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I everybody Good evening on. Welcome to the sweets. Mind the big webinar today. Doctor lives with Evans. Will be covering palpitations. Um, just just the beginning. Before we get started, we're gonna have a word from one of us Once is the the BMA, So I'm just gonna handle it down from the same. It's just chatting about what they do. Thank you. Yeah. Ah, I can't share while the other person's sharing. It's a message I'm getting from you. Okay? Cool. Yeah, I I won't be too long. Goes down my I just share my screen. Requip. Klay Like a day. You're stupid. See? I know. Um, so yeah, just requested for me before you guys kick off today, um, gonna put a couple of, ah links in the chart first. Oh, I think like I can't do it. No. Um, yeah. And maybe things fury posted. So they're not right. Let's just do this. Not fasting around for me. Um, yeah. Uh, just for I talk, you'll see a secure code on the screen. So it's just if you want to sign up to here from the BMA, it doesn't. 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It's It's an attractive session. Please do drop any questions in the comments section, and I will pass them on to Great. Thank you. So hello, everyone. My name's Lizzie on eye on ST to anesthetics. It's just training in southwest London. Um, so today we're going to be doing palpitations. Um, which is quite a big subject s. So we're going to go try by the end of session. Teo, get you to be a bit more confident in approaching patients who present the palpitations. Focusing on some history taken easy, GI interpretation. Help to investigate them on emergency management or some keep presentations. So someone sides are bit wordy, so we'll see how we go. I'm open to feedback on how you feel. The session is gone. We're gonna be doing it mostly. Case faced because I think that's a bit more of an interesting way to do so. But for case based work, I do need you to try and interact. I can't see any of you. So he's going to be my eyes and ears and tell me all the questions that coming in or the answers. If you comment down in the comment, section your answers to the questions and then we will discuss them. It's a safe space. There's no silly questions and see the answers. So most of the questions so just have ago when we can get some discussions going. So you are the F one working in a knee on that expression you picked up is Miss Kay. She's a 24 year old lady. You surprise. Surprise has presented with palpitations so interactive straight off the bat. So before you even going to see the patient, you're going to be thinking about what things am I worried about what the things I want to ask her. So when you go in there and you're a little bit more pet, So what questions did you like to ask this part of your history? So if you can write in the comments. And the key thing is that you like to ask her, um, specifically about the palpitations. I remember the purpose of your history is to think of it as many different choices possible. They're thinking about palpitations. What? All of the things it could be across all different systems on how am I going to use my history to narrow down my differential, Jules, to test my hypotheses and come up with the differentials, I'm going to use my investigations to test further for so I'll just give you, um, a couple of minutes spoke time, um, and just didn't have to be long things. Just some key symptoms or key questions that you'd like to ask. It's part of your history. So we've had a few really good answers coming already. Firstly, what she actually means by conversations, right? Another one is other signs and symptoms. Well, then, houses happened before. Yeah, Great. Then when the symptoms began, uh, did anything received the palpitations, then one surgery, a shin triggers frequency. That's what I'm understanding more about the quality off the palpitations that characterize it. Mom. Yeah. Lovely. Those people who put about the quality off the palpitations. Are there any specific questions that you don't on? But also think that's any other signs or symptoms? Could you opposites good to start with open questions. But there any specific symptoms that you're worried about that you'd like to specifically ask for? Remember, you need to think about what I was doing. What is the worst case scenario this could baby on How my gonna hopefully world I'll So we've had a couple of those as well, so I'm specifically asking about chest pain and breathlessness it. Yeah. Any loss of consciousness is Well, um, other suggestions. Shortness of breath, pain, dizziness, loss of consciousness. Uh, any relations exercise. And, you know, when the when the symptoms come on. Good. No. Okay. Well, sounds good. Any other ones coming in? Should be, Yeah. Feeling of sense of doom? Yeah, the feeling of heaviness. Eyes only pain on expiration. Is there a fluttering sensation in the chest? It will, but I does nothing. And you're the ones who should be going to the next side. I think that it would be good. Perfect. Lovely. So already good suggestions. Think you get involved. So this is what I've come up with so describe the palpitations. I agree. So you want to kind of clarify. Is this Ms Beat? So can you feel every now and then hot? It's kind of dry. The drop in or skipping a beat? Can they get a sense of whether it's working or irregular? Have they got the sensation that it's their normal heartbeat? We're going fast. So what? I tend to ask this isn't even feel your heart racing against your chest? Or is it like a fluttering like a butterfly in the chest? Um, when did it start? So I think someone, someone said, Um when where? How long you think qualify, and how long did it starts? It has been going on for several years. What's the frequency? Is it something that it's crescendo? And so it's getting worse and getting more frequent? Or is it one of those things that happens every couple of months? Or it actually also in the last 24 hours and you've never had something like this before. The red flags with any history that you're taken, the red flags are things that you definitely to ask, and again it's catastrophize and say, Okay, what's the work before you walk and look at this patient. What's the worst thing I'm worried about? So your shortness of breath, your chest pain, the symptoms of heart failure is that the palpitations potentially so bad that the heart started to fail? So it's not a sufficient pump. You're getting back log in Palmer edema or there's such a high. Well, it might work with my collagen that you'll now don't get adequate perfusion to the corner arteries. Your syncope, your lightheadedness is suggest, then, that you're not getting sufficient cardiac out, that you're getting cerebral hyperperfusion. And again, that's a medical emergency that we need to treat. So your red flags always, you know, it's not just the asking is it's a real life. What we're gonna what's the meetings I'm worried about? How can I roll them out quickly or they ruled them in to the point I need to So investigator any cardiac thing. I was asked about positive history or family history of any heart disease, and that includes BP. Um, if there's an Easter history of sudden cardiac death in the family and that's has someone died very young, very suddenly in the family because then you're thinking about your long heat using dreams you regardless injury in your channel. These You called him up to these? That running family that would put some of the high risk of significant palpitations with heart