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Hello, everyone. Um um Thanks so much for attending the session today. Um My name is AA, I'm one of the um it doctors and in the northwest. And can I just check that you guys can hear me and see me if you can just um just pop on anything in the chat? Yeah, perfect. Right. Um So due to some technical issues and what I'll do is I will probably um sort of use, sorry, I will probably use um my phone to see the chat, so I won't have my eyes on the chat all the time. Um But I'll be using my computer for the presentation itself. I hope that's ok. Um All right, that's done. Sorry, I'm just sorting some tech issues. So, um, today we will be talking about mainly collapse and arrhythmias and palpitations and I've been trying to sort of marry all these themes together and, and give you guys an idea about things that you might very commonly see um on the A&E in the take um or on the medical ward and going to start sharing my slides now. Perfect. Right. So, um again, my name is a, I'm one of the IM GS and I am actually an I MG. So I'm Egyptian. Um, I came to the UK around a couple of years ago or 2.5 years ago and I graduated back home in Egypt, had all my undergraduate study in there and had to take the OE and then the pla uh, probably during the COVID Times. Um, and then I came here afterwards, um, did an A&E job, um and then did sort of a different academic post. And then after that I joined I training. So that's pretty much um um where I am at the moment and I was wondering if you guys can scan the QR code and perhaps give me an idea about, you know, and not, not necessarily who you are, it's completely anonymous. But if you're happy to just tell me what your w where you are in your career at the minute and, and, um, you know, what, what sort of specialty are you interested in? Um And I'll be able to view the, the results from my end, um As well. Yeah. Uh It seems like that's working but if it's not just let me know, um and I'll, I'll try and send you a link. Um If he, so as I said, it's completely anonymous. So even if uh slider, which is the, the app I'm using, um to, to sort of ask you questions if it asks for your name and it's still anonymous. Um, so I've got some, um, replies. So, but some medical students and got some people who are GMC registered for her job hunting at the minute and just waiting for more employs to come ahead. Yeah. Ok. You've got someone working in the UK or in the process of working in the UK. You got a good, good mix in, in there. Um Perfect. Right. So, uh, thanks for, you know, sharing where you are at the minute. It's, it's really important for us to actually know what, what sort of um WW where you are at the minute so that we can try and, and tailor what we discuss based on what, you know, what you, where you are in your, in your path. Um I'm not sure if it says um uh next or anything. I've got another question about which specialty you're you're interested in. I'm not sure if you can press next from your end uh or get the, the second fall on and if not, let me know that's fine. Um OK, perfect. That, that should be fine and right. So thanks so much for sharing. That's quite helpful and we'll probably go for the aims and objectives for today. Um So to start with will be discussing these sort of common types of arrhythmias that we commonly see in practice. Um We'll be discussing some cases. So I I'm trying to make it sort of case heavy and then we will discuss the perhaps the workup and the treatment plan as we go. Um So discussing some cases for patients with attending with things like palpitations or perhaps Presyncope um reviewing what we need to do and how to treat the patient. Um But equally trying to use a holistic approach, um common causes of collapse. So collapse is a very broad topic and it spans different systems in the body. So we'll just be going through these systems and, and identifying the sort of treatment plan for anyone attending with collapse. Um And the common causes for that and I have to say that we won't be able to cover all the causes of arrhythmias and collapse in in this session. And hopefully I'll be able to perhaps do more sessions with you guys. But um at the moment I just chose the common um things that we usually see. Uh So trying to see some cases, please please feel free to pop in any message in the chat and feel free to ask any questions at any point. Again, I've not got my eyes on the chat. Um But I'll try and look every now and then to see if there's anything you guys need to discuss and if you're not able to scan the QR code from out from, from now on, I'll be sending um I'll be sending a link um which should, which should redirect you to the uh quiz. OK? And so I'm, I'm trying to do some tech stuff here. I'm not, not an expert but I, you know, I'm trying my best, um, so that we can keep it interactive. So that's how you actually understand, um, stuff and, and, um, perhaps how that's how you gain the most out of this succession. I've got the first case. I've got a 65 year old gentleman, uh, brought in by ambulance. Uh, he's got a history of palpitations. Um, So just checking the chart, uh history of palpitations worsening, shortness of breath over the last few days, he's got no chest pain. He's got background hypertension, diverticulosis. He's got CKD and he type two diabetic. Um He's on Ramipril for his hypertension. He's on Metformin twice daily and he is on some laxatives. He's got no allergies. Um No family history of note. Um I've put, put some social history in details and we'll discuss why that is important um as we go along with the cases, but basically he lives with wife manages well and no package of care. Um which means that he manages well without carers and um at home, et stands for exercise tolerance. And it's a very good way to try and find out how frail your patient is or how capable your patient is. And, and anyone who's got worsening exercise tolerance can also that can also indicate that the patient has got probable heart failure that wasn't diagnosed or someone who's known to have heart failure, who then are having worsening of their symptoms indicating some sort of acute heart failure or fluid overload. Um, so that patient has got an exercise tolerance of around 50 yards, which means that when they walk 50 yards, that's when they get breathless or they have to stop to catch their breath. So how I normally ask the patient patient about this is and how far can you normally walk before starting to get breathless? And they tell, oh, I can walk just a few steps and I can walk 500 m. And so always try and quantify these numbers because as doctors, we are quite interested in numbers and so you can do either yards, meters or steps. And if, if someone has got a very poor baseline and and they can only walk a few steps, you can, you can write in the notes. Oh, the exercise tolerance is 12 steps, for example. Um As long as you write on number in there, that would be quite helpful and objective. Um Patient is an exsmoker and occasionally drinks alcohol. So examination, um so you go and see the patient. Um ideally that patient would be in A&E and he would be referred to you. So you're either the A&E doctor who sees the patient or you are the medical doctor who's just picked up a patient for clerking um after they've been referred to you. Um So you, you look at the monitor which is the what we call the telemetry, um which is the monitor by the patient's bedside. Um And you found that the patient is going quite fast as 140 BPM. Um So if you scan the QR code and tell me what you would do next, um and also send the link on the chat. Ok? So I'm just copy paste the link for those if you are not able to, to scan the code, I'm just having a look at the results. I've got a few votes coming. Um You can, you can definitely choose more than one option if, if you want to. Um OK, so you've got, I've got, I've got a few coming, I've got um 71% of you saying that we will do OK? The majority of you, I'm I'm just just going to wait until we have the number because the percentages keep changing frequently and right. Great. So majority, you went for a assessment check BP, print out a 12 lead ECG and someone chose wait for the routine bloods to come back. OK, perfect. So let's agree that throughout this session, uh we'll try and make it as realistic as possible. And which is what I've been trying to do through the questions, which means that, you know, in an exam setting, you