300 divided by the number of large squares between our interval. Okay, a lot of people saying yes. Um, yeah. And someone said this methods only works in the regular rhythm. That's correct. I'll mention how we can work. How heart rate in a irregular rhythm in a bit. But essentially yes. If, um yeah, this equation only would work if the heart rhythm is regular. So the reason for why this equation works, uh, in a regular rhythm s e g is because most of the C G is proliferated at 25 milliseconds. Sorry. Millimeters per seconds on each off The small square that you see on a PCG paper is one millimeter by one millimeter. So essentially in one minute, the c G paper would go through about ah, 1500 millimeter in terms of distance on this corresponds to 300 large squares on. Then when you divide that by the regular interval between the are square, that would give you the heart rate in a regular rhythm. S E g. So that's the reason why we use that equation eso later on, when I present other e c gs. I'll just met. Quickly mention how come we calculate the heart rate in a irregular rhythm? Uh, CG So yes. So in terms off, determining rhythms so broadly kind of splits into three groups first ones, regular Sinus rhythm. So if you look hat the diagram at the bottom of this lies Regular Sinus rhythm means that, uh, every P wave is followed by a curious complex on that the P to pee interval are equal between each one and then in terms off regularly. Irregular Sinus rhythm is when the cure as follows every P wave. But the P to pee intervals are unequal. But this type of our rhythm, it's quite rare. Usually there's some sorts of damage to the mile. Um, cardio. Um, but the majority of the rhythms you would get is either regular Sinus rhythm or irregularly irregular is, um, which is our third one. So that's when that peewee way it is No, always present before cure us on Essentially is it is basically atrial fibrilation, which, um, we will see a e c g later on on. Um, by the way, if you have any questions, please just put that on the chat. Um, okay, So in terms of determining cardiac access, I know a lot of people, especially during their early clinical years, found this very difficult on down. You can go through a lot of complicated mathematical equations and also factors in order to work it out. But I'm just gonna present a very simple way off working it out when you're under high pressure to present any C g. So in majority of the cases, you only need to look at too early. So if you look at lead one and 80 f in a lot, Uh, yeah. In the majority of cases, you can already work out. What is the access? So if the heart has a normal access lead one and 80 s, we'll both have a positive deflection upwards. So they would both be going towards the same direction on if you're the right toe axis. Deviation did be going towards each other, whereas if you have a left axis deviation to be going away from each other, and I just put loads hit so underside of the table to remind you is entry. If they're going towards each other, they're right for each other. And if going away for each other, that means you know, they don't get on that so that they've left each other. That's sort of a quick way off working out cardiac taxes on D This is what I was saying in terms Off usually dance a lot of complicated factors in terms of working out partying access, but essentially just to remind you normal cardiac access is minus 30 degrees to 90 degrees on essentially cardiac access represents some off depolarizations vectors generated by individual cardiomyocyte on, but usually because left ventricle makes up most off the cardiac mask muscles. That's why normal cardiac axis is pointing toward downwards as well as towards the left on, because there are various reasons for either left on right cardiac, um, axis deviation. So, for example, you can have hypertrophy off either the right or the left heart on. Sometimes you can have valvular problems that causes hypertrophy on be causing the heart to essentially deviate from the normal axis on. Yeah, and then So this one essentially pr interval. Just the delay between, um what I was mentioning at the 80 node on. Normally, it's 23 to 5 small squares and ever in their correspondent time limits on there as well. On Cure us should normally be within 2 to 2.5 small squares on that. Usually we call that narrow QRS complex. So whenever someone says the cure s complexes narrow, that means that it is normal, whereas want it is a larger than that. It means you've got a broad, curious complex, and that's when that's underlying cardiomyocyte fiber damages. That's when it's abnormal. On in terms off q T interval. That just represents how long it takes the heart. The cardiomyocyte to Repola rise itself. In order, Teo essentially be ready to start the next cardiac cycle. Onda. If you look at the literature, there are a lot of different ranges for Q T intervals on. But I've just written one off the salt. Yeah, Granger's I've found unlit in the literature here, but essentially Q t interval from very a lot on. The problem occurs when you have prolonged QT interval, which is normally about 440 milliseconds. Were men on day, 460 milliseconds for women on gum when, um, so So there's an equation again for corrected QT interval just because sometimes when people have low heart rate so Bradley Cardia the Q T interval is naturally prolonged. So sometimes need Teo essentially use this equation trend us written here to workout lost the standard Q T interval at a standard heart rate, which is presumed to be 60 BPM. Um, Andi, when you're again, when you're commenting on the c G in under time pressure, a tip I've got for you is that if you look at the bottom picture of the diagram, if you again draw cross. So in between the two each of the peak off the cure s waves on, then if the t way forced before, um, the vertical line off the cross If it if it finishes before that, then it usually means think UTI interval is normal, whereas if it overlaps that or force behind, that usually means that there is prolonged QT interval. Um, okay, so right, if we just move on to this one again, I think it be good if you just again comment on what you think is the problem here. And also, um, if you want it be to get into