disease again, You want to qualify? Was it that granddad had a heart attack or had atrial fibrilation when he was 94? Or was that actually my dad had a significant heart attack with stenting man who's in his late thirties, um gives you more of an indication of this is if this is a familial problem or if this is something that is acquired over time. I think so. I mentioned about exercise. Exercise is really important. One So have they, with with these symptoms or ever before, had a syncope on exertion again. You're getting a lot of cardiac output with increased my cardio demand. So you think about the structure, heart disease or potentially life threatening arrhythmias. Someone said I think again about anything preceded. So how have you been before this happened? Have you been Have you been the last couple of days? Last couple of weeks? Have you had any symptoms of infection, cough cold chest infections, urinary symptoms, diarrhea, vomiting something that might make you intravascularly depleted. To put you hire a higher risk of certain or reveal certain of birthdays on bleeding is a significant thing to think about. While particularly women with periods are they having heavy bleeding? And that's put them, you know, Inter inter basket deplete state set in. Do they have an anemia? And they're in high up that heart failure, which is why they get this visitation tachycardia. Um, so significant things to think about that you may be able to reverse decide Attack of the palpitations. Thyroid is also important one. So is there any Have you got any symptoms of hypo hyperthyroidism? Is there any family history of any thyroid problems on? I was Think about peace. Someone's coming in with a sensation of the heart race and science Tachycardia is one of the most common easy findings therapy. So you just didn't quit. I know we do a quick screen for anyone with shortness of breath, chest pain, palpitations, syncope. Um, have you had any recent travel abroad world? Any inability? Recent surgery next? Well, in any cramping up, these are the real family do you take the pill? Any rescue could be pregnant and just doing quick screens. Think about what your difference was. Our can help people. All of that's no no breast appear you want to the next differential. Another thing with computations is thinking about by a Tradjenta causes. So are they having seven coffees a day? Are they knock it back? A massive kind of monster for Because it starts to the revision on that's triggering the palpitations. Did they take drugs? Cocaine, Amphetamines will trigger, um, written cardiogenic states on any medications that have they started new meds? Are they puffing away on a cell booster? More inhaler Hate? Oh, that's romping up. The heart rate is into new medications. Changed the medications and all things to think about. And do they take any medication? That might be, um, hiding the palpitations? Or maybe controlling the palpitations if they've got a history of atrial fibrilation and they're on digoxin on the sample. Oh, what's that? Compliance for that? Um, nothing. I would think about any recent stress, anything. Worry new. Something's changed, you know. Has anything triggered this at home? Any complaints ends at work. Always good things to Kentucky to tackle with any part of history. Lovely. So that's kind of my general before I go in called in a Structure and What I'm going to lost them, which I think to be honest, most of you go seven. Oh, okay. Okay. So for this lady, Gee is a transfer. A lady who reports a four week history palpitations, She nobody notice if she's sitting down at night watching television or when she's lying in bed at night. That's when their particular problem you are specifically Are you waking up this participation? She says. No, not really. It's just that I'm lying there awake and I can't get to sleep because I could feel the sensation of my heart racing. You've gone through all of your red flower patterns. She denies any of those symptoms. She's not be fitting. Well, it's got no room prosthetic, a history on. There's no significant family history there. Coronation. Studying for exams she's recently broken up with partners is a lot going on in the background, but otherwise no history of infection bleeding in. She's not sexually active, and it has got the court in situ, and you don't quit scream to pee. And there's nothing really that that is jumping out with you. So how would you like to investigate this lady? So really, this is this they do about it? Looks like a palpitations in general. Um, what sort off investigations would you like to do again? You can put it down in the comments. So it's always good to try. Instruct your answer. So thinking about a simple bedside tests that you can do things that might be around the bedside, then thinking about blood tests and then think about in the gym. So sometimes it's a nice little structure on, so particularly going to exam set. But it also makes your kind of makes you think about things I want to mess for. Patient presented with palpitations. How would you like to investigate? Remember, you're in any. So we're already getting a lot of insisting bloods and the CD. Let me see. J. Sounds good for the blood. Could you give me any specific clots that you would like? Are we just gonna do a whole pump? Well, what we do? You got any advancements in bloods and e c. J? I agree. That is correct. So uh, crp FBC Talk screen D dimer Urea cream. I mean, electrolytes drops just by function tests BMP Yeah, Not good or good suggestions. Anything else? Hours before meal? I think that's pretty much what? The consensus? Nothing. I mean, that's a good start. Water. Um, so I'm always gonna do an 80 assessment. First thing first, Most basic bursitis you can do is observations. How's your this patient's got got significant part to her palpitations or palpitations that translate if you don't have a look at their observations. And again, remember, when you're going to see a patient you want to ask yourself, Is this patient stable or unstable? Is this person presented palpitations and that compensated So the blood pressure's okay, This up. Okay, they're not short of breath. Or is this person presented palpitations and crash in that? Your first question when you walk into the room. So observations. Conversely, that's the end of the bed test, does you, 88. But your observations are gonna be the first thing you're going to get. We're gonna ask the heart rate. BP starts respirator up. Hook them up to the monitor generally. Ideally, I guess you should really have them on a cardiac monitor, particularly have abnormal EKG. Um, And if they have any red flag, symptoms of patients with chest pain seem to be tends to be quick to safer. To put him on a cardiac monitor early. Um, in this a d. I probably would hold off just the now on in any trying to find a a bed with a cardiac monitor. So you do have to be, uh, just if I want a needle and good. And I think blood screen wise basically got everything. So FBC looking for anemia and signs of infection, a CRP as well for the infections. Out of things, you sneeze, I think you mentioned so that can tell you about their dehydration with the hydration status on. Also, look at the sodium and the potassium. Remember, he wanted further electrolytes. Such a see How See, um, magnesium loss. They you need to add on a bone proof on magnesium, which I would definitely do it in a rhythm. Your patients this idea get to be taped surgery either as a urine or the serum blood test. Unfortunately for