can only do one thing at a time. Whereas in real life, you will gradually find out that you can actually multitask with the patient, you can delegate the task to so to someone else. So you can grab the nurse and tell her, you know, please, could you do a BP on that patient with a heart rate of 140 because I would like to know whether they dropped their BP or not. And you can perform your a a assessment. At that point, you can also get he help from someone else. If you feel the patient is too unwell and, and because the patient is on a monitor, you can always print out a 12 lead out of that monitor. Or you can again ask another nurse to do a 12 lead if that's not an option where you work, um, wait for the routine bloods to come back and with a patient with a heart rate of 140 they are at the verge of becoming hemodynamically unstable and we will discuss what that means in numbers and in symptoms. Um And II wouldn't really, I wouldn't be as interested in the bloods at the minute if my patient has got that um a heart rate with that cost. Um give diuretics, no one went for that, which I'm glad, you know, don't give medications obviously before seeing the patient and give a beta blocker, no one went through that. So that's great. Um Perfect. So, um so you, you're doing your sort of a and assessment patient is talking to. So you're happy with the airway. Um You hear that there are some widespread crackles on the long basis, but no wheeze and patient who has got some mild lower limb edema. Um, but they've got no murmurs when you examine their heart. Um, neurologically, they are free and you know, rest of the examination is really not, not that exciting. Um, BP is actually normal. So, although the patient is quite tachycardic, their BP is normal and with tachyarrhythmias, that's usually the case. And in, in the in a smaller proportion of patients, you would find that the patient is tachycardic and hypotensive and we'll discuss how we deal with these patients. Um but generally speaking, the patient is having an acceptable BP. So um now again, scan the QR code for the World Cup, I going to send the link. So just tell me any test, you would think of literally anything. And you know, again, you can you, you've got all the resources that you need, just just anything that comes into mind, just write it down. Mhm And perfect. I sent the the link as well and for the workup. Right? Ok. Mm OK. Right. I've got quite a few votes and right, I'm just waiting um until everyone has um wrote their answers. Mhm. Quite compre comprehensive reading. Perfect. So what I'll do is I'll just show show the answers for you guys uh if you're still on the same page. Um So So the answers are basically you've got B and P. Um II totally agree if the patient is displaying um features of heart failure of fluid overload, particularly if their past medical history, it doesn't really say that they have heart failure. Definitely go for that. Um 12 lead EKG. Definitely. Yeah. Yeah. So you, you know, there's a fast heart rate, but you don't know which arrhythmia is that or whether the patient has got a, an arrhythmia or whether it's a sinus tachy. So definitely, um I can see that lots of, you have mentioned troponin and, and DD, which is quite interesting and in terms of the reasons of why troponin might be raised in that patient. And if, if they don't have a chest pain, I wouldn't rush to do a troponin only because um troponin can sometimes be falsely elevated in patients attending with a very fast heart rate. And we call that a troponin leak, which means that troponin might leak from the cardiac muscle and that's bumping at 140 BPM and leading to a raised proponent and not because of a genuine A CS but because of the pa heart rate essentially. Um So I wouldn't rush to do troponin. Um However, if the patient didn't mention any signs of um chest pain or chest discomfort, I would then be tempted to still do a troponin. And even if that means that I might get stuck with a falsely eased troponin. Um, but I don't want to miss an acs in that patient. Um, I would wait for the ECG. I would ask the patient if they have chest pain before rushing to do that. Um, ABG again, if the patient is maintaining their SA W, I don't really want to, um, give them the trouble of having an ABG done. Um, ABG is quite painful, um, to the patient and it, it, it, you know, it carries the risk of hematoma and stuff. I know that it, it is seemingly a simple procedure and, but unless the patient generally needs an ABG, I wouldn't rush to do that as well. Um Deer, and again, you know, patients can be breathless, but you have to think about what's the probability of that patient having a pe. And perhaps if you wait for the CD to come back and if that EC D showed just sinus tachy and you think, oh, that patient has got some risk factors, um, f for a pe than maybe and, but I wouldn't rush to do it before. I have a look at the ECG results. But I agree with you that anyone with presumed sinus tachycardia with the risk factors of, of a pe, um, does, um, buy themselves a DDIMER and there is an excellent, um, risk stratification scoring, um, called the Well score for PE II strongly recommend using that before, um, heading to, to do a DDIMER in a patient and just, just, just to try and avoid getting stuck with a positive number that, that is unexplained, essentially agreed with the rest of the investigations. Um, so you, you, you've written about calcium magnesium and, and phosphate. Um, so you're looking about your arrhythmia bloods, which we'll discuss in detail afterwards. Um, chest x-ray. Absolutely. Yeah. Yeah. So you want to try and see if the patient has got any features of pulmonary edema um echo. Yeah, I would um II would want to have an echo on that patient and we'll, we'll discuss that in detail and it's just whether to do that echo as an inpatient or an outpatient. And it, it's something that, you know, you would uh book the patient for. And ideally if the patient has got suspected heart failure and you know, regardless of the arrhythmia, they ideally should have an echo within two weeks um in, in some trusts. That's the, the guidance. Um So yeah, I would, I would book that patient for an echo. Um just bear in mind that um the echo ideally shouldn't be done with the patient, just tachycardic. Um because that might give a false impression of, of LVSD or left ventricular systolic dysfunction. So you have to re control the patient first control their heart rate and then do the echo. Um But there is no harm in requesting that preemptively. Thank you. Um So work up. So II usually try and split it into sort of bedside bloods and imaging. And so bedside, you've got the 12 lead ECG, you've got some basic imaging, like a chest X ray as well and you've got some bloods, which you've all mentioned. Um, I'm just going to add to the thyroid function tests. Um, don't, uh, don't forget that patients, um, with arrhythmias, you, you have to rule out hyper or hypothyroidism, um, other investigations, a 24 hour ECG or Holter monitor. And you would, you would want to do that if, um, if you did the ECG the 12 lead ECG and let's say that the patient is not on telemetry and you find that they are in sinus rhythm. Well, the patient tells you that they keep getting these palpitations and you would want to rule out paroxysmal af as well in these patients. So you would definitely book them, um for, for a 24 hour ECG and, and we talked about the echo as well. So these are your bloods. Um So you've got a CRP of 27 for those of you who mentioned the BNP. So it's actually raised, um HP is slightly low. A patient has got some raised white cell count and you've got a bit of any derangement. I didn't put the GFR in there until we forgot. But anyway, it's only mildly dipped down from the baseline. Um And you know, you did calcium, did magnesium, both of them are normal and the TSH is normal as well. For those of you who requested a chest X ray, that's the chest X ray. So, what do you think about it? I didn't, didn't do a quiz for that. Please feel free to, um, put down in the chart. What do you think about it? Just, just by looking at the chest X ray probably should have uh, put an anonymous fall about it. Um Is anyone? Yeah, perfect alveolar edema. Exactly. So, so this patient has got basically a picture consistent with pulmonary edema. Um So they, they've got what we call the bad wing appearance. Um So if you look, it does resemble sort of a bad wing um where you have sort of