a good habit just to write how each components of the CT on. But just even comment on them, even if you think is normal. Yes, sir. It's just for a previous slide. Someone just asked, Isn't q t just time for ventricular contraction and relax. Asian. Yeah, essentially Like that. Does it? I was just speaking terms off electrophysiology, but essentially, that's what it means. So yet that's right on d. Just wondering any of the founders. Have you got anything to add at this point? So I think I've been steadily adding things on the chat. I'm slowly adding things on the chat. I've kept commenting and putting things in the chart. Okay, Okay. Nor something not going. I'm not going to talk. All keep posting things in the chart. Okay? Thank you. Yes. So, majority of people identified as absent P waves and hence atrial fibrilation. Uh, yeah, I agree with that. That is. You guys correct. Um, so if we just go through atrial fibrilation a little bit, essentially, Yeah. Atrial fibrilation happens when there's a lot of random signals in the, um, atrium on do, um so that would make essentially the atrial continuously contract on gum. So it started contract. It's not the quite word in centrally, they would, um, make not contract properly on. That's why you don't see a discernible P wave. But every now and then one off the signals gets to the 80 note and then conduct down the bundle of histo cause, ah, ventricular contraction. That's why you see, very run yet your ass complex at very random interval and no discernible P waves on essentially atrial fibrilation can be a process more, which means it happens spontaneously and revert back to Sinus rhythm spontaneously or persistent, which normally means they cause this beyond seven days on also permanent. So that just means that family and a f And sometimes even when you defibrillator, um, the heart wouldn't go back to normal rhythms. Onda Um yeah, there are quite a few risk factors and that can be divided into vascular and non basket left. As I've written here, and usually with vascular pathologies, it can be anything down to, um, BP or damage to the myocardium. Due to estimate heart disease or any valvular pathologies on one of the major nonvascular risk factor would be hyperthyroidism. So, in terms off off skis that would be something definitely on the top of the list to exclude on dust. Other miscellaneous ones would be a exposure to certain substance, such as caffeine on sometimes when you have chronic underlying, um, spiritually pathologies Onda, Um, just quickly in terms off management. The most important thing when you find someone who is in a f is to went to determine if a patient is humid on that dynamically stable that just means like whether, um, their heart, whether they're called tachycardia or whether they're BP, is dropping. Is there heart essentially the workload off the heart able to support her to put out enough blood supply for the body without them deteriorating? And if they're know, then normally you need Teo do Immediate. A direct cardioversion, too, is entry Roberta Heart back to a normal rhythm so that they become hemodynamically stable on. But if they are hemodynamically stable, which is usually the case, but sometimes they can have fast a F, which means they have a F A heart rate off over 100. Then you would normally use medication to rate control, so that includes be two blockers or non dye hydro period in calcium channel blockers such as, um, your tires, um on. Also, you determine whether there's a need to and to coagulate them just because there's a lot of turbulent flow within the heart itself. And therefore people are predisposed when they're in a F to form clots on deviously. If you form a cross and you're more prone to have a stroke on the the way to determine whether they need us to use the chance mask score usually above two would mean you would have to go onto coggle a on d. Sometimes, obviously, that would be a higher decision by seniors. They were determined whether you should attempt to restore the normal rhythm on. This is usually after four weeks off anticoagulations. Okay, so now we're on our third case. So again, if we just do the same as before, just comment under chat off what you think this is? Um, yet this easy GI shows. So I see some. A lot of people only have written a diagnosis here. It be good if you just kind of look through the whole thing and try to comment on each individual component, as well as presenting a conclusion for the c. G. So I see a lot of people saying anterior myocardial infarction on some people thinks it's got, uh, s saddle ST elevation across the board. So hence pericarditis is so, like the correct answer here. It's sort of stemi from the chest lease. We want to be five. Um, B six is not very convincing off ST Elevation, but I think there is a C elevation and be one on 80 l Where us a lof. The other leaves. I can't see any convincing ST elevations, are you? If you hear, If you guys disagree, just let me know, because I I can understand why some people think his pericard isis, because I think sometimes the the elevation can be for the line. So, in clinical practice, in terms of pericarditis, eso usually ST elevations bit more uniform. It's not where you to see one lead where it's massively increased compared to the others, so usually be, you know, 12 millimeters uniformly across a leads. Now, if you're looking at the one to the four, as Linda was mentioning, there's massive ST Elevation ST elevation there, which is quite abnormal for pericarditis that points more towards a stemi and again chemical. The chemical picture is quite important again, you know, Have they got you know, some symptoms ParaGard that has pain worse with meaning forward. Worse with inspiration, you know, high inflammatory markers. But again, from this sed alone, you would say it's more likely to be sort of untrue. Oh, lateral same process, because I n a b l o also affected. But when you look at to free ABF Frida's possibly some T wave inversion azelas flat and teas and a V f deem should just reciprocal changes in ST Depression and need free. So this overall to me would point more towards a stab me than it would pericarditis. On Another thing is why I said you should always can't comment on the