women, if you off childbearing age, you will be having a pregnancy test regardless, unless you come in from PE. But generally it's just safe to screen thyroid functions. Absolutely D dimer haven't. I'd have a low you have to go to justify You can't just do screens for everyone. Infection will raise your dude. I'm, er if you are having really make you might be a bit quite a path thinking about roasted i'ma There's lots of reasons for an elevated D dimer. It's no specific necessary for Pa although we do use this part off screen. Um, so you have to be out of justify this lady has got no real symptoms of pa and normally CJ. Then I would probably hold off. But it's very dependent on your supervisor and you're kind of rational in your department. I think some people mentions trucks and being peace s your BMP is looking at your heart failure. So in elevated being pretty suggestive off Um, not recess on proponents. Ah, about the PT can use a piece, but generally for um I've guess they don't want I don't drops and BNPs. I think given the history with no chest pain on intermittent palpitations, I would hold off on your own. Um, remember that someone is is in a tree. Arrhythmia on his attack you're with here. They're gonna have an elevated troponin because they are, um, because of the, uh, introduction requirement heart. They're gonna go into a bit of a scheming picture on Sometimes you can get ST Depression is across multiple leaves. When you have attack, you're here. Do you think you have to again? We have to got to rationalize why or give a rationale for why you're doing a blood test. So troponin bmp certainly sent it very mind if you're concerned this person has had a cardiac event that baron in mind Patient pray for in front of us 24 year old. He's only fitting. Well, with no significant cardiac background or family history, I probably hold off the truck and BNP for now. You definitely need any CJ remember, with the CDs, unless they're having the symptoms of palpitation, you may not pick up something S O is a snapshot, but absolutely get any TV on dive said urine dip, maybe for the takes a GI that if you're concerned that there might be sounds of infection, then even did a chest X ray would be pretty proved on if there's shortness of breath, signs of heart failure. Um, it may be a problem to get a chest sexually. Depends on how stable the patient this lovely. So with this lady, are you doing a TSS? Um, ever is patent from a B perspective. It seems okay. See, she's a bit talk it 105. It is regular, have blood. Pressure's good and there's no signs off heart failure. Abdomen is fine. Um, her system to otherwise okay and her Bloods panel has come back for everything you've mentioned. Andre is negative. I think someone said em talk spring a swell and talks we we don't tend to dio that often Germany, because main talks going to do is processing on salicylate for overdoses on if there's any overdose, you always add on a personal level of salicylate because you don't want to. So, um, unless I see very much if you give in process with this problem, um, tox screens Occasionally we've done If he's up there under age or every think it might help the diagnosis, they take a while to come back on. Generally, if you ask people will tend to give you an answer. There's not many. Unless if something is going to be have a reversible effect that something that you can kind of give something. And I looked on antidote to to correct you don't necessary need to do top screen, but something to think about again imported, Be dependent on the trust you go to So so you're going back to this one s So she's a little bit tachycardia, but otherwise pretty normal examination. So this is how you CJ I appreciate the leads all over the place. It's not the best E c. J um, but this is what you've been presented with. So in terms of eating the interpretation, just take a bit of a side step. Has anyone got a cyst in front part in the cogs? Do we feel confident on SED interpretation? Um, has anyone got any tips that they could put that they would recommend that they found helpful when you can see, See? Geez, So any thoughts you don't necessary if you have comments on this EKG lovely. But really, the question is, what's your approach to interpret in the easy tree? You know, any takers just waiting for things. True, it's ago. If not, I can always tell you the answer. But it was good to go. So we got a couple of Bunches now on how we generally have any surgeries of people saying Start looking. If it's generally irregularly regular, check the heart rate, then kind of go step by step. Soapy waves to arrest complex ST segment. Yeah, perfect. Good. I think that's a good, systematic way. Teo. Approach it. That's how I tend to project. So, um, but you check patient's details. Make sure it's the right. You see GI after a patient. Just have a quick check of calibration just because, um, you terms off calculating your rate and rhythm if you're counting number squares is in the standard is 25 m a second. If you have the 50 millimeters, it looks much bigger anyway, but your calculations might be a little bit off, so just have a quick look. Then I tend to do you rate and rhythm. So is the way the top of the page. But Germany can kind of eyeball. There are complications you can do you, I think if you do 1500 divided by number of small squares or between your anal complexes. Or, I think, 300 divided by the number of large. Where's it will give you the rains. If it's regular again, it's normal at the top. Um, then I have, like, access. Is it normal? Left or right? Deviated. And then again, I think some of said just working way systematically. So looking at the P wave commented on the morphology of the P wave. Is it deferred? They do. They look symmetrical or is it kind of abnormal is inverted and most importantly, does every P wave have a QRS complex, then move on to PR Interval short. Long is it getting longer with each step? Curious Isn't Wydell narrow? Taking the context of tachycardia is Does every curious complex of the P wave on Is there any indication of bundle? Branch Block ST is pretty classic is elevated, a little depressed on the most important thing. That elevation of depression is what leads a day in. You need to be out. Oh, think about territories that the elevation depression will be in that that's gonna give you indications to which artery is involved. Um, I'm with his elevation is only reciprocal Depression on there Looked at it. He rose again. What's the morphology? The T waves are They all tend to t waves in hyperkalemia. Are they inverted? Suggested old ischemia on generally. If you work, you know to you that you tend to find if there's a problem. So what about well, with this CCG? What do we think? I know you appreciate the leads. That would have been a funny place. And I'm very much a pattern recognition. And this story is my brain a bit. But generally what we think about this e c j A couple going so far saying a regular Sinus Tacky, but also TV or inversion in view on. Yeah, so I would agree. I would say so. Great wise. Ah, about 100 is not, say three big squares to 300 divided Way three to about 100. Um, P waves look fine. Every period has a cure. Rest every caresses a P wave. PR looks okay. It's narrow complex. There's no bundle branch block on ST looks. Fine. TV conversion to be one can be normal. And it's nice. Later lead. So there is. Yeah, but I'm I wouldn't worry too much about that, so Yeah, Good. I think I'm a look. Absolutely a shin. I genuinely can't do within