increased bronchovascular markings. Um And um you, you can, you can find some sort of trace and pleural effusion on the left and on the right side as well. Um So, so that patient is basically in fluid overload and it makes sense with the crackles that you hear in the lower limb edema as well. So that's the ECG for those of you who wanted an ECG. Um So just, just by looking at the ECG, um the first thing you ask yourself is it regular? Um and you know, obviously you go systematically to rate rhythm axis and, and then when you ask yourself whether there are P waves or not, there are no P waves on there. So that patient is in af essentially. So how would you treat this patient? Um and you know, with management or just mean any further workup? Um And how, how would you manage? Um In other words, what questions would you want to ask yourself now about that patient, what would you want to know? Um how would you treat them um by the bedside? Um All right. So you just scan the QR code and I'm sending over the uh link. OK. So you're treating the fluid overload? Ok. I agree with that. For control. Would it depend on hemodynamic stability? Yeah, absolutely. Yeah. So, so these are the sort of thought process that you would have um just by looking at the patient, are they hemodynamically stable? Do I prioritize rate or rhythm control? And we just briefly talk about that. So the patient pride if you're breathless. Yeah, I agree with that. These patients normally you would find them semi setting in research quite unwell. And yeah, you know, with a, with a heart rate of 140 they would, they would normally maintain that position, propped up position. Ok. Any other thoughts? Yeah. Yeah, I think I've, I've um modified the options that you can, you can actually give more than one answer. Um diuretics position. Ok. So you seem to agree in prioritizing the diuresis um in that patient? Ok. What if their, their BP is low? Would you still prioritize diuresis? Would that change your treatment or priorities? Oxygen therapy which of those sets are fine in room air. Would you still give them oxygen? Ok. I don't know what the semi faller position is. Um, I'm, I'm actually going to look this up, um, to be fair. Ok. So that's technically a semisitting position, right? Vasopressors. And the BP is low and. Ok, good one. So if you, if you gave the patient vasopressors, what do you think that would affect the, the, the rate the heart rate? And what, what's the main thing we're worried about in vasopressor is the most famous uh side effect of those pressors is tachycardia. So yes, you, you'll fix the BP. Um But, but then technically you will increase the heart rate even further, which would then lead to a flash pulmon edema and the failing heart. So you don't want to do that to the patient. Um So are there any sort of magic drugs or any, I wouldn't say magic? But are there any options to do if the BP is low? Patients don't tachycardia couldn't give them vaso pressures? You couldn't give them beta blockers because their BP is low. What do you do? No more answers? And you got 16 both. So I don't know why it's only showing me. OK, fine. OK. These, these are the answers I got fine. OK. So um agreed with everyone who said, depending on the hemodynamic instability or stability. So you have to ask yourself with that patient is this a new af or not? Um with, with the new af I mean, the acuteness um of, of the af um could it be that the patient has had previous episodes of palpitations? And they really hadn't booked themselves into an A&E and came to hospital. Is the patient hemodynamically stable or not? That's important thinking what the reversible causes. Remember that that patient had a raised white cell count, raised CRP. We haven't really asked them many questions about whether they have an infection going on. And is there a coexistent heart failure which I imagine most of you have um have have been discussed and and acknowledged in, in your answers. So af is generally from the outset, not a treatable condition, it can be treatable with things like cardioversion with potential to, to to flip back. Um But your main priorities in these patients are symptom control and preventing complications. When I say symptom control, I mean tachycardia. Um and when I say preventing complications, I really mean tia and strokes. So these will be our priorities in treating that patient. So we talked about unstable. And so when you talk about an unstable patient, again, as doctors, we're normally very interested in numbers. So we need a cut of number to actually say I need to stop treating that patient medically. I cannot wait, I have to intervene now. And in terms of numbers, um any systolic BP less than 90 beats, 90 millimeters mercury or heart rate more than 150 BPM. If the patient has got symptoms, suggestive of free syncope or syncope with the patient. If you feel that the patient is not really perfusing your brain and loss of consciousness syncope, and if you have severe chest pain, palpitations and breathlessness and sometimes just from the bedside and by experience, you will try and identify who is the unwell patient just from the end of the bed along with the numbers as well. Um If the patient is hemodynamically unstable, ask yourself, is this life threatening or not? And I'll talk about that if it is life threatening. Um If you're talking about a systolic of like 75/45 for example, and a patient who is extremely tachycardia and you feel that the patient is confused, not really be able to talk to you. At that point, you would urgently call the patient. It will not be your decision to grab your medical register and because you need to call the anesthesia team as well to try and involve everyone. And ideally that patient would be seen in um in, in A&E and the defibrillator pads are basically the ones that we use in cardiac arrest, but we don't know, we don't always use them just in cardiac arrest. If the patient is per rest, you can still put the pads on in preparation for cardioversion. So these are the things that as junior doctors were, you know, were meant to try and help with. And until the, the help comes from the ICU team and a team in the medical reg. And again, I'm talking about a very unwell patient, um, who are, who are likely to deteriorate. Um, a common mistake that happens. And I do, I think most of us would be guilty about doing is, you know, being a bit overwhelmed with the fact that the patient is quite unwell and forgetting to do a A&E a reassessment. So now you've called for help and you've called your medical registry. You've called an easy team and you've got everyone by the bedside and don't forget that there is a patient in the middle of all of that. So just try and make sure you go through A&E again, um a three assessment again, check if the patient is still breathing spontaneously check if they're um uh if, if they desaturated it, someone talked about oxygen. I totally agree. If the patient desaturates, then you would put high flow oxygen ideally 15 L by no breath mask. Um And obviously your main issue is the disease. So you need to try and make sure that there is an adequate circulation. Um Any questions so far, just keeping an eye on the shot, nothing on there. So I'll just go on right. Um I'm I'm always a bit skeptical about hemodynamically unstable versus hemodynamically stable because there is a proportion of patients who are always in the gray zone and who you think might deteriorate soon, who have not deteriorated yet, but they're also not 100% stable. Um, I'm just going to put them as like an amber patient who is likely to deteriorate, but he's talking to you in full sentences, slightly short of breath, heart rate around 120. Some people would even have a heart rate of 141 150 they would be sat there chatting to you. They have a stable BP and you're maintaining in a a proper circulation. So there is time to intervene medically. You don't need to cardiovert that patient yet, but you need to intervene medically and you need to use a medication which can, um you know, try and try and reduce their heart rate quickly. So in that case, you can, um at least you can, you can still cardiovert these patients but you still have room for medical intervention. So I would uh probably give them something like IV digoxin. You would load them with an IV dose of Digoxin that said digoxin does take time to, to work. So if you think that your patient is likely to deteriorate quickly, and this is a judgment call