individual component off the HCG is that if you look quite closely, you can actually see pr interval um, prolonged PR interval. So normally it would be ah within 45 squares. But I think with this one it essentially drags out to about 6 to 7 squares on DS. Actually, they would this would be a a anterolateral stemi on, but, uh, PR, the first degree heart block essentially could be from what they had before the m I. Well, um there is a possibility that in a small minority of people, um s a, uh a navy node is actually supplied by the left circumplex artery. But when we wouldn't be showing this taste just because we don't have a previous PCG how about to start going? Uh, I think it's the right at the RC that mostly supplies the SCN even. But sometimes there is left or right dominance. See, they talk about it. I'm not cardiologists, but people are built very differently. Eso as then he was saying, with some m following and then mine as a complication of the MRI rather than having had it. So that's a lot. Yeah. So? So if we again just go through this one on if people could just stop start Commons in in a chat again, Okay? There's some people who said it's tacky. Carsick, I agree. So it looks so that's about two large squares between each, uh your ass complex so should corresponds to about 150 BPM on day. Some people have also said regular rhythm, which I will so agree because there is a QRS Sorry, p by followed by, um curious in every leads here. Yeah, and some people have said on ST segment depression, which is also correct. So, um yes. So from what I can see, there is the depression in him. Legs one and two as well as, um, uh, chest be four to be six. So if we just quickly go through acute coronary syndrome Essentially, um, what I want to stress about is that, uh, in terms off a C s on stemi and sorry. Uh, ST Depression and ST Elevation are not the only possible e c t changes. Sometimes in terms, overly warning signs. You can have tea wave inversion s. So that's a part from lead A B R. Because lead a VR normally has t wave in Bertran s o t wave inversion. Other leads, though, could indicate a possible, um, early s skinnier signs on. Also, if you have a previous CCG that you can compare it to any new onset left bundle branch blocks. So that's if you will know about William and Marrow. That's W in the one and 22 on gum m shaped up your ass in be five and six. So essentially in, um, left bundle Branch block, you have a wide QRS complex on. The reason for that is, um, after the the bundle of his brunch hour into a the to individual large fry was supplying the two sides of the heart. One of them has become so one of the heart, one side off the heart has a infarctions. In this case, the left side there four and one side off the heart contracts earlier than the other side giving a wide, curious, complex appearance on. But obviously with my presentation, central chest pain associated was northern vomiting pain would radiate the left side. And sometimes I have loss of consciousness if the patient's hemodynamically unstable on gum just in terms off, um, the region that corresponds to different coronary arteries. It's really important when you present into a sed is to mention which leaves the ST changes occur. And I've just listed the least with their corresponding arteries on the right hand side table here. That's for your reference. Yeah, after this structural on, just to quickly talk about just immediate management in terms off, um, a C s. So normally you'd offer pain relief. So because white painful. So you would go through out to morphine on with some anti sickness on, then the guideline. Um, so they changed from when I was studying this by essentially. Now you're only give oxygen if the outside in saturation is low. That's to prevent any free oxygen radicals from generated on doing more damage. And then for everyone. You should commence on your anti platelets. So that's normally 3 mg off aspirin and then with another anti platelet agents, depending on your trust. Guideline on then. Sometimes you would also give a low molecular weight heparin. So in this case, fund a paradox unless, ah, primary angioplasty or percutaneously PCI is planned within 24 hours. In that case, you wouldn't give the fund parents you would give happen instead because it's easier to reverse heparin because heparin has a essentially direct antidote, whereas low molecular weight happened. Doesn't. So, um, yes. So that's suggest off a a. C s management. Um, yes. So this is like half almost halfway through Roget or oh, um, just if there's any questions, just you can type it on the chart and they'll be really happy to answer it on door. Probably give about a minute, and then we can carry on with the rest of digitorum. Lily, is it possible to go back to the Sinus rhythm? Me see gi? Cause I think someone just to explain what deflection is Sinus? Yeah, just the normal one. Just to show what? What what we mean by deflection. So I'm not sure you ask deflection question. And how did it if I am with a regular visit, Our come back to that one in the second week. So in terms of deflection, so four deflection is either to leader freely. Method is the add mention everyone. So you look at the needs one to a V f or one bus ATF I I looked it all free, but it doesn't matter how you do. So when we talk about the flexion, you're looking at the QRS complex, secure us being made of a cube and are on this point. So when you're looking to see the overall deflection off a QRS way, you're comparing the height of the R wave, which is there. So that's about what five plus free about eight small squares to the top you compare that to the depth of the S wave, which is down the front, which is about two small squares. If you take them away. Eight minus to the overall deflection is positive. Six. Which means it's a it's over upright position. It's a positive deflection in the I lied. I eat if you just eyeball it is the R wave taller than the s way. There's basically that's what positive deflection means and you get 12 and Avia 12 and 80 s all of them. The curious is having overall positive deflection. I mean, it's normal cardiac access. Now. If the S way was a lot bigger compared to the always, I put mostly pointing downwards. That