Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

About arrhythmias. Um So he been one of the fy one doctors working at hospital at the moment. I'm currently in my tu um It's nice to see you and thanks for, thanks a lot for joining um arrhythmias is quite a huge topic. I'm going to try and cover it as much as I can. Um So I've just, I'm just going to start with um cardiac arrest and then talk a little bit about narrow complex tachycardia, broad complex, a cardia and heart block. Um So for the, for the cardiac arrest, but it, it's like trying to cover um the shockable nonshockable rhythms and then we'll talk a little bit about each one. They are all SPS, so a short based answers as um and they're all case based discussions. So that's gonna help a little bit. So I'm just gonna move on to the next screen. Um So I've got there if you'd like to have a go at it and then we'll discuss, I'm just gonna give you a round of minute for you to read and um think about what the answer could be. No. OK. So hopefully that's enough time um for you to answer the question. Um So here we've got a 54 year old male who had a cardiac arrest and um you start chest compressions and the association team are contacted, assessment of the rhythm shows ventricle tachycardia um and three cycles are performed and successive shocks given. Um So the question asks about which medication to give. Um So, ventricle tachycardia, um pulses, affecting ventricular tachycardia is one of their shockable rhythms. Um So that's hence, they had given shocks. Um They are that if you cut your card, there are two different rhythms and there are two different types, there's one shockable rhythm and there's one non shock rhythm. So um pulses, the ventricle tachycardia, it's really important to note the, the pulse, whether the patient has got a pulse or not. And then if the pulse is that ventricle tachycardia and ventricle fibrillation um are the two shockable rhythms. Um And for this, the, the medications given are, are different. Um The answer for this question is amiodarone, 2 mg and 1 mg. Um once three successive uh shocks are given, um you need to give amiodarone and, and um the shock uh the, the basically the, the quality of a shock needs to be good. It starts with 100 and 50 joules and, and then it, it basically increases, they increase it if the patient doesn't um get any spontaneous um circulation back into the system. Um So um the rest of the answers are wrong because that's, that's the dose that you need to give. Um patients who are, who have got a shockable rhythm. Um OK, so I'm just gonna move on to the next SV. OK. Does want to answer in the chart as to what they think the answer might be for this question. OK. So um we, for this question, we've got a 67 year old male patient and they've had an M I two days ago. Um two nurses are currently performing chest compressions and a man with a defibrillator has just been attached chest compressions, that pulse briefly. So the rhythm can be analyzed, pulse, less electrical activities observed. So this is one of those nonshockable rhythms. Um There are two different, there are two rhythms that are nonshockable. One is pulseless electrical activity which includes anything and everything apart from asystole ventricular fibrillation and ventricular tachycardia that so it could be a sinus rhythm, it could be any other rhythms. Um But if there's no pulse and you can see an electrical activity then um and this, this is a nonshockable rhythm um for something for non rhythms, the most main, the main priority is to do CPR, start CPR and um get somebody to um get a adrenaline immediately. Um So the answer, the answer to this question is b um adrenaline should be commenced immediately. Um So, so as soon as you get it ready, um it should be given and it needs to be given every alternative cycle of cure. Um Adrenaline needs to be given and then amiodarone can also be given after the third uh sorry, after three cycles. OK. So we've got another question there. Um If you just wanna have a look at the question and then try and answer it and then we'll talk a bit a little bit about it. If anyone has any suggestions, you could put them in the box in the chart um to see what, what rhythm this is. So uh this is a 58 year old man who was rushed to the emergency department by the ambulance. He was found unresponsive on the, on the roadside and then no other information was provided. So you've been given this ECG let's say a nurse comes and gives it to you. Um What do you think this rhythm is? Um So this is ventricular fibrillation. Um Ventricle fibrillation is very chaotic if you think about atrial fibrillation where the there's no particular period. Similarly, um this is ventricular fibrillation is very chaotic. You can't actually, there's no pattern to it and you can't see any periods properly. Um And you can't see any periods at all. Actually, that's what atrial fibrillation is. Um And then ventricle tachycardia. So the answer is, it's, it's not b because ventricle