this. Former, I have to have it in a certain pattern to do my, uh, to interpret it. So by seen this No access deviation. So this is Sinus talking? Um uh, nothing. It again, it's a multi cardia. So how are you gonna manage this lady? We have a lady who has a four weeks of intermittent palpitations when she's watching television on at night. She's got no pre seed and symptoms from it for blood to fine her ob stuff line apartment, mom tachycardia. And that s E G shows slight Sinus talkie. What? We're going to do this study. I'm like the time Just jump forward onto this one. But do you write your comments in there? We can talk about, um um so I would say that this history is address of anxiety in high stress. Maybe because she's getting the palpitations at times when she's sitting on it's not distracted. Is undestructable to me that she could go to you can walk around doing throughout the day without having any palpitations. That sensation is when she's sitting down, What to tell you? You're lying in bed and decision of the heart racing. There's no red flags. Her blood Suffian had any surgeries or normal, I would be my munchkin beater. Reassure this aging. I would talk through the red flags and say the reasons we're concerned. Palpitations is if you're getting any chest armed, your neck back pain with it, you gettin short of breath. So you're content coming down the stairs. You're sitting upright at night. You're getting any leg swollen, and particularly in this young age group, if you're getting dizziness or losing consciousness with that, you must come back to a Otherwise, I would say, as we've said with HCG, Is there a snapshot this may not. You know, we may just not be picking up anything that's causing palpitations. We've given you a full mot that blood, which will seem normal if it's an ongoing problem. You may need to have a 24 hour tape. We do an EKG over a period of time and see if we can pick up anything causing palpitations. Your GP can organize that, and then I think the discussion of stress management took about mindfulness and psychological therapy is is always an option as well. For this day, diodes say it's Sinus tachycardia. The palpitations don't have any red flags. Um, and I'd be happy to discharge her home. You agree? If anyone strongly disagrees, do you let me know in the comments? So what if same lady actually tells you what I have had four weeks of this? Um, and it's intermittent. It can happen any time. I could be sitting there doing nothing when I get these palpitations or been at work and somebody hit, say on. But I lost about 5, 10 minutes and then it goes away on its own. I don't really have any symptoms. If it was a bit weird, I don't feel great, but there's no ocean was a breath I've never passed out from it. On be screened for peeing is no symptoms when you push it further, she says. Well, I guess thinking about it had a bit of loose stool for loss kind of a couple of months on. My period hasn't quite been the same as they usually are. Um, actually, no, he said it will spell Forget a ground in weight. Um, but otherwise day, my family's fine. I'm fine. Have a couple cups tea a day. I've got a partner, but I'm on the pill, Um, on otherwise new things with the infection. Well, do you, Dom? Unexamined. A shin and again. Pretty normal. But again, you've got this tachycardia about 110. It feels regular on probation. Um, you notice any trees? Kind of putting hands out, picking things up. Just got a bit of a fine tremor bilaterally. Actually, she looks a bit sweaty, a bit clammy, and she just seems quite anxious. What do you think about this lady? So a couple of months is suggesting hyperthyroidism? Yeah, I think that's reasonable. So we have a lady here, has a change in bowel habit, changing her periods, weight loss and palpitations that sound a bit more convincing to be in cardiac in nature. She's got a lotus age which is suggestive of hypothyroidism in some trust. My trust me, Don't do take the t three t four. We just do a TSH on the TSH is abnormal. We have two recent T three t four. Motility is eight point of view. They suggest that there's a overactive thyroid that sent in because the high amount of thyroid hormone being produced it's and a negative feedback to hypothalamus and this last year say it's being produced. So in this age, we haven't organic cause, right? So we're still want this. The same message is a Sinus tachycardia. But in this instance, you said, Well, you are tachycardia and we seem to have a gun it calls for. So this lady, we have something to do. So the management of her, um, you explain the diagnosis we need to send a T three and t four on detect. This isn't this is clinical or subclinical. Hypothyroidism on auto antibodies may be a pre prior nick in the graves disease exception you would authorities some on. At some point, he's gonna need to have management investigation that thyroid so usually ultrasound with doctor letter. Quantify. If there's any tremors or anything or masses that might be causing the problem management generally that you give a panel Oh, for the tachycardia on For the management of thyroid, it's either block in a place sometimes radio ideal surgery. You may want to consider a 24 hour holter to see if he's actually runs a day off again. It's all seems to be indicative of the hypothyroidism, but something to consider on. She probably needs discussion of the end of crime and in whether, as an inpatient outpatient with repeated if he's in a couple of weeks after management's been initiated. So this idea is similar stories, but off presented palpitations. But it's subtle differences on further program has seen that there's a pathological cause for this lady's palpitations. So what about if this lady is, say, maybe 24 year old, having a really bad run, his now come in with a one hour history of persistent palpitations? So today she's been at work. She's had three cups of coffee throughout the day, was walking home, felt perfectly fine and then suddenly had this horrible feeling. Her chest of like factory and heartburn racing understand awful again. You screen the red flags or flaxseed. Okay, she's never has another before. There's no significant family history. She does drink quite a coffee for other day on. She smokes, but says, know where you're pregnant? I felt upset If I stay and just come out blue, Um, what's going on with me. So one thing about this lady, so you start processing. You've gone through your history. Um, Mrs Her findings. What's have a quick read through and see what you think. A little bit different. The last one. So in this one again, areas, patient trust, it's fine. But we've got a good going tachycardia. 