would mean it's a negative deflection that lead in the Pentagon. As Lily was saying, the combination of positive and negative deflection in the leads comparing wanted to or one TDF. That's what gives you overall cardiac access. Sometimes it can appear very neutral. We could be different, difficult to distinguish, in which case you have to calculate it manually or use the machine synthetic calculate for you that's suggestive. Chronic axis. Uh, that's all right. I'm just looking at the questions on what these course wants to walk artery. Um, like, I'll just want to track, like because, Yeah. Were there any error in my Yeah, I think I think for the Circumplex artery was saying that it was inferior out of the last time. Yes, all right, so I can see that It's so good. I've mentioned it a little good. Ah, what house and very quickly on centimeters. Question about a F with a regular so F by definition, is no p waves irregularly irregular. If it's regular, you have to ask yourself whether the E. C G is correct. I have you positioned the leaves in the correct way to see if there's peewee of activity and sometimes is different things you can use to work it up, such as a Lupus need, which are not going to go into. But for that, for the sake, take a purpose is keeping it simple for the sake of, you know, non called your just level start. If there's no P waves and it's irregularly irregular and have a feel of the pulse, it's it's a F. Sometimes fast F can be so fast that it can be really difficult to work out with. The underlying rhythm is I've seen people in fasting 100 eighty's, and sometimes it's so close that it looks like it's regular, but it it isn't in the only two at the house by slowing the heart rate down, depending on what you think it is. So it very much is going to be in 100 87 200 going to be working out whether this is an STD I When you give a dentist, you need to regulate the C G monitoring and see when you slow it down, what the underlying rhythm is, If that makes sense or if you do think it is fast there, you'd be given, you know, by several. If they're if they no, I stopped a beat. A blocker. If they're hemodynamically stable. Such a IV, um, a topical. If they're really, um, well or you know, a little bit of blockage, you think they're okay, things like the doxepin, he said. Amiodarone calcium channel blockers is different things for, but essentially the only time where it was really difficult identifies if the rhythm is so fast, where everything is so close together. That's my, uh, fasting on that I think would dress a little the question suddenly. So So yeah. Um, yeah. So if guys there's any more questions, just keep them coming in the chart. I'll just move on with the treat oral now. So yes. So this is our 50 cg again. Just start commenting on what you think is the conclusion or just anything that you can identify from this CCG eso the feedback link. So I've got a feedback link a t end off this Chitauro? Um yeah, the one in unproduced Lied is is not the right one. It's it's nowhere All POSTOP, POSTOP, the feedback, like, for for anybody that eight. Is this being recorded as well? Yes, being recorded that. So we'll put it up on the metal catchup content guys, and you can actually get a certificate from that. And so then a few back form, too. So there's there's multiple ways for Utomo certificate. Okay, so, um, people haven't quiet, um, host it for this one, but someone that has kind of said it might be atrial flutter. Um, I can see why you think that essentially we go through it together. I think why you thought is atrial flutters. Probably because that you can see sort of, like two small waves. But for each cure us. Um And I think maybe that's why you think is a crew flat PSA. But essentially, what this shows is if we go from the beginning, is Sinus rhythm. Because there's a P wave before every QRS on in terms of rate, uh, spell 90 to 100. I want to say on gum, so cardiac access is normal on, But when you look at PR interval, you can see here that is prolonged is quiet, obvious. If you look at lead one onto, um so normally be within, um be between 4 to 5 small squares. But in this one, um, it's about maybe eight or nine small squares on essentially what the two waves together you're seeing. I think the first one is a T wave that you saw on on the second one. Is the P wave on, followed by a long PR interval than a cure s. I don't know if that answers your question, but let me know. But essentially Yeah, and again, moving on Curious is narrow complex on, but, um, I can't see any ST changes on day Q T interval. Looks okay to me. A swell on. Essentially, what this is is is isolated abnormality off prolonged PR interval, and hence the sticky shows first degree, heart block. Um, so if we move onto the next one, I'm gonna have a summary slides off the next three 3 to 4 e c gs a DNA, and so that we couldn't go through a heart blocks all together s But for now, if you could just start commenting on what you see for this one, Yeah, so some people have responded is up second degree heart block on? Yes. Someone said missing cure s. That's exactly it. So again, if we go through it systematically again, is in Sinus rhythm And, um but when you so yet. But when you look at the PR interval, um, if you look hot, the rhythm lead. So the, um, limb leads to on the bottom. You can see that the first key our interval to the fast complex is PR. Interval is within the normal range on then, as you go along, the leads the PR interval each time it gets a little bit longer. Um, until so after the fifth pee wave, Um, there is no cure at. So essentially, there is a gradual prolongation off PR interval on until under 50. It drops the ventricles. The signals don't conduct down to the ventricles, and therefore it doesn't contract on. Yes, in this case is a second degree heart block also known as smooth as type one or otherwise known as they went back phenomenon. Um, if we just go to this one, So again, just comment on what you conceive on this. Okay, so there are a lot people saying it's movies type two, Um, some people think is ah, third degree heart block again if we just go through it systematically. Um, so yet in this case, um, again, um, there is a, um, P wave before curious, however, um, for