tachycardia would be more um less chaotic than this basically. And it, it will have a bit better rhythm than this. Um um and then P ea pulseless electric activity. Um It's more, it, it, it's more um like I mentioned earlier, pulseless electric activity includes anything and everything apart from VF and VT as well as A and both Parkinson's white. This is when the delta wave is slightly slurred and that atrial fibrillation is from those rhythms where you can see, you can see the difference between one T wave and the other one. So this is ventricular fibrillation. Um So this is again, reiterating what the difference is between the shock and the shockable rhythms are um shockable rhythms, fibrillation, nonshockable pulses, electrical activity and asystole. So we, and this is a protocol for it. Um So, um sorry about that. This is the algorithm for a, a downside support A S um When you see a patient and they're unresponsive, not breathing, you do the full assessment first and see whether they are breathing, whether they have a pulse. Um You need to start CPR. If you, if you see no side of life, that's the main priority for any patient with no breathing and unresponsive. Um Even if this is a shockable rhythm, you need to make sure the CPR start quickly and the pads on arm. Um You don't delay CPR and you put, you try the uh somebody else needs to be in charge of putting the pads on um for the shocks. Um And somebody else needs to try and do the CPR simultaneously um just so that you have no, um, no time when you're not actually doing CPR for the patient, apart from when you're giving the shock and apart from when you're giving the breaths, um and then once that, once you start with CPR, you assess the rhythm and then see whether this is a shockable, no rhythm. And then, um if it's a shock rhythm, you give one shock and then you need to assume CPR and you continue with that and you keep continuing um assessing the rhythm because it's quite important, it can move on from a shockable to nonshockable rhythm every single time you check the rhythm. So that's very important for nonshockable rhythm. You just continue CPR and give adrenine every other cycle. OK. So we talked a little about a narrow complex tachycardia. Now, um this is the B give a few minutes just to uh sorry, a few seconds just for you to think about it. OK. So, um we've been asked to, I just review a 61 year old female on the cardiology ward due to difficulty in breathing. Um An examination shows a raised ABP with bilateral fine crackles to the mid zone. Um These are signs of heart failure. Um That's, that's, that's why it's really important in this question. BP is 100/60. Um The pulse is 100 and 50 100 and 4200 and 50 irregular and ECG confirmed atrial fibrillation, a review of her notes and previous ECG shows no prior history of atrial fibrillation. So this is an um a diagnosis of new af the most appropriate management in this is to give an urgent synchro BC card diversion. And um that's, that's because the patient has got signs of hemodynamic instability. One of the signs is the heart failure signs. Um and therefore you need to give that um the IV amiodarone IV Digoxin Digoxin used for atrial fibrillation sometimes um for rhythm control. But the most urgent thing at the moment is to get the urgent synchronized cardio version. Um So, and sort of move on to the next and just to, to show, explain a little bit more. Um there are four different things that if you, if you do remember this, the his mnemonic for hemody and compromise, it will really, really help, it helps for all sort of rhythms actually. Um So heart failure, myocardial infarction, the eye for his and then syncope and shock. These are the four different things that you need to look out for, for any rhythms um particularly not the one for cardiac arrest, but these are mainly for the for the other things for the nerve complex tachycardia for broad complex tachycardia. Um you just need to be careful and think about, look about, look for these signs because if they do have these signs, then the management might be slightly different to what it is usually So um signs of shock pace, hypertension, which is a BP of less than 90 th sweating, cold clammy, extremities, confusion or impaired consciousness. These are the signs of shock and then syncope. If they didn't have any signs of syncope, uh history of syncope, then these are signs, these are things that you need to look out for 25. Ok. So we've got another question there. I'm just gonna give you a few seconds again. The OK. So what, so you got a 45 year old male um who prevents to the ed with a sudden onset set of uh palpitations and dizziness. He describes it as rapid, regular heartbeat that began suddenly when he was resting at home on examination, his heart rate is under 80 BPM, BP, 100 and 40 to 90 saturation is 98% in an ECG is obtained which shows a narrow complex tachycardia and absent p waves bag maneuvers attempt to without success in terminating the tachycardia. So, what's the most