100 90 we put regular but 100 ninety's quite a horse. Tell something's regular from palpate him on. Remembers while if your heart is going to kick in pretty fast, particularly with regulation going the rate perfectly, maybe different to your rate over your atrium. So auscultated is really important to try and get the tree. Great off what patrons there, but BP is okay, she out? Um, it's fine. And it is a for bro. She looks bit anxious, but fine. Um and you're sensing blood so often that's dependent. We know that she's not a problem. The woman Excellent is So this is a recent J little bit different. The last one. What are our thoughts on this? I'll give you a couple of minutes to have a look. Getting quite a one c is suggesting SPT. Okay, Good so it looks like an s e t of any other comments? Was that the general consensus? Yeah. Stuff in the general consensus is yeah. So it produces something else? No, I'm just saying you had over the last month or two people beating internists. It's Nestle. See? Yeah. So I would agree. I think this is an STD. Say, how we gonna manage this? Well, first we need to think about what the diagnosis is, So I'll be This is a narrow, complex working the tachycardia, which, by definition, is Germany a super ventricular tachycardia. So when you think about supraventricular, you think about what's the site of the arrhythmia and is it regular or irregular? So if you think about from your atrial trigger point on it's regular, it's could be Sinus tacky. It could be a tachycardia, an eight or flutter that's regular. So with their want to book wanted three book irregular atrial will be a tribulation or atrial flutter that's got a variable block, and then you've got your atrioventricular causes of a supraventricular tachycardia. Which of these horrible a V e r t a n a b N r t, which I really struggled with when I was eating, and I still struggle with now. So this thing has gone on a V a v e n r t. So I was using that quite confused with What's this ab an rt and a B R t. So at the bottom, we've got to diagrams. The one on the left is your HIV and Artie, the one on the right is an a B r t. I know I was thinking it easy to remember a BRT as Parkinson white, because that's like the the most common one. So your a b r t you have a physical accessory pathway. It's an additional branch coming down here that it's causing havoc to your, um, uh, you're electrical system in the hall in your a B n Artie's, you get a functional disorder, so there's no physical accessory. Pathway is all within the A, VN that you have this short and faster factory pathway. The functional is the one on the left, which is a B and T is most common cause of palpitations in hearts that are structurally normal, they normally come on and off on. There's lots of triggers for them, so exertion in this case caffeine alcohol. So it's more on amphetamines. It's normally younger women on. They can go really fast. They can go from 1 42 180 on Generally, it's regular. I think if we look back difficult, I mean, I think it's I think, it when it's going this fast. It's hard to always appreciate. It's regular, but this looks pretty, pretty uniform prepared to something like a tribulation you're going to bury mind is that is you got narrow complex, which is characteristic of your supraventricular tachycardia on some things that can help you pick out what this is A V and Artie is that the P ways in certain needs will be retrograde. So the be inverted, which I think if you go back, can you see them? Do you think you can carry the problem with the going? This passes that the P wave start to merge with curious complexes, so it can be really tricky to pick up um, and again you got his ST segment depression, which we can see throughout all leads, which is suggested again of the market. This strain on the my cardio on does not necessarily indicative off scheme it calls. It's in terms of your treatment. The the main management is again you're 80. We know that she's stable on is thinking about your about South of maneuvers. So either getting to blow into a syringe, getting to bear down strain. Or there's the modified of ourselves, which I did the other day and watch would. Well, if you get into a blow blow, blow, blow, blow, blow blow into a syringe, letting to lay down lift the legs up. Um, I called you about my lady immediately. Eso it sometimes do in the uterus when you go over the quarter to do cortisone last notch or get into blowing syringe variable six bucks, but it's the first place to start. Remember, with karate massage number one only Do one karate it don't do to karate is because they will lose card proficient in the brain, and they will be ourself. The second thing to do is auscultated over the cortisone and make sure there's no rage in breweries that you're going to do a cross in massage on send off some sort of embolize not to scare you, but just like to cut yourself one quarters and having ostentation before you go. If that's not working, a dentist is the main treatment, and that's to first. You can cardiovert. Secondly, can also revealed the rhythm. So it's going this fast and we don't know sometimes given identity means it slows it down enough that you can get in the C G and say, Hey, it's flutter or okay, it's an age or tachycardia. Um, so you haven't any surgery next to someone who can work it quickly is always helpful. The main thing to do is when the patient that they are going to feel absolutely shocked him remember to having to washing it being done. It's an F one. I'm watching this heart rate go from 200 to 1. 50 to 100 to 92 52 30. I think my heart went down to 30. What I was auction up on that goes back up again. You have to warn them they're going to feel shocking, but it would be temporary. And make sure you got your monitoring on the main contraindications. Predict for adenosine is if they've got severe asthma or COPD because it was in the winter Bronchospasm, in which case, the ropinirole will be an option on other agents. You can use toe control. Give rate control would be cast on channel blockers. Be two blockers on amiodarone is always a backup. If adenosine doesn't work long term Geminis, well tolerated on it, could be managed, either patients doing their own about salvors or rate control. But sometimes you need ablation is ongoing. But generally, you know, Although it is going fast and you need to slow the heart rate down, they're quite well tolerated. So what if the easy gi for one of these ladies like this, it's not longer 1 90. But what? Your thoughts on this CCG Any ideas and the thoughts coming through so called been suggesting with Parkinson White. Yeah, good. I think that's a good spot. Diagnosis. So many things of wolf, Parkinson White. I remember this is your A VRT. So this is that there is an accessory pathway. So the bond of can, which is also getting involved in send in the signals from the agent. Your ventricle problem is, um, the's a written these these pathologies is that if something changes in factory, so if some reason there's a skipped beat or the original impulse from the 80 to the ventricles delayed forever Reason the accessory pathway can kick in and start to get this refractory tachycardia where it's going from the world and going up into the atrium is just going around in the ventricle on the heart risk of getting ventricular tachycardia is from the from this so many things to pick off with Parkinson White is S o You've got your P waves of really short PR interval. There's hardly any space between the P wave and the cure us on. Can you see this up Slow to slant in there from the just next to the PR the the QR bit There's adults, a wave which is a significant. You can also get this t wave inversion in your anterior leagues. Um, which again isn't it is suggestive of walking some weight, so don't want it too much. You think you're thinking about this Kenya. So, um what we said so signs were them very short PR intervals get a broad caress and out a wave, um, and can get that t waves and it mimics your right ventricular hypertrophy mentions pre excitation on. They can present quite sick eso they can either. You can show this small pockets and why it comes. Subject. Go better go incredibly tachycardia, and you can also get concomitant atrial fibrilation as well. The main management of these is the question is again. Is his patient stable or unstable? If they're unsafe, don't