every third heart beats at the yet cardiac cycle, the curious complex disappears. That signal doesn't conduct down to the ventricles on dumb. When you look at a PR interval is actually regular, so within the normal range. So this would be consistent with a mobile is type two heart block. So a second degree heart block mobiles type two on gum. But if you also, um, look at Chesley so this quite interesting. So if you mainly in the one B two on V's, three possibly in before as well so you can see that the cure s wave the Q. We waive. The downward deflection is quite a lot. It's a lot larger than what you normally expect. Normally, it's about 1 to 2 millimeter tool, but this one is almost like five or six millimeter on this CCG. So that's essentially what we call a pathological Q wave when the to waive the coupon of the curious weight is abnormally, essentially abnormally large for what it should be. Eso. Normally that indicates a past Am I on? That's a old infarction. Some old damage to the cardiac muscles on Obviously be one to be for us. We've mentioned earlier. Corresponds to um, the ah anteriorly. So the left a sending sorry left anterior descending artery. So this person probably had some sort of a, um, anterior infarction in the past on um, it's very likely because any damage to the underlying heart muscles can result in any heart blocks, so it's very likely that this rhythm is, um, caused by that old infarction on D If we go to the next one. Yes. So, again, just the head is not the type of heart block. If we could just comment on that, and then we can go through heart blocks as a collective. Um, so somebody else if I can show you a coupon saver by the mouse. So after this, what? I could go back on, point out what I mean by the cube waves. Yes. So some answers coming in. So obviously we're talking about heart blocks at this point. Obviously. The only ones we have a mentioned. Yeah, but is the degree heart block or also known as complete heart block? So this is what iss Essentially, Yeah. You can't see any discernible associations between the P wave and the cure us. So if I just, like, three point out, um, So some of the peewee waves that, um that isn't any association whatsoever. Um, yeah. In terms off how the atria and the ventricles are contracting, And also another way, another good way off. I guess I raise your suspicion about complete heart block. Is that the natural rhythm. So all of the heart muscle can His can generate signals and contract by itself. So the natural rhythm off the ventricles eventually cells is actually, um, about 30 to 40 beats Come in. It's on gum because you can tell, like from from this CCG that each of the cure s are so far apart on. But person is extremely bad. Ikari sick on. But just from that alone, it should raise some suspicion off complete heart block. Um, so yes, so that's that. And if I just go back to, um, what we're talking about in terms off pathological Q waves, So, um, I don't know if, like, you can see my mouth's, but let me know in the chart. But essentially, this is the coupon off the your ass complexes R s. So essentially this part is abnormally like large for boys should being normally. It should be very small on because of this. This what I was saying is not quite normal on do this is this is known as pathological Q waves on the C G. Um, okay, cause war. Okay, so someone okay? Someone asked me, Was this pack load for a few ways. Essentially, it's just past, Um, it's, uh yet past heart attacks past my card in functions. Okay, so I'm just going to go through a complete heart. Blocks just heart blocks, asshole. So in terms of its definitions, just a delay in the transmission off electrical impulses, from the atrial to the ventricles on down in terms of presentation is on a spectrum. So with first degree heart block, it can be like, completely normal on, um on. There's no symptoms whatsoever. But when you get to the more severe end of the spectrum, you can get short of breath Fatigue on DA. When it gets really bad, you can get something called Adam Stokes attack. Essentially, Ah, the cardinal science when your face just goes pale and you would faint, Um, due to the lack off cardiac output in order yet, Teo supply enough oxygen, foot, brain on dive, just a listed a couple of causes for um yeah, in terms for heart block. So can be a variety. Any damage to the underlying heart muscles can cause heart block heart blocks when the heart block when there is damage to it. When the original tissue off the muscle is replaced by fibrous tissues. That part off the tissue stops conducting on. Then you get the CGs us we have seen in the last three or four on do in terms off cardiac causes. A lot of it. If you get out, you can just say esteem a heart disease because that basically causes everything in the heart on day are other things like infiltrative causes like sock week doses and amyloid doses where what proteins are deposited in the heart muscles to prevent to the signals from traveling smoothly on then, um, there can also be medications. So sometimes if people are wrongly put on, um, both be two blockers and some of the calcium channel blockers you can cause, um, severe heart block and cause severe bradycardia. Eso It's good practice. A swell Teo with reviewed a drug chart to see if any medication could be a cause off heart blocks. Um, and then just the table. Teo summarize the treatment. So usually first degree heart block and movies type one are quite benign. Onda um, not it just needs regular monitoring. Teo, um, a guest touch any progressions early, and, um, no active treatment is needed is where it's when you get to move his type two on a complete heart block. These are your medical emergencies and normally pay front should be expedited toe have a pacemaker and sometimes pass a miner's a implantable cardiac different laser. Um inserted us well on. So yes. So we're getting to the last two e c gs. If you just keep the answers coming, I'm just gonna have a look. Cabbage. Okay? Some people have said VF Some people have said b t so yeah, and some people have said tachycardia regular rhythm. So again, if we just go If we just described this CCG eventually what you see, um, soft, Very uniformed. Um oh, your broad