appropriate next step in the management? This question is shows that now complex cures uh complex tachycardia is svt supraventricular tachycardia. And um for this, the main thing to do is um because the patient's got the uh you tried the vagal maneuvers and they are attempted without success. Um You need to give the a adenosine, that's what you need to give. Um adenosine adenosine intravenously. Um Adenosine works by um stopping the, the pulse, the pulse basically going from the SVT, from the SA node to the AP node. Um That's how adenosine works. And it's, it's used particularly in SVT. And then a adenosine is given in a dose of 6, 12 and 18. And then if that doesn't work, then you'll have to move on, step up to maybe D cardioversion and the like. Um but that's the first options that you need to do. If the patient did come on with any hemo any signs of hemodynamic instability. Again, you would straight go on DC cardioversion. And that's, that's the one it would be option B but because this patient is quite stable at this point of time, you can try it, don't you see and see how the patient does. So, um there are two different types of neuro complex acardia, the regular and the irregular. So the regular one, that's the one that we just talk about a little bit, the vagal maneuvers first and then followed by the IV adenosine. If they don't, then you can also um you can consider a diagnosis of atrial flutter and control the rate. Um So beta blockers and the like, and if it's irregular, it probably a atrial fibrillation. If onset is less than 48 hours, then you can consider electrical or chemical cardioversion. And the reason for this is because um as you may know, um for atrial fibrillation, it increases the risk of blood clots inside the Atria. Um, so we just need to make sure that you're not. Um, if, if you did, um, cardiovert them after 48 hours, if, if they do have a clot that, that can basically cause a stroke and that's why it's, it's, um, you shouldn't be basically doing an electrical or chemical cardioversion unless you've discussed with the cardiologist and then beta blockers are the, you know, first line, unless there's any sort of um contraindications to it. Ok. So we move on to both complex tachycardia now. Ok. So, um you've got a 50 year old female which represents with palpitations and dizziness and ECG reveals a broad complex cardia with a rate of 200 per minute and an irregular rhythm. The most likely diagnosis here is b ventricle tachycardia and the reason for um is they are very, they, it says basically they've got a good complex tachycardia. Um Atrial fibrillation is for a complex tachycardia which we mentioned earlier. SVT again, it's again, um now complex, usually the same atrial fibrillation with rapid ventricular response is not, it is one of those. Um um um sorry, it's just a narrow complex tachycardia. So that's the reason why. Um So this is ventricular tachycardia when you have the sciatic mm um broad complex tachycardia. Ok. Ok. So you've got 31 year old man who's presenting e feeling very unwell and he's been prescribed a course of antibiotics from his up for chest infection Um And this shows polymorphic ventricular tachycardia. So, torsades, which medication is he most likely to be taking for this. Um So, macrolides including Clarithromycin, they usually cause a prolonged Qt syndrome which will then cause torsades. Um So the other medications are not known to cause long Qt syndrome. Um But yeah, um what can happen is because of the LLE Syndrome, we can actually get to, to points where um basically you're getting um an irregular rhythm. Um And it's different from ventricular fibrillation because ventricular fibrillation is quite chaotic here. You can actually see a swinging sort of a pattern that, that can be seen by the polymorphic ventricul cardia. So, um the there are different causes of Long Qt syndrome. They include electrolytes, hypocalcemia, hypomagnesemia and hyperkalemia drugs such as um antiarrhythmics. Um So social um antibiotics. So we mentioned how um macrolides can cause um lo uh they can cause long Qt, it can cause polymorphic um waves as well as some antipsychotic drugs including sri s antidepressants that can, these, these all can cause long Qt syndrome which can then cause toss. OK. So there are two different types of VT. Um There's monomorphic, which is usually most commonly caused by Myco infarction and polymorphic VT which we just discussed. And uh this is how it looks like. Basically. Um this is an ecg that you can typically typically get. Um So where, whereby VF is, you know, very chaotic and quivering of heart ventricles. TORS is usually a distinctive twisting pattern that, which is, as you can see from this, it's more of like um a twisting pattern and that's the difference between dorsal and V VF and it's, it's, it's important to know the difference between the two because the management is completely different. Um That's fine. Ok. Um If you have any questions at the point, please let me know on the chart. So