you? Shock thumb? It's a synchronized shock, so the idea of synchronized cardioversion is that you are trying to give a shock on your wave. Um, so there's a certain cells on the machine. I think it's 50. Jules, you give. If it's stable, we then you have to give some anti arrhythmics. So you thinking about starting a little on your during flecainide? You avoid these drugs, the digoxin verapamil, because they were short in the refractory period off your normal pathway, which brings the accessory pathway, can start to kick in and start triggering Bt's. I'm be, too, because don't really work. So that's quite specific, um, management for these and again. It would be called you driven, and you have to refer these people to call it allergy. A long term, the management is ablating the accessory pathway. Lovely. So that's the young people time. Really? Okay. You need it. So your cilia, you're still in a knee. You're still seeing patients on you now. Picked up Mr Be. He was a 74 year old gentleman with palpitations. Shot him. So he's had 24 hours of popped A shins. No red flags again, Um, been about into the But the last couple of days he's had been in Syria. They get hot and cold, not eating and drinking as much as you know, Type two, diabetic and hypertensive. Uh, these are his Isn't examination on his bloods. So again, a be fine. See, He's a bit tachycardia 140. And you think it's irregular? Um, abdomen better suprapubic pain, but low grade temperature and got positive urine dip. The's of his blood's. So, um, been ever since November. Infection from the white cells and CRP crossings. Bit off baseline. Sodium's a bit high on electrolytes are fine. Iced tea at age is within normal range. This is a BCG. What's your thoughts on this gentleman would be? Got any goats? Yeah, I got a few initial thoughts coming in, so people are suggesting dehydration or a k I with the UTI Yeah, lovely. I think it's reasonable. We're forgetting some comments. Investing. Yes. Yeah. Good. I think that's good. So in the history, any examination on investigation finds you said UTI and dehydration and then the Easter JV said I have a thing. That's good. So if it if it is easier GI, we can say great is a bit difficult But I would say it's probably going about 120. 130. Um, it is P wave wise. Coming. See any P waves? No convincingly consistent P waves too well to pr until can't comment on. We have a narrow, complex tachycardia that is erected, uh, on the ST segments like Okay, this is like high takeoff from be two on access is fine. Might be a bit of ST Depression, really three, But again, it looks isolated. So we have got a patient with atrial fibrilation with a rapid ventricular rate. Um, who has signs of hyperbole via a possible infection. How we gonna manage the station? Don't take the approach. We got some bloods. What would your management day? I promise. This is one of the most common things that I see on on the walls in a always false there, anything was coming through. It's been a couple comments suggesting fluids and to six. Good. So we're treating underlying course. So 80 fibrilation can be triggered by hypovolemia either from infection, dehydration. Bleeding can be from electrolyte abnormalities that we've checked those, and they seem okay my authority to contribute atrial fibrilation. But again, that was in Okay, What about if you gave them my flutes and you gave semantics, but he's still growing fast. What would you like to do? So people noticed resting rate control. So beautiful vision like, Yeah, Good. So we need to give him something, don't we? So we can do initial management generally with these patients. It's in the side. Um so busy is there cause I can treat so half? They got into heart failure. Either. They've had a big, um I got a heart failure on a tribulation. How they had a problem going to heart failure. Are they dry on? Dehydrated? Got an infection that's driving up. Used to a good fluid status examination before you start giving anyone any fluid. Um, if the hype of any make by all means IV fluid resuscitation on I would have this gentleman. He sounds dry from from the history, So remember your fluid resuscitation or given bonuses So 2 50 to 500 ml of sodium chloride a heart lands on your reassess. In every intervention you do, you must reassess fluid. Bonus. Reassess through a bonus recess on giving those notices of 15 20 minutes. Want to give it a couple of this is You can give a maximum two liters bonus because it's not working to your teachers. They're gonna need something stronger, like basic price is exactly well, once you give us and bonuses. If there's a response to the BP in the heart rate, you can move on to slow a buck. So for our maintenance fluid, six hour maintenance for it's depends on the patient, right? And I always give my museum monkeys in can drop your BP to be aware. But generally, if I have a patient in a tribulation, give him some mark. Um, cause sometimes that can work really well. I don't know the physiology behind it made my flat maybe discussing it today because you give market for lots of things asthma on a set, It to give it a pet analgesia. Um, we come in pretty comes here like a wonder drug. But I've been back on treat infection. If that doesn't look like it's any acute statin from the guidelines, I've looked at first in George's and for Kingston, which is where I work. Um, you contaminate. Apparently, if F is in 24 hours to contaminate with flecainide I've never given flecainide in my life on I would be very I think I would be cautious to get like a night on my own. Other options say the most common that I give given is the the postop follow on the top A low dose up a low. You can get a stop date if that BP is holding their note Asthmatic if they're not septic or bleed in and you're gonna crash the BP. But stop low is reasonable. Was up a low to take 68 hours to kick in eso the alternative is given. I'm alive in the top. You know, AVM atop low can kick in within kind of 30 seconds a minute. Um, usually quite a rapid change, but it tends to wear off after 5 10 minutes or so, so it's quickly reversible, so you tend to get it if you want to see if it, you know, give it, see if it works on different don't you know they start to have bad side effects from it will wear off quickly. And but because it was a great play, it doesn't always do the job long term. The other option is to Jackson, So digoxin tend to give if patients are known history of heart failure. The drops is a good drug. You give loading doses of 2. 