caressed complex on. But when you see any CD like that, um, that means is in of a triple A tachycardia. The difference between VF um, Beattie in terms off the morphology on the C g. Is that with, um, VF is not, um, it's no uniformed like this. You can see distinctive waves. It's literally how can I describe it? Just scribbles squiggle on the paper on Done, um, someone, um yeah, and then you could get another type all spent Triple A tachycardia, but it's polymorphic, so that means they're not uniform in height on gum. Some sometimes be a segment that's off. That's off. It gets like a higher amplitude on, then followed by a segment off a lower amplitude. That's something called a torus. Odd on that's usually, um, caused by medications or electrolyte disturbances. If we just goes through, um, some of the cardiac arrest rhythm so just listed them here. I already explained differences between the F and G t so v f Like I said, it's very disorganized that I'm just squiggle on the paper where his V t is monomorphic very organized, broad, complex, uh, sort of broad, curious, complex Onda in terms off a post this electrical activity, so is a normal praise. But when you fill for a pulse, you can't feel for one. So that's termed a pulseless. Electrical activity on a systole is just a flat line, essentially on, but just very quickly. Uh, these are divided into shock, a ball and non tropical rhythms. The top two you can shut them. Where's the bottom? Teo? Essentially, you can't trust them. You have to commence CPR on, but when you have different relate on, they will assess the rhythm for you on, um, advise you if the rhythm becomes shaka ble as you. Yeah, as you do your CPR and then just very quickly, Um, there are Ah, yes. So what's called Fourteens and four h is in terms of reversible causes off Guardia caressed. So normally people would have different related attached to them while they're being ventilated on having CPR done on them on. But you would want to find out if any of these causes listed here Ah, a ah, cause it'd factor for the cardiac arrest. Because if one of these factors are present, then we need to reverse it. And in theory, that should get their heart restarted again off, of course, with all of the other supportive measures Such a CPR on the ventilation on, um, possibly defibrillation. So I think would come to Yeah, it comes off fine or E c g, um, again, I just give you a minute if you can. Just owl, huh? Yet just write what you can see on this one. I think, um, so there's a divide between people saying it's SPT and some people saying it's Sinus tachycardia. So, um, to the correct answer in this case is is a super ventricular tachycardia. So the reason for this is, um, there is essentially a uniform narrow, complex, curious waves followed by t waves. But there isn't any visible or discernible P waves on this on gum, Usually when there's no p waves visible. And there is, um, uniformed, narrow, complex cure us. That means it's yeah, easy to use something showing super ventricular tachycardia on. But I'm just gonna quickly go through the the two types so you can have a BRCA and 80 and r t Essentially, I'm just way is is a VRT. You have a accessory? Um, pathway that's present in within the myocardium I've pointed out here s O. Normally, this is known as a wolf Parkinson white syndrome on this accessory pathway. Um, it's Tom bundle of Kent on bend. Their know in spc. Aiken. Just show you a, uh, example off a PCG after this slice Now. Yeah, um, point out, that's not the cardinal signs off. Why is it a wolf? Parkinson White on the other one is 80 and not see essentially again. There is an accessory pathway, but it just goes through the IV node itself on because is a loop on itself. It just keeps going through like that and keeps causing the ventricles to contract on dust or bypasses. Thie, Atria on D So that's is actually the Jess off there and what I was talking about in terms off a wolf Parkinson White. So normally, if patients in SBT um, they, um I mean in the fourth time, they might be okay, but it's not, um, you might dynamically safer in the long term. So when you defibrillator, um, back into a normal Sinus rhythm, ask is in showing on this CCG if you see, like just in the right red circle does slurred, um, at put slant off the QRS complex so it looks like the curious is broad. But when you look at it a bit closer, the first part of the curious is very slanted. Whereas in our previous normally CGs, the angle is, um, a lot steeper, I guess, than this. So this is essentially what, um, yes, caused by the bundle of hiss a stroke on this slide here on but normally the treatment to this the permanent solution would just refer them Teo a blade for ablation to essentially burn away the accessory pathway. Um, so that, um they're less likely in the future to go into super ventricular tachycardia. Um, so I think that that's everything that I've got to present it. Be lovely. If you can just stand the cure a code on the left hand side with your phone and just quickly fill in the feedback for me, it wouldn't take that long. It was about a minute on. Um, yeah, we'll be staying on hair for a couple of more minutes just to answer any questions. And if you want me to go back to any slides, fill free. I'll be very happy to. Oh, and that was That was brilliant. Uh, thank you very much. Thank you. Everyone stay to the end S o guys for the feedback. You get a certificate. If you fill out a feedback if you have a metal account, uh, then all of your certificates can be there on it's very, very clean and tidy. And, you know, you control record of all your educational activity. If you haven't checked out, it's probably worth checking out making account? Um, the MCQ. So, yeah, we have lots of empty cues on our page. Were thinking about doing something this year. Guys, we want to do pre and post test mints. Want to know how you guys would feel about that? We want to run a couple of qualitative studies about, you know. Is this making a difference? How good is this? Does this help you that kind of stuff. So, uh, tell him that shot if you'd be happy with that. We very keen to know. Thea. Other thing is the recordings metal being a great platform have now provide the system where you can have