that you would make with the, with the medical registrar, you would, you would still cardiovert your patient and obviously beta blockers, the only problem with beta blockers, as we said earlier, is that if you're a patient, if you're in a dilemma of trying to break control, a patient who's got a very low baseline BP below 90 then don't use beta blockers. Now, you've got a stable patient, you know, speaking to you chatting. Um you're not worried about them again, like that patient, for example, she's maintaining her BP, maintaining saturations nowhere. She might be a little bit breathless, but that's about it. Um Your, your option really is rate control. Um So the medication of choice would be a beta blocker unless there are any contraindications. Obviously, I know the literature would say that if the patient has got severe asthma or COPD, then you would probably to give them a calcium channel blocker instead of that. Um in practice, unless the patient is having a severe asthma exacerbation or they have a severe form of asthma, we wouldn't, you know, we wouldn't opt for changing that to calcium channel blocker. And I know that some of the literature would, would advise a calcium channel blocker and most patients are actually fine on beta blockers, even those with stable asthma or stable COPD. Um You can use digoxin. Um The problem with digoxin is again, it, it takes time and uh every patient has got electrolyte imbalance, then you would keep an eye on the digoxin levels. There is a, there is a, a potential that digoxin might lead the patients might get digoxin toxicity. And so really, it's one of those drugs where you kind of want to tiptoe with a patient. So you wouldn't use it as a first line. Some patients despite giving them Bisoprolol are still running quite fast on their heart rate. So at that point, you would still load them with digoxin. Um It has the benefit of, you know, you're able to give it IV or oral. So you can use either the IV or the oral form. It's a 1 to 1 conversion. Um And uh yeah, just keep an eye on the kidney function and keep an eye on the digoxin levels, particularly if, for example, the patient is hypokalemic because that might increase the risk of having digoxin toxicity. So just some things to bear in mind. Um So some people are settled with just bisoprolol, some people you would just load them with digoxin with that. And it really depends. Um I know that some of the guidelines to the nice guidelines actually would say that if the onset is less than 48 hours. And if you're quite sure that the onset is less than 48 hours, if you have a clear time of onset, you can use either rhythm control um or DC cardioversion. Still, even in a, in a stable patient, you have that option. And I would just say that this is a very small proportion of patients because most patients will tell you, I've been having these palpitations for a few days, you don't really know. Um how long ago have they had their af uh so just to be aware that, you know, although the guidelines say that you would rarely find a patient who would come in within the 1st 48 hours of their af we can use amiodarone sometimes and that's part of your rhythm control. Um But, but it is only used in selected cases, particularly if some patients are really refractory to treatment with beta blockers and with digoxin. Um and sometimes it can be used as a bridging therapy um until cardioversion in these patients where you couldn't really rate, control them with, with all the options that you have, you've kind of exhausted all the options. Um All right. So we talked about symptom control. So we've got the options for symptom control. We've got the, talked about the beta blockers, the role of digoxin. We talked about rhythm control, we talked about DC cardioversion. Now, we're worried about preventing complications and, and I feel this is more important than rate control really because whilst, you know, whilst the patient's tachycardia would lead to breathlessness and it's quite, you know, patients are really unstable and such a pulse rate of 140 you really don't want these patients to have a tia or a stroke. Um So there is a, a quite well known um scoring system and some people just refer to it as a shock VSC score. Um and it looks into various things like the age, the sex and the history of congestive heart failure, um hypertension, uh previous thromboembolism or a stroke or a tia a um vascular disease and diabetes. Um If we put a, if, if we scored that patient, he would score one for the age and zero for being a male. Um If he has a probable congestive heart failure, I would give him another one for, for the congestive heart failure. I would ideally wait for the echo but he's got raised B MT um hypertension and diabetes. So it's got at least a score of a three or four. The guidance says that anyone with a SH FOSC score who's a male patient with a score of one or more or a female patient with a score of two or more needs to be anticoagulated. Um And the reason of the discrepancy between the male and the female is basically because women usually get one point just by being a woman. And so you would normally wait until they score two or more. Whereas with a male patient, anything more than one they need and coagulation and an anticoagulation could be either a DOAC which is the direct oral anticoagulant. We're talking things like Apixaban, Rivaroxaban or dabigatran for example. Um and um Warfarin if, if the first group of drugs are not not tolerated and we have the orbit score as well. So the orbit score is basically a scoring system. That gives you an idea about how likely is your patient going to bleed or at risk of bleeding when you start them on anticoagulation. And most in most cases, even if patients are scoring high on the orbit score, and you speak to the cardiologist and say, look, this patient are very likely to bleed. Do you still want to give him anticoagulation? In most cases? They would say yes, because the risk of them having a stroke outweighs the risk of them having a bleed. And I have seen a few patients who, you know, the decision has been made, not trying to coagulate them. For example, someone who's at a very high risk of falls in their eighties and you know, previous brain bleeds, et cetera. So at that point, they would stop anticoagulation. Again, that is a completely specialist advice and the orbit score just gives you an idea about how likely your patient is to bleed, but it wouldn't really guide your decision. Ok. So you would start your patient on anticoagulation. Ideally, in most cases, unless you're extremely worried about them bleeding. So this is the orbit score. And again, it has more than one parameter and it has a di different HB between men and women. So with women usually HB if less than 12 is the or hematocrit, I think if less than 30 or 35 is the cut off point um where in males is slightly higher. Um but that's the interpretation from the nice guidelines. You have a low risk group, a medium and high risk group. And I would say, you know, some people would say if the, if the orbit score is higher than the VOS score don't anticoagulate the patient, I would say, speak to the cardiologist first. Um before making the decision not to anticoagulate and particularly if the patient has known af and you've taken the decision to stop that, I would say make it a multidisciplinary team decision. Don't take that decision on your own. Um I'm just going to have a look at the chart to see if there are any questions so far. I think um II think you, when you say join, you mean join the questions, the pull or do you mean join the actual presentation? OK. Well, I do, I don't think there are me any questions on there. Um And ma'am, can you just, if you can um I guess if you can, if you can see the slides and you feel that you're in the meeting just uh just say yes or I can hear you or anything, right? I will just continue, I guess. So this is just an algorithm that I tried to make to get my head and your head around symptom management for af um As you can see, this is basically a summary of what the guidelines are set so far. You will find that in clinical practice, you would only need to ask yourself only a very few questions about whether your patient is stable or not, whether you know, the there is room to give them beta blockers or digoxin or not. And, and either they're refractory to both. In which case, you would involve the cardiology team and maybe consider things like amiodarone