50 to 502 50 if the little bad renal function 500 otherwise on you can give up to the 1.5 mg off the drops in over multiple loading doses. Remember, with the jocks in, it takes six hours for it to kick him. So you're not going to be immediate response? You can have to need your patient tachycardia, Um, but within 4 to 6 hours to start, see the drops and kick in, and you can always give them another boat. This afterwards, it could be forgiven to jokes in what you've given your loading doses, you don't need to give him a daily dose. Otherwise, all that node, it's been wasted. So starting in 1 60.5 or something with Jackson once you've had the lady in doses, um, diltiazem is another option. So calcium channel blockers is noxious? Well, I know there's always a medical school always number being completely stressed by rate buses, rhythm control. Mind believe we've got a good summary on this online about it. Regulation on. They have said that the indications for rhythm control is generally it is acute onset in less than 48 hours. It's paroxysmal is a young patient with a structure normal heart, uh, with his heart failure, then talking to cardiology about rhythm control, maybe more paper up. But generally, I've always done rate control. Um, my own on, but basically holding jobs intend to work quite well. So these are the medical management options from the guidelines that my trust there may be slightly different really work with a defibrillation once you stabilize them. The main things is, I think the street risk so cut closing. The trans fat scan has been school on, but they need to be referred to either to cardiology as an inpatient outpatient order with metal neck having guns, too much detail about age of preparation because I believe that would be another minute sleep session just on a trip. Reparation. But I couldn't really do have palpitations actually out. And then the last one. I promise on it. Well, kind of this man. You go back to him to tell him your excellent management plan that you come up with on. You think all here than that? Really good. He looks very pale. He looks quite clammy. You quickly redo the BP on. Do you get this BP of 75? 40? Ah, he's going well. Region feel very well. What are you going to do? What is your next management? You now have a hypertensive peripherally cool talking carded patient. He was complaining of a pre syncope sensation. Any takers? You still without that what you may or may talking to myself again. Still, plenty of you think you think everyone's just deliberating on what to do in this in this emergency situation. So getting for you from and suggesting that it's a shock fluid bolus, rapid fluids check blood sugars. Yeah. Good. I think that's reasonable someone's just considering adrenaline. Yeah. So you're dreadful in a drink in Germany tends to be confined to your reflexes and your Ah, sorry, uh, cortic arrests. Okay, this is metaraminol. There's effort during that. You can do for the BP, but I think let's think about in the contact. This is a patient who, you know, has had atrial fibrilation with a rapid ventricular eight. He was previously stable. I agree. I think, given the context of say, Okay, well, we think he's drawing. He could be septic. This could be sexist, driven, completely reasonable. I've given some fluid notice. Is treating the infection is reasonable. But if you given fluids and you've given antibiotics and this is his BP in the context of atrial fibrillation and a tachyarrhythmia with hypertension precinct pee, any thoughts of what we could do Because you're right. He's in shock. Do you need to think about what's driving? The shock is it's abscess. Ah, Hypovolemia. Is it something else? A few comments coming through suggesting DC cardioversion. Yeah, so I think this is versus the This is a situation off. I will help. My golden rule was sick. Patients. Is I asked myself, I'm a happy to walk away from the patient. So firstly, am I happy to walk away? Go make a phone call to ask for help? Or am I happy to take a blood gas and go over to the machine or walk the other water machine and run it and come back? If the question the answer to my question is I'm not leaving this patient side, you hit the alarm or you call for help. You get more people in the office and see and then you put out, uh, either get seen usable by the phone. We put our Perry arrest and I have no fresh opinion. Well, I don't care about finding out. I'd rather put them out on people roll their eyes, they're not. Put them out. So I would say in this situation immediately without BP, who he he looks on while with that accurate mia. Cool. Well, so generally the golden rule is and so you have an unstable tachyarrhythmia. So But there are any of the red flags. They're candidates for DC cardioversion on which you will never have to do on your own. I've never done it much to, uh um, quite so. It's done, but I've never done it on. But you would need to. Lots of people around Teo insured patients safe. Um, particularly in a different relations with the risk of blood clots. They need to be a conversation about the risks off thrown off a blood clot exception. But obviously the patient is unstable and deteriorated. You need to prioritize the cardiogenic shock first. So in until able learning point is unstable. Tachyarrhythmia is, um you need to do for DC. Cardioversion is one of the first thing for you to think about, um DC cardioversion in my trust. Can anybody recess? We're not. We weren't Astelin awards. So another thing to think about logistics of where this patient's going to go love it is the last one. I promise. Thank you for sticking with May on this very muggy. Even So, Mr Be, uh, you've gone in and actually, history tells you is that he's had a two hour history. Palpitations, um, no red flags that he can think off, but he throws in or actually did have a name I couple years ago. I'm still talk to diabetic hypertensive. Um, this is his observations if he walked through the door. So sorts of 99% breast rate, 22 heart rate of 1 90. Low blood Russia of some to 40 on a febrile on the necessarily be rushed him around to recess on you. Get into resource. And this is what you see on the rhythm strip on their cardiac monitor. I didn't know anyone else that that puts my heart rate is about 200 itself. Um, so the nurses already print 70 g for you. And this is the CD. What do you think is the problem? Okay. Got a few early birds come in with VT. Lovely. Yeah, this is the tea. So this needs to be It is a spot diagnosis on, but this is probably one of my worst nightmares to say just but really maybe actress. So this is a broad, complex tachycardia. In some instances, just be careful, people. A paste. Um, sometimes you can look at a pacer of the stricken think. Oh, my goodness. What is this? But this is very distinct in that if you look at the morphology, there is no the morphology is completely off. There's no p wave your ass. It's a logistic, massive mountains of squiggly lines. So you're morphology is completely different. You're still maintain some morphology and paste leads. So well said I Mrs VT, what we're gonna do It's the Golden question part. Maybe wipe away it here. Try not to cry. Take some breaths. Any thoughts on the management of ventricular tachycardia? So shock cardiova you. Do you see a cardio for yeah, getting a strong consensus for cardioversion So ventricle tachycardia. It's sustained ventricular tachycardia. If it's more than 30 seconds or something will go into runs a B two and it settles, which is less of an emergency. Can be. I want a more fit like we saw or polymorphic, which is there to start Depart it kind of winds all right around the base line on that, regardless, if it's monomorphic polymorphic, you treat it the same creative. Supposing conditions, too. It's a channel with these Regard a wolf, Parkinson White on it have Q t prolongation, either from things like remind award. Other common with the other hand. Uh, was it the congenital QT prolongation syndromes, but also remember common antibiotics like macrolide you're through icing clarithromycin metoclopramide haloperidol, methadone and on paradigm can all cause people qt prolongation take You remember the, um on to psychotics A big offenders for this. So drugs competing out at a cardiogenic they may have used knees disturbances. So hyper hyper Columbia, hypo Magnesium me A and calcium composes Well, hypothermia is a big trigger. Anything got structural heart disease. So they had just had an MRI on me that could they could go into present