recordings on the platform so you can have catch up content. In fact, you can tell your friends about it. If they haven't had a chance to watch the teaching session on, they can actually watch it get a certificate for that and feeling a feedback form. So, you know, it's kind of unlimited number of times that you can you can watch it. So we're gonna we're gonna add files to that, um, is probably gonna be, uh, hooking us up with that. Anything else? Anything else you want to ask Please do that A snow We're all available here Hit me up on Instagram All I'm my instagram here is well on then if anyone's interested in trauma North Pedic So anything research, let me know There's a couple of projects were running. They're all going really well on, uh, thank you for coming. I believe in terms of this or some was asking about. Tried watching Webinars and medal doesn't not access for non attendees. I'm pretty sure it's under me can account. We can change your settings without anybody is going on in our can can access. So that's no issue. Ask ask a just yet, please Make sure to join Middle of a share was saying it is where we're gonna post up our our slides in the form of catch up content. You'll get your certificates and that's your medicine. Is the video so no brainer? You get all your stuff there Basically drowned? Uh, yeah. Guys follow our socials. That's where we'll have all kinds of amount sticks and we go. So, you know, we're gonna We're gonna not to be a plug. I mean, nothing. We get out of it, but it's really really good to see that. You know, if people are actually liking the stuff that they're following on the socials and, you know, there's a good, uh, feedback response from us from that as well. Um, let me see. Some people have sent some messages here. Ah, I'm just replying to Yeah. Yeah, absolutely. So someone said to Facebook, Mexico saying that after the early. So again, I'll reiterate, you know, if you have to the Burleigh, there's no stress. Go on medal. Go on. Our Facebook page will leave links for a catch up, and you can probably have catch up. Content available quite easily. And you could catch up from that on Madoff. Um, so I think somebody would ask Social. Go ahead. No eso I'll give you mine is to ground for anyone that wants to contact me. There's a couple of I am GI related projects as well. Guys, there's something really interesting the recruitment agencies gotten in touch with me and regards to iron Geez, that want to transition to the UK. So, you know, if you're a British national and your training, you did some of your training abroad, you can you can speak to me. I'm trying to figure that out where, you know, it's very race that at no cost of that, the students on but still fine tuning that. But other than that, guys will have lots of stuff going on another pole that I want to run its to see what topic or subject. But you feel in medical school is not well talk. Or, you know, some people tell me stuff like ophthalmology is, Ah, 56 weeks of the entirety of medical school or or I don't know whether it's some topic that's, ah, need surgical topic that's not covered really well, maybe we can do more on that front. So do you do that? A snow, Um, just coming back to a question where somebody was asking, How do you calculate rate based on that 300 calculations, so freeways that you can do it? The easiest way is as long as the rhythm strip is 25 millimeters per second, she's always check the bottom of the EKG because some STD Sutton's consent. The paper speed a bit too fast to 50 as long as it's 25 multiplied the number of curious complexes by six I've always done that, cause that's easy to do, and you can get with irregular, irregular rhythm as well. 300 method is you. Divide 300 by the number of large squares between each art are interval. So that's the way that you do that. Or you could do if, if you're really extra one part divided by the number of small squares between each part of our interval is the other way of doing it. But I just always use the six times the number of your X complex methods. That's not one way. Also, I forgot to mention my back that in a regularly irregular rhythm, you have to count the number of curious complex on the rhythm lead at the bottom so usually to add normally on one SEC papers 10 seconds. So you just have to count it yourself within times it by six. That would give you the heart, right? Well, um, and the one last thing I wanted to add was, it was something about the Q T question from longer. So as the knee was mentioned is lots of different ranges for Q T intervals. The most important thing is the Q TC, where it correct it for heart rate of 60 so that we know if the beauty is actually high or not, because, as the the was saying, Acut can be naturally longer just because you have a slow heart rate. So we need to correct correct that. See if it's actually high for a stunned Hori of 60. And the reason we worry about that because, say, if it's sort of different ranges. But in clinical practice, I'm not saying example clinical practice. A range of about 500 milliseconds exponentially increases the risk of what really is really mention, which is polymorphic CT, also known as close as that part. And it looks like a lady was saying the sort of high aptitude sort of smooth has moved, so I don't know. It's quite describe swimming, and then it turns tiny and then comes back us like a twisting. It's sort of like a not quite the start twisting cone that's untwisting off was the best way I could describe it really on. The reason we worry about that is because that has a risk of progressing onto, uh, you know, the FOBT, a more serious arrhythmia, which is why we treat and try and figure out what what the cause of it was. Whether that's, you know, drugs, electrolytes, abnormalities such as no potassium, calcium, magnesium or even some cases hereditary. In which case most common hereditary cause is a defect in a potassium channel on that's Q t seen you in a in a nutshell, and you often have to calculate and patients with drug overdoses, particularly if they take and things that you know, such as antidepressants or whatever it is. But there's a whole garden on talks based on what to follow for that, that's all they have to mention