or DC cardioversion. But here, I think it does look a bit more complex. But for those, if you are quite keen on knowing what the guidelines say, basically, again, if the patient is unstable, you would cardiovert them and in an emergency setting. And the reason why we don't do that in all patients is ESSE essentially because ideally, you need the patient to be anticoagulated for at least three weeks before you can revert them. Because if he the, the consensus is that if you cardiovert them whilst they have an AF which has been there for more than 48 hours, it's likely that they might have uh more time have elapsed for them to form some thrombi in the heart, which would then and might then fire an embolism into the brain if you then cardioverted them and you don't want that to happen, which is why, ideally, if you don't know when that ef started, you would and to graduate the patient first. Um and then cardiovert and then after that, you would anticoagulate afterwards. Um Again, if the onset is um as uncertain, you sort of have the option to rate control or cardiovert. Um, rhythm control could either be done um, pharmacologically with medications, things like amiodarone and fid. Um with flecaine, you have to ideally make sure that your patient has got a structurally normal heart. Um, you don't want to give flecainid in someone with LDS D, for example, in which case, most people would safely use amiodarone because you uh realistically you're not going to grab an echo and do the echo on the patient on admission. And so in the early stages, until you find out you can, you can use amiodarone. But again, that's a med decision or a specialist decision. So, back to our case, um so other considerations with that patient just to try and think about the holistic approach, it's not just treating the rhythm or, or the af um we need to think about reversible causes and one of the famous reversible causes of AF are basically infection. So as a patient has known, af and they are normally uh sort of asymptomatic with it. They didn't even know. And once they get a superimposed infection, they might flip into a and, and at that point, you would want to treat the infection. So you would do an infection screen when I say infection screen, I basically mean asking the patient if they might have any focus of infection. So for example, for the chest, you would ask them if they have any cough and any increased sputum, um or any flu symptoms and for the urine, you would ask them if they have any urine symptoms. Um The famous one that we usually sort of, most of us would overlook would be the skin. Have you got any skin infections? Any skin breaks, ulcers? Um And if you got any sort of diarrhea, which might suggest sort of infective diarrhea as well and dehydration is a good one. obviously signs and symptoms of thyroid um of an overactive thyroid or hyperthy thyroidism. And it think that things that you should ask about in, in patients with tachyarrhythmia. So that patient, if you calculate their curb 65 score, which is the famously and your mo most commonly used score for community acquired pneumonia, they would score two on that, which means that they, they need antibiotics, ideally, oral antibiotics and, and you know, do do a viral respiratory swabs on them, things like COVID flu swabs, uh sputum cultures and, and, and treat the pneumonia. For those of you who mentioned IV furosemide. Yes. Once you stabilize the patient, you're happy with the BP, you've um you know, you've treated the, the fast heart rate, then yes, you, you would give them an IV ball of fur with that chest X ray. Don't have to wait for the echo and part of their breathlessness is definitely driven by their fluid over load, correct the anemia. This is very interesting. Um Probably I didn't get the chance to, to, to um, send you guys some of the literature about um how treating anemia is very, very helpful and is proven to um improve morbidity and mortality in patients with known heart failure. And so if someone is coming to you and they're quite reckless, but they're also anemic and you find out that they have either known or suspected heart failure, please treat the anemia as well. Um, a common thing that we're um we're guilty of is treating that patient starting them on beta blockers and, and you know, sending them home with like five or 10 mg of, of. So for example, and then leaving them at that and then the patient might sometimes flip into bradycardia or bradyarrhythmia. So we don't want that to happen. So make sure that you arrange some sort of full up for them and on discharge. Um within one week of starting the rate control medication, you don't want to leave your patient with a beta blocker or digoxin or both without really reviewing. What was the effect of that medication? Once the infection was treated? Because the patient might flip again to the normal rhythm. The patient might have an already rate controlled af and they might have a baseline heart rate of around 80. And when you gave them that beta blocker, they became 40 or 50. So just to be aware of making that decision to arrange a follow up for them um in terms of follow up, it can happen in primary care. So you can ask the patient to ring their GP within one or two weeks and to get a review. If not, then you can arrange them for an outpatient cardiology for follow up or even an ec followup, which is the same day emergency clinic. Um Just a glimpse about same day emergency clinic is the, it's part of, it's basically a department which is linked to medicine. So you you'll get sort of medical doctors treating patients who can go home the same day as the name suggests. So if you need anyone to be seen, you know, reviewed by a medical doctor, either registrar or an sh um in medicine within one week or two weeks for, for any given reason. And, and obviously there are criteria for that but for, for these patients, they might be suitable for that sort of review as well. So you perfect. Um I like that quote and that says sometimes less is more. Um and you know, it's quite relevant in patients with, with some forms of AF and I guess the question is whether or not to give to rate control everyone with AF um and we'll, we'll speak about that in the coming cases, but be aware of some cases in AF where actually the treatment is not rate control and it's not beta blockers and and beta blockers can be fatal to patients just a making sure that, that you're, you're happy that, that ECG is a genuine AF and making sure that this is the af that you want to treat with beta blockers. So have a look at this ECG, what do you think? Please, please open your results in the chat and I didn't make a pull for that one but you know, just, just in the chat, if that's ok, don't really get a chance. I'm still waiting for you guys to give me any answers on the chart. Yeah, I'll just wait for 30 seconds. No, no idea. No n no one is motivated enough to the message, but fine. So basically, this is, this is a patient with af there is a pose. Absolutely. Absolutely. Thanks from. So, so there is a pose. So that's, that's the, just jumping to, to, to the fact that the main pathology here is that that patient has got a very prolonged pose. And, and when we say a propose, we mean that there is some sort of uh it, it so a period in the, in the contraction and or the period in the um cardiac cycle where there is no sort of effective um contraction uh in short. And you can see that in, in the long lead too, which is the best lead where you can assess the rhythm of the heart. There's a very prolonged pose. And if that patient comes to you um with, with symptoms of syncope or presyncope then you would definitely admit them for a cardiology review. But my question is, would you give that patient a beta blocker? They have af so that, that's an easy view of, of an atrial fibrillation patient. Um But would you give them af yes or no and why, you know, why would you give them, why would you not give them, what are you worried about? Ok. So, so essentially in, in, in these patients, you, they they might have some sort of a if a if a sign sinus node disease and if you gave them beta blocker, you're at risk of simply flipping that into, into heart block. Um or, or a high grade block and, and whi which is really the, the complete opposite of your, what you want. So yes, you want great control. But if the patient has prolonged ps, then rate control here is not the answer. Beta blockers are not the answer that patient