with ventricular tachycardia equally if they've had, they've got left untreated, like chronic left untreated scar tissue. They can go into rooms on physical structure, pump of the heart. So heart failure Hakem contrast, disease completely. What high risk. So the management of this was only life in the fast lane, and I thought was a really good division of how to approach her. So, Bt remember, is part of you'll a less you adult advanced lexical. Well, I'll s protocol. So they a pulses and they're on BT it's a shock. A bowl rhythm your to shock your rhythms, your beauty or VF your non sugar balls of asystole and p a. So in a shock aboard them, you're putting the pads on a given three shocks. Um, that's for the air. That's protocol. You started CPR. Once you get everything ready, always putting oxygen on maintaining the airway on you be given adrenaline and amiodarone Adrenaline you give of every 3 to 5 minutes on amiodarone. You give up to the third shock. Um, remember, And you called a caressed You go for your haters Know ti's. Um, if it's not familiar to you, you would do it when you do your daily aspirin, your ls course, as their forms. Um, but it's important to remember that you can have a ventricular tachycardia on no pokes on. That is a cardiac arrest. And you treat it as such. Which means pull the alarm on power. Cardiac arrest. That's the That's your monitor bread flag. So they have a post. They are conscious, but they're human out Can stable the question chest pain or signs, ischemia, then heart failure or there been tricked. Your rate is more than 100 50 BPM. Then you're gonna have to DC cardiovert the most. They're awake. You're gonna give him three synchronize shocks to remember a synchrony. Is that the heart always and CP all the situations. That poster situation that is not always toe dyssynchronous, too. So you do a new credit. Unsinkable eyes to cardioversion Cardiac arrest. It's synchronized in there. There is a pulse today. Three shocks you to try and think about. What's the cause and hungry? Reverse it and then it depends on your trust. Some say Give lignocaine infusions. Some get a meal during infusions for Kmart infusions. I think my trust is Get bonuses of lignocaine on, then infusion on amiodarone. If it doesn't work on the other thing you can do that was reading about is overdrive pace in so you could do external pacing on the patient? If Wash just went out, the cardioversion and he basically paste them to slightly faster heart rate than normal. So say 101 110. And sometimes that can just reset the holes well, so you gotta CPR management. You got a red flag management, which as well, said Cardiova reverse the course and considered IV infusions. And if they're stable, although you get to read the side side of relief, it's still a medical emergency. They still may deteriorate. You still need to get seen a support again. It's gonna be amiodarone started or infusions if you're given medical therapy and that doesn't work he to college ever. And what's their stable? You need to get a new test involved to sedate them because it's not pleasant to be awake, for they may have pacing again. You're gonna reverse and treat the cause on. But if in doubt, give a bit of Mark because it's the magic drug. Um, main thing is, you don't get back until because it will make things worse, so I think it's going to survive. It's a post less red flag stable, but regardless it's all a medical emergency. Need to get seen. Your support you quickly, and that's it. Say, I hope this has been helpful. I'm more than welcome to have suggestions because it was quite big topic on. It was difficult to try and get breath. So I have. It's been helpful and thank you for sticking with May I know we've gone over again. So summary take home message is, Is that palpitations? Concolor? An array of presentations from the reasonably benign to medical emergencies. We had a talk about what investigations you would help you. The diagnosis how you depreciates patients as that any patient you see start with 80 approach and consider, if asked, asked Was up the question. Are they stable or unstable? Are the compensated decompensated um on the key for everything is calling for help. Really, I want to emphasize that we've gone to the management. We've gone through specific management's for all these things, but the expectation of view is F ones. Junior doctors is not that you are starting a meal during infusions, you know, starting lignocaine infusions. The expectation and you want to learn to do is to recognize patients on while start your 80 assessment, call for help really, and work within the remainder of your experience. In your knowledge, there is no expectation that you're gonna be put in puzzle and coordinating DC cardioversion. But if you can say bring your Medrol will put the peri rest out because you're concerned this is unstable patient with a tachyarrhythmia. He may need DC cardioversion. That's all we're askin. I that's the most that I would do that at this stage. I put the Paris out, start a start thinking about what I might need, but not many people are going to be making these decisions on their own. Even a perirectal chew a shins Med Reg to cardiology will be having discussions about Ms Procrit treatment. So be aware of the treatments is good for exams is good for general knowledge and understanding of the pathology. But do not worry about having to learn all this heart. We just want I just want you to get a feel bit more confident when I'm seeing patients on Call him a present with palpitations on. Hopefully you're not more confident in approaching these patients. You're happy with history, Taken it a bit happy with the EKG interpretation, thinking about how to investigate them on a more aware of Motrin. See management of these patients. These are my references. I'd really recommend them. Um, this one at the top of the bottom are the specific guidelines for Saint George's in Kingston. But I think they're really accident for general knowledge on, uh, this, um, other guidelines, and then that might be helpful. Love. You have any questions? If anyone still with me? I'm very grateful for you. Stayed on Well done. I'm happy to answer any questions. Um hum about Daddy. Thanks. so much easier. We actually had a lot of people sticking on to the end of about 80 on the face with life. I posted a link to the feedback in the comments. If if any, are you still with us, could fill that out, that we really, really usual for us and you can also get certificate for attending. So hopefully there's listen enough. Everyone, Um, it says the comments were just getting lots of thanks in the in the chart and of those really, really great session. Um, well, just look around for a minute or so. Just in case there's any questions, you please get some feedback, just so it helps us make the sessions more tailored to what's useful for you on Also, it means that I can demonstrate that I have gotten some teaching to use my portfolio, so I'd be really grateful. But I would like to hear about your feedback on how this has the structure of the session, because I was debating how to do it to do let me know. Unhappy sounds. Any questions? I'll try and answer questions if needed. We'll just give you another 30 seconds or so well I think everyone's pretty happy with, uh oh, We have those. So thanks, Ted. One who attended and thanks again. Too busy for, but it's another citrate. Webinar on. We'll see you guys for, uh, for next seven. Thanks so much. Thank you. Bye. I'm just going to sex.