that. So, have you heard about the orbit? Uh, trial you? No, I've come across it, but I haven't actually had a chance to. I haven't actually translated it. So people saying it'll taste has been because I know we're still using chance last. I have no heart of hearts. I I didn't hear about not, you know, Monica, is she? I didn't hurt. I did hear about it. I don't know much about it, guys, I'm not the most medically, uh, And if you know me and I say anything medical here, please don't come to work and asking for medical stuff. But But what I do know is yes, there is some studies available. I put some stuff in the chat. It's actually quite interesting. I read about it the other day, but what I would say is for the stage that you're at unless you're actually being examined on this, you don't necessarily need to worry about it. Followed the nice guidelines because I actually posted something from the nice guidelines on atrial fibrilation management. That probably is the main stay of what you should glance over in Terms of your examinations are posted here. Again, anyone's particularly interested. But, uh, the Orbits study is actually very interesting because assesses bleeding risk not just for patients that are antique regulate, but really in general, but taking into account the risk of bleeding with anti coagulation. So, um, I can't say I can talk about it very much. If it comes up again, I'll read up a, uh, about a bit more. We can talk about it in the next. I'm definitely gonna have a look at it. Someone asked this instead, and same process depression. So no. So in terms of a C s. You've got free things in acute coronary syndrome. One is a stem in which is the top. And these which is people that need to go straight to the cath lab Chest pain, ST elevation or left new left on the branch block chest pain. Then you've got sort of and stemi, which is, you know, basically, as it says, there's no ST Elevation, but there is cardiac damage eye that can be ST Depression, the Candy T wave inversion. But the troponin is a reason which suggests cardiac damage. And then there's unstable angina, a k a crescendo decrescendo sort of angina, whatever you want to call it, which is people with a history of cardiac sort of. It sounded definite in history. Sounds like cardiac testing, but you've got no notable damage, which produce, and depending on how severe it is, you need to send these patients home and some stuff and urgent chest pain clinic, or, if it's pain at rest or very minimal exertion, which is what sort of decrease center unstable angina counts as there's no troponin that, but you still keep them in and treat the same as you would with unsteadiness make sense? Uh, just that one on. Sorry. Let me I keep talking. Teo was like, You want, um, opposed to feedback? Like, one more time. There's anybody else Have any other questions for me or really? No. Tomorrow, guys, please join us in six PM again. All be covering arterial blood gases. Uh, on be using the poor function Quite better people asking about using 20 or the poor function. So you you do use a poor function, but I think he sees that's a bit difficult to do since you But we will be using pause for the ABG tomorrow. We have lots of cases. Please send your IgE handles. I don't have. It's the ground. I'm not planning on getting way. Haven't instagram 16 Siris Page. Leave it at that. So, uh, yeah, so you can reach us on that Are all the, uh, my handle here. So you could certainly up by my name. Uh, it's not very common. Name s so that's probably need anything to do. Uh, or you can follow the I get a handle on the reason I've been good. Yeah, nose, because I'm actually gonna add a lot more anatomy on M s K related stuff on it. It's not like a personal instagram. One picture of me and nothing else. Uh, so, uh, it's going to be education oriented. Ah, yeah, that's it. So, yeah. Guys, make sure you follow, uh, what really gets up to this year? A swell. She's going to be doing quite a bit, Uh, on and, uh, I am actually quite excited to these. Uh uh, she's recently graduations. Next one, if somebody joined weight on. You know, we're very, very keen on promoting people. Uh, that that are going to be newer this year on. Do you have done a fantastic job with slides? The slides of the out, a use designed them. I found out on our group chat. Uh, really Good. I think that the rare a claim they're really get on do. Yeah. So, guys, if some of you didn't hear what I said before, is everyone happy? If I was to do a couple of poll based things, post some polls on our socials, it would you be happy to answer them? They won't be very long, but I'm trying to get to the bottom off. You know what is well thought. What isn't well thought well can be done better if people are interested in surgery. Would you be interested in, for example, if I pulled out one of these and we did some stricturing stuff? I have a really, really good colleague. I'm a course surgical training right now. One of my colleagues is also a course surgical trainee on He's very good at the Not to me. Eso uh, he comes in the Middle East. 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I can show you how you can make the most out of, uh, that free resource. So we ended hair guys, I I talked to much their their labs if you need on the same machine here. So don't worry, guys. When When you get going and it's something medical and very, very interesting, you will be going. But the only difference is you actually says valuable stuff. I say a lot of waffles. That's absolutely for sure. That's absolutely what for? If you if you are, If you ask me any orthopedic question, I will. I will give you a governor and I'll hand it over to Sha here. No idea. I think it has been a very long time since about a copper. I missed touch. Touch the knee. I touched. Not a doctor. I'm I'm I touched me. I may be prone. Ultrasound on the receivers and infusion. Comfortable with examination. Okay, bro. I think we will end it there. Thanks for joining us. Guys. Please join again tomorrow. A She has a journal. Socials like the pages please recommend to your friends will see tomorrow six PM for arterial blood gases. Thank you very much and hope to see you soon. Take every cells I was seen about. See my