needs admission cardiology review. And then they would suggest either medications and or a pacemaker relief. Um Yeah, I wouldn't give beta blocker calcium channel blocker or digoxin and agreed. Yeah, absolutely. And with calcium channel blockers, just be aware of the nondihydropyridine calcium channel blockers. Obviously, you've got two types of calcium channel blockers broadly speaking, you've got the amLODIPine, which doesn't lead to Bradycardia as such. And then you've got your Baril or dilTIAZem and these ba these meds can lead to bradycardia. So they are a big, no. How about that? Eg So what do you think it looks like an af, like an atrial fibrillation? But it's not an atrial fibrillation. This is a flutter. Absolutely. Yeah. Yeah. So this is a flutter with a variable AV block. So, wh the flutter is normally regular. So you would, you know, in, in, in, in normal situations, you would, you would find it easy to differentiate between atrial fibrillation and atrial flutter. And in most cases, they, they, they are more treated the same way, but just be aware of things like atrial flutter with variable conduction block, which means that there are variable conduction of the P wave. So it's not the, the, the block doesn't occur, the avial block doesn't occur at a regular interval in which case. And you know, the patient would have an irregular rhythm which might mimic af obviously, if they're going first, you would still treat about the same just to be aware of the diagnosis itself. How about that? Ecg So you, so you, you know, you, you come into A&E you're just starting your shift um and or, or you're on the ward, you're just starting your, your shift. And then one of the nursing team just, you know, shoved that ECG um on the table and said, look, please, can you sign this ECG what do you think about it? I mean, it looks scary from the outset. Um But I'm not sure if you know, if you, if you get the message from that ECG in general, I do think this is af, yeah, I mean, it does look like flutter but equally, I would, I would have it repeated. Absolutely. So that's the thing if in ECGS see the problem is sometimes they really flip so they, they give you the ECG without a context and, and I, you know, I know how busy it can get and I, I'm kind of in the same boat and, but the, the, the problem with that, if you, if you see the ECG, you'll make a judgment upon the ECG without really correlating with the patient. So if you see that ECG and then you rush to the patient and then they are sat there, the nurse tells you actually they were salbutamol nebulizer, nebulizer, they've just finished and the patient is shaking, they are cold, they've got their top um off and they're, you know, they're very cold and they're shaking and you, you don't want to accept that. ECG, just wait for the patient to calm down. Very famously happens after sotol nebulizers where the patient can get tremors and, and tachycardia and, and, and then that's, you know, that's the worst time that someone can choose to do an ECG on them. Yeah. So, uh so definitely repeat the ECG and II had a patient not long ago and I fell into that trap and I actually, uh you know, was under the verge of starting them on anticoagulation for af and, but then when I repeated the ECG a day later, it was completely fine and, and the patient has just had nebulizer. So just to, just to make sure that your patient is in a state to have a proper ECG. So um thanks everyone for participating. I think, you know, that's great and it gets better as when you, when you drop things in the chat and then the po that's when, you know, we we get the maximum benefit of the session really. So the second case, we've got a 26 year old gentleman, no, post medical history of note, he had a one day history of a fluttery chest, um palpitations feeling faint more than one occasion. Um He hasn't lost consciousness and his Apple watch showed a heart rate of 150 BPM. And, you know, there is a big proportion of patients now, particularly in the young population who would come in just because the Apple watch have um have diagnosed some sort of dysrhythmias, which is quite interesting. Um They have a BP which is stable. We have a heart rate of 190. Um your UIC um chest is clear and, and no murmurs on cardiovascular examination and, and that one, I'm just going to jump a, a big chunk of the history just to get to the workup and, and, and treatment. So what do you think about the workup? What would you want to do for that patient? Um Just reflecting on the case that we've seen earlier, it kind of, it sounds like a similar pattern of presentation and, but however, in a younger patient. Mhm. Let me go to the pool. I will send the link as well. Just give me a second. Ok. Um yeah, so we got, got quite a few. Yeah. OK. Someone, someone said troponin, I mean to be fair, I haven't really um I haven't really mentioned whether the patient has had chest pain or not. Let's assume the patient does not have chest pain with a heart rate of 190. I would be surprised if they had a normal troponin. And again, for the same reason as we talked about troponin, we realistically it would be very difficult to find out whether the troponin is raised because of the ACS or because of the trop leak. The only way to find out is by doing an echo. And if the echo did show some regional wall motion abnormalities, then yes, that's possible monitor for proper acs. And whereas if not, then probably, you know, still the patient could have had an acs which wasn't severe enough to cause regional wall motion abnormalities. So realistically, it's really hard to find out. But my message is, please don't make tests unless they are going to help you answer the clinical question. Not for more questions if that makes sense. So, your thyroid function tests. Um someone wrote II, I'm pretty sure that's a but it said um B12 and D3. I don't uh ECG bloods FBC using these thyroid function test. BM. Yeah, absolutely. We'll talk about the collapse for a couple. I like that. So BM is really important. You need to rule out other causes. Um FBC 12 lead, ECG. Yeah. Troponin chest X ray. ECG full electrolytes, CSH, ECG 12 lead ECG. Brilliant, brilliant. Someone's typing. Yeah. Oh, vitamin B12 and vitamin D3. Fine. Um I go back to the history. Ok. It was 26 chest palpitations. I haven't mentioned the neurological examination but I'm just interested in finding out what maybe a suspect for vitamin B12. Vitamin D deficiency. I am aware that Vitamin D deficiency in severe forms can lead to cardiomyopathy. Um Vitamin B12. Um mainly sort of neuropathy or subacute combined degeneration uh with anemia. Um As far as I'm aware, um I wouldn't jump to do that but it's something that, you know, definitely no one is going to disagree with. I guess it's just not something that I would do as a priority. Ok. So fine. So, so that's the ECG for those of you have asked about the ECG. So what do you think? Um just, just pop in the your answers in the chat? Ok. Still waiting for you guys too. Tell me, what do you think about E CG that E CG on the chart. Do we all agree that this is a no complex tachycardia when we say no complex, it just mean that the patients QR S complex looks really narrow essentially to look at anything less than 0.12 mill. Ok. OK. SVT SVT. Yeah, definitely, definitely. Yeah, that's basically an SVT and it can be a bit confusing between SVT and AF in some situations. I mean that that is an ideal ECG, but there's been situations where really the P wave is hidden within the QR S complex because of how frequently it happens. And so, so in that situation, it might be hard to find out the difference. These are the bloods for those of you who asked for the bloods and, and you know, we talked about the TSH and I can see that you guys have requested some um and your calcium magnesium. So you still do all your arrhythmia bloods. And we'll establish that as we go along and you've got your full blood count and your sodium, potassium, your urine electrolytes in general. And then you've got the magnesium and calcium, which is quite important and TSH and all, all of them are looking perfectly fine. So what's your diagnosis? Because you've already mentioned that your diagnosis is SVT. Um And I agree with you. So this is basically symptomatic tachyarrhythmia secondary to neuro complex tachycardia, which is SVT. So what's your next step? What would you do next? Um Again, QR code, I'm gonna send a link. I hope you guys are not fed up. So now