the management um, for VT for, for, um, yeah, for, um, broad complex tachycardia is, uh, if the management has, if a patient has adverse signs and you do immediate cardioversion, um, drug therapy, you can give, um, amiodarone lidocaine or pro um, but if, if none of these drugs do, do, um, basically they fail, then you have to put the patient on an ICD. Um, this is the management for a blood complex that he called in. Not for, um Torsades for Torsades, magnesium sulfate that you start with. Ok. And then we'll come move on to heart block. So you've got a question there and there's an ECG as well. Ok. So you've got a 72 year old, um, who presents the surgery complaining after GP surgery, complaining of dizziness and you've got this ECG and, um, the most likely diagnosis for this. So a bunch of tachycardia wouldn't look like. So you wouldn't actually see any P waves in the cardia. Um, the differences between the different types of blocks. Um, so we're just gonna delve into a little bit more about different types of blocks. But looking at this ecg um this, this patient has, has got QR S complexes at the same interval as P waves as well. But every P wave is not, is not, actually, is not preceded by E, every QR S complex is not preceded by AP wave and the P waves and the QR S complexes are completely dissociative. Um And for that, this is a third degree heart block. Um So a a quick um so a very a cardiologist basically told me a quick way to know this is to basically take a piece of paper and trace every QR S complex at the top and, and basically see whether um the distance between them and the same as well as the P waves. And that would particularly show that uh you know, P waves are actually are happening to QR are happening, but they're just not following each other properly. So this is a third degree heart block. So for first degree, yeah, delaying the electrical signals and through the node, but then all signals eventually reach the ventricles. So the pr intervals actually increased. And the second drug, your heart, heart block has got two different types. Type one, which is also known as the back, which is progressively lengthening of pr interval. And there's a drop in the QR while type two, it there is an occasionally dropped to complex but then there's no PPR interval, lengthening and third degree is when there's a complete blockage between the atria and ventricles. And this results in complete independent beating of both the chambers. Um And this, the ones that you need to worry about are the second degree, type two and third degree. Um because for these patients, they need intervention um very quickly, basically, first degree heart block, some patients who athletes may have this um as a as a normal variant. So it's not very um concerning see you. So these basically these other rhythms. So um I just thought I'm gonna add this um rhythm for bradycardia as well. OK. Your first year old man, he comes to the ed with a two hour history of dizziness and palpitations. He demands any chest pain or shortness of breath. His past medical history includes hypertension, stable angina and his observations are temperature is fine. The heart rate is 44 which is bradycardic. Um BP is on the lower side, 90 or 51 hypotensive uh respirator rate is fine. Often situations are OK. You need to basically monitor it to make sure it doesn't go below 94%. And an examination, he's got a regular pulse, his calves are soft and tender on auscultation, vesicular breath sounds are hurt and heart sounds are normal. So you look do an ECG and ECG shows sinus rhythm and the pr interval is prolonged. What is the most appropriate next step in the management of this patient. So the patients basically got is bradycardic and sinus bradycardic and also has got a long PPR interval. So also got a um type one half block. So for this patient to give intravenous atropin, so any patient who's got a sinus bradycardia, um if they've got any signs of shock, then you would stop the treatment algorithm. Um which is um this basically and I have mentioned his particularly earlier and that's really important. Again, if you have any, any certain sign of shock, syncope ischemia or heart failure, um you need to start the patient on management. And the first thing to do is give atropin, this can be, this can be given to a maximum of 3 mg. So you can give atropin multiple times until there's a response. But if that doesn't work, then you also give isoprin on and then if that doesn't work, then you have to go, you have to go under transcutaneous pacing. And these are all done under vision and um under the correct conditions, it needs to be done at in recess or in a cardiac um unit basically where they can monitor the patient properly. So this is the algorithm for sinus bradycardia. Um I'm not sure whether they can see it. I think it's really small, but just to go through it, um you, you start again with the ABCD approach um to see whether there is any signs of um life threatening signs. If they do have it, then