we think this is an SVT, what would you do? I'm just sending the link, you find the link and the QR code is in the bottom right end of the screen. Ok. Iine carotid massage, bagel maneuvers, loo, living reflex. I like that. Ok. It was a we maneuvers. So can you elaborate more on what maneuvers would you want to do? Um, I'm not sure if the poll gives you the chance to actually type your answer twice. But what describe what you would do if, if you guys, um, if you want or if you want vagal maneuvers, if unsuccessful administer adenosine if unstable DC cor diversion. That's quite, yeah, that's, that's quite awesome. It's over course it sinus massage. Ok. Yeah. Um Absolutely. Absolutely. So, so, um, so any assessment, um I know that we did that already but assuming that the patient is quite unwell, don't forget assessing and reassessing. Yeah. Vagal moves. So we've got the modified Valsalva and we'll talk about it and in, in some of the patients, it does help a lot. And um in terms of the carotid massage, theoretically, it does help and haven't found much about it in the literature in terms of how effective it is, could be helpful. Um, the risk of dislodging a sort of AAA plaque in the carotid arteries is theoretically theoretically exists. But, I mean, in real life, it's, it's rare. Um So yeah, that, that could be an option. Um something which is commonly done um in the UK as well in, in A&E setting and is, is the modified will. So, and I'll, I'll show you AAA video um about it and as we go along, adenosine. So for those of you who mentioned adenosine, you can try adenosine six and then 12 and then 18 mg, you've got you, you can try adenosine up to three times. This is all I assuming that your patient is hemodynamically stable and we've defined that in numbers and in symptoms before and by now, I think you would probably think or picture how an unstable patient might look like and in which case you would call you straight away. Um So I'm just going to play that video but I think someone talked about the diving reflex. So I'm just going to play that video. So just pop in the chart if you can hear anything in the video. No. Oh OK. So you can only see but you cannot hear. All right. Um Well, I'm not sure how to fix that. I can uh just copy, paste the link. I imagine everyone else are unable to sort of hear the video. Fine. I just the presentation, stop sharing and it and fine. So I'm just going to mhm Just give me a second and presenting a window. Mm And if you guys can just pop on the chart if he can hear anything. No, no sound. So it's a shame. Fine. So that's fine. That takes us to. So, so that video is from the uh renowned TV series. Um uh I will look at that um from the TV series um er um and it basically talks about someone um with um an SVT. Um and then they sort of did that sort of diving reflex thing, uh which takes us to the second video. You don't need the sound for the second video. So I'm hoping I could just chat through it. And that basically is a more serious video that talks about what you should do. Um If a patient came and hemodynamically stable with SVT, does that mean that there's no sound at all? You can't even hear me. Oh, we can hear you. OK, perfect. Thanks Rana. Perfect. Sorry guys. Um um My tech is not really great, so fine. So let's start the video. So you shouldn't need any sound for that. That's fine. So this is someone who's got an SVT on the, on the monitor as you can see. Um it's going to actually stop the side, so I don't distract myself and you can see. So, so let's uh let's just go back. So what, what they are doing now is that they are giving the patient a 10 mile syringe and they're asking the patient to blow into that syringe all the way until the plunger is literally out. OK. So the patient is blowing, blowing, blowing in the, in the syringe as you can see. And then at the same time, what they are doing is that they are flipping the patient's legs up. Quite interesting. And then the patient is still blowing. So ideally, patient blows for 15 seconds, legs up for 15 seconds. And then you, you just um wait for the rhythm to come back essentially. Um And because we've got this video on the internet, that was a successful attempt. So you can see that the patient magically just flipped into sinus after that maneuver. And then he can tell that I'm glad there are subtitles there. He can tell that um He's actually, he felt it slow down. OK, let's repeat the EKG fine. So, so as you can see that someone who's had a modified Vasso for SVT quite common to find that done in A&E quite satisfying if you did it and it actually worked. I did it on three patients and unfortunately, it failed and we ended up giving them adenosine which, which then fixed them. And so, so yeah, just be aware that again, adenosine is one of those medications which can lead to bronchospasm. So if your patient has got CVS or COPD, um you, you would give them a instead and of adenosine. Um So just to let you know, um so I'm just going to go through your next slide. That's the third case. Um We would have a short break after the third case, I don't want to burn you guys out. So, um I hope that was useful so far. So the third case, you've got a 78 year old lady collapsed today in church. She fell backwards, unsure if she hit her head briefly blacked out. That's her third episode in a few months. She's known af this time and she's got CO PD, she's hypertensive and she's been to A&E before and you know, on the, on the online systems and the pr you would normally have a look at the previous attendance. It's very helpful to look at the scanned notes, scanned ecgs. She had one attendance with Bradycardia and then an attendance with an AF with a forced AF RVR is rapid ventricular response, which basically means that the patient has got forced af with a heart rate of 136 BPM. You can imagine at that point, she was started on beta blockers anticoagulated. So if you look at her medication history, I was usually on the COPD inhalers. She's on Ramipril, she's on Ther and Aaban social history um are quite big on social history and I'll tell you why. And as we go along in the slides, basically, she lives alone in a semi-detached house. No package of care. Are you? No carers will help her with, with her daily activities. PA DL stands for personal ADLs. So ADL is essentially activities of daily living. And it's a term that's commonly used here in the UK. For those of you haven't worked here yet. It basically means the activities that people would do on a daily basis. So things like um, washing, cooking, shopping and personal ADL S, things like showering and, you know, self care and like if they need support to the toilet, for example. And so you would normally find that sort of acron of pee ADL S for personal activities of daily living and P OC is package of care essentially. And obviously, some people struggle living on their own without help. And so they would hire carers either privately or by the social services, which I imagine could also be paid at times. I don't know the exact details, but different carers do different things and some carers would only help with things like um cooking, some carers would help with medications and or both. So these are all things you need to ask your patient to try and make sure that they are safe at home when you plan to discharge them, she eats microwave food, so does the shopping. So you, you know, you've had a, an, a grip on on her own home situation. She struggles with the chair, she stairs, she's got an upstairs bathroom but she's still breathless. She can't really go to the bathroom immobilizes with a walking stick. We talked about the et which stands for exercise tolerance and, and it's been worse recently. So that gives you an idea as well about what's happening. She's an exsmoker and she occasionally drinks alcohol. So you look at her and again, she's stable and then her heart rate is 38 BPM, which is quite worrying. Really? So you're looking at a heart rate of around 60 to 100 that's quite low. A assessment again, basic, you know, go ABCD E her main issue really is in the C and chest is clear. She thought it was unremarkable. You sort of have a look, just, just make sure you with this, particularly with elderly patients who has had a fall, make sure that they don't have any external injuries, make sure you palpate the spine for any spinal tenderness, which might indicate a spinal fracture and can be subtle in these patients work. So, um I don't think