you basically start with the management or else if they don't, um then you, you again assess the patient and see whether they've got any other risk factors. Basically. Um If, then you, if the patient has any, any signs you give atropine and you continue giving atropine and then is, is, is the option A, is an option and then transcutaneous pacing. And if, if this doesn't work again, then you need, they need to seek expert help, which should we include cardiologists and then arrange transvenous pacing for this for patients. Ok. So the, the, the different potential risks that we just came across is complete heart block, which complex u recent asystole, they have a history recently morbid type two block and it for any ventricle pauses for more than three seconds. Um I did see a patient recently with a, um, a patient who was, who was actually getting about 30 seconds of a pause in between. And that was actually quite, it's quite scary to see because the patient could go into asystole at any point of time. So it's important to put pads on these patients just to make sure and monitor them very, very closely. Um, just to make sure that they don't actually go into asystole and then uh um cardiac arrest basically. So you've got this now and a question. Ok. Ok. So we've got a two year old pilot who attends for his annual physical check. He has no other past past medical history, um and he takes some regular medications. There's nothing that's concerning so symptomatically. Um, and he's got a very healthy lifestyle and as part of the physical check, he has an E CG performed his ECG from the previous first year was unremarkable. What ECG feature would be the greatest, would be the greatest cause cause of concern. So for this, it would be a left bone branch block. A new left bone branch block is always pathological. We always think about causes such as ischemia as well as a stenosis. Um So with, so if a patient does come on with, with any chest pain, particularly this patient doesn't, hasn't got any chest pain. But let's say if a patient did come in with some chest pain and if a new less than a branch block, you need to be concerned about the patient and you need to monitor to check the troponins and monitor the patient. Um For AJ wave, it is, it's just a a deflection from the ST segment. And that's usually for hyperthermia, you usually get AJ wave left AIS eu can be a variant of normal. It can also signify left ventricle hypertrophy, but it can also be a variant of normal secondary degree heart block is not a major concern. Again, um if somebody is actually an athlete particularly can, they can have second degree heart block, but you if you want to, they're fine. It should just be a variant. So these are the reasons why the rest of the answers are not correct. OK. I'm just gonna give it a few more seconds because this is quite a long question. OK. So this is a 58 year old male presented to Ed with severe chest pain in the left arm and jaw. And ECG S have obtained showing ST segment depression leads B1 to B6 with total symmetrical T waves. The patient's vital signs are stable. What is the most appropriate next time for management? So, um this is a patient who's got a cardic sounding like chest pain, the pain relating to left arm and jaw. Um And the options are either you give oxygen and initiate therapy with aspirin, perform immediate PCI starting the venous lyin infusion or admit the patient for serial trauma monitoring and further evaluation or treat for the correct answer for this question is PCI. Um And the reasons why this is one of the one of the causes for um urgent uh which needs to be ba basically blue lighted to another hospital or the nearest PC hospital. Um This is one thing that can be missed and people may think that the T waves are symmetrical T waves could be a sign of hyperkalemia. Uh But this is one of those things that um that can, they can show an um acute M I. Um because based in the symmetrical. So ST segment depression, V one to V six. It does show that they might have an, an infarct basically in L ad in the left anterior descending artery. And this can easily then later on be become the ST elevation. So if you did see this, um which I'm gonna show you an EC U that can be that, that basically shows this the down sloping and the ST depression and then basically, it goes up again. So this is an urgent thing that needs to be looked at um and needs to be um PC urgently. It's the same things for segment elevation will also the rules, the same rules apply to this as well. So just to have a, a really good look at this, this is also called the, the winter T waves uh where you have an ST segment depression and then upsloping ST segment and, and then you've got this tall tented T wave, tall, narrow T waves and that come up. And so, yeah, so this needs to go for urgent PCI. OK. So that's end of this, of this, uh this end of this um teaching today. If you've got any questions, please put them on the chart. I'm just gonna stay in a few minutes more. No.