I did a QR code for that one, but please please tell me what you would want to do with her. No, no P no QR code just um just the chat for a change, I think right now, 99.9% of the answers on the previous cases were absolutely right. So, um I'm, I'm quite tempted to see what you think about that case because I don't think, you know, anything can go wrong by just typing in what you think. So, I had a lady who had a collapse. Let's go back. Had a lady had a collapse. There's no one af what would you do? Ok. I'm sure some of you might be typing. I need CT scan. Yes. Yeah. Had CT scan. Absolutely. Absolutely. Interesting. Ok. Does anyone disagree with that? Does he, do you have CT head and standing medicine compliance check? Ok. Are you worried about compliance or, or would you be happy if she's noncompliant? Um, so let's go back to the meds. So she's, she's got a heart rate of 38. She was started on beta blockers on her last attendance. The one where, where she had the AF, with, with the first AF called anticoag. Ok. Yeah, absolutely. Why do you want to hold it in case of a head bleed? Yeah. Just thinking ahead. Absolutely. Absolutely brilliant. Yeah, exactly. Ambulatory BP. Standing and sitting um E ECG as well. Ok. Yeah, absolutely. Yeah. Good one. That's the ECG for those of you who thought about ECG. So what do you think? It, it's a bit of a com I wouldn't say a complicated ECG, but it's just that there is, there is a more than one thing going on. So let's ask ourselves. So again, back to the basic, I don't want to jump to conclusions with ecgs because I usually get them wrong and I'm not an ECG guru. So I'm not going to pretend I know everything about ECG. So is this a sinus rhythm? Yes or No. Do you think this is sinus? Just type a yes or no. You proper p waves on there. Just wait for me. No. Yeah. Yeah, exactly. So, the patient is in af duration is an A, but she flipped, she basically flipped into slow A and I think, I think at that point she's ex extremely Bradycor. She's going with a very slow air, that lady. And, yeah, absolutely. So, that's one thing that you wouldn't do is maybe something to do with her beta blocker. So that's one case where we talked about less is more sometimes. And why we think that if we discharge someone with a rate control medication, particularly if it's a new af or presumably new af, please get them to be reviewed promptly. These are the bloods. So she's slightly hypomagnesemic. But other than that, she's fine diagnosis. So essentially if we wrote a problem list for that lady. And so, you know, if, if you, if you work in the NHS or in the UK, one thing that they are quite big about is being organized and having that organized thought process. And from a medical point of view, the patient would have a problem list. Not just one thing going on, you have more than one thing going on. Um First thing here is she had a collapse and that collapse was secondary to bradyarrhythmia and that Brady arrhythmia is that she had a slow air. Second thing she's mildly hypomagnesemic and the third thing and I think some of you have mentioned that we need to rule out an intracranial bleed. And that lady she had a fall and she's an oral antic. Ok? Now, if you want to just scan that QR code, I'll send you a link as well and tell me how would you treat that patient with these problems in mind? Mm, I'm waiting for uh ulcers literally anything. And I think again, so far I haven't had any answers which are away from what we're talking about. So please please tell me your thoughts. Pacemaker. Ok, let's say that this uh lady came in to you at 2 a.m. on a night shift. What would you do? Medication review for rate control? Ok. I'm not going to say the answers. I'm not, I I'm just going to wait until you guys tell me your thoughts. Ok. Mhm. Interesting. Any more for any more? I mean I've, I've left the problem list in here. So you know, management also entails that if you need to, if you need to do any more imaging or any more tests, you know, please drop them down. So management is sort of workup plus treatment kind of thing. So ID, I don't know who's voting, but I've only got three people who voted and I'm pretty sure that we've got more than that. Ok. Keep them coming. Ok. Ok. So I'll just make it visible for everyone if you're still on the page. So some of you mentioned about the pacemaker, that's sort of definitive treatment. But if the patient, you know that situation where you're, you're in the in the middle of, of nowhere and you know, if you don't have the capacity or the the team who could put a pacemaker overnight, and that's quite, you know, the norm, what would you do medication review for rate control? So you would want to stop beta blockers from the outset, just stop, just don't take them and just hope that the patient is not compliant with them. Sorry. And and then oral withhold, oral anticoagulation, atropine could be an option. And in most cases, if you, if you work on a medical tape, you would find that the A&E team would give the patient a bolus of atropine even before speaking to you about that patient. And so it, it, it sometimes given very quickly and it acts within very few minutes like 5 to 10 minutes. So you would, most people would um would actually respond to that external pacing with analgesia is quite, quite specialized. Um Or I would say it's something that I would want to pick up the phone and speak to the cardiology consultant about before doing um it it is a a good bridge um whilst patients get their pacemaker are agreed. And if the patient has got very prolonged pauses or slipped into asystole, and I would, I would do external of course, if they flipped into asystole, that's a cardiac arrest. But if they are at risk of asystole, then, yeah. Um, I would think about that, but I would, um, I would speak with a cardiology consultant about it, vasopressors. Would you specify which vasopressor? Um, but yeah, I mean, that's an option. CT scan for the head, head, CT scan and an echo again, echo is something that could be done in hours if that patient came over a weekend or at 2 a.m. in the morning. And II wouldn't do an echo, but I, yes, you would definitely book them for an echo. And I want to find out, I want that echo before the pacemaker to find the LV function because that's where they place the leads of the pacemaker. And, and I want to find out if they have an ischemic um pathology that's led to, to their bradyarrhythmia. And absolutely, I would avoid the vasopressors mentioned. Ok, 24 hour monitor. Yes. So you definitely keep that patient on telemetry. Absolutely interesting. So, treatment again, take a step back. Look at the patient from the end of the bed. Is that patient is a risk of having an asystole, is he or she bradycardic to the extent that I'm worried they might flip into asystole ie they might arrest or not. We'll talk about how to make that judgment. And I've taken a snippet of the A OS protocol which I really like about um Brady arrhythmias definitely involves the med reg definitely that you or the med reg will ring ICU, you need to, you know, gather the whole team around and that patient is about to become very popular. Um, you need that patient, um, on monitored back ideally in Rhesus, um, that's their whereabouts in, in A&E and you, plus your mind is attaching their, their defib pads. And again, you know, you would use the res only in a cardiac arrest. But it's quite common practice that if the patient is at risk of flipping into l hoses or a, so just on the pads and in, in preparation for transcutaneous pacing, um, which I don't want to go into with details because someone mentioned about external pacing with analgesia and it's just basically taking control of the heart rhythm until they get a pacemaker until they get AAA proper sort of pacing. And, um, but I'm not going to go do that down that route because it's very specialized. Um IV atropine. So someone mentioned about a atropine. So the A S protocol says give 500 marks can be repeated up to three times in most cases quite effective. And the problem is it lasts for only a very few and it's very, very little time and, and the patient can flip back isopril infusion in the trust where I work. It's the common practice. Different trusts use different and um medications uh to treat brady arrhythmias. Um But in my trust, you use isopreno. And so I'm just going to take that with a pinch of salt if I were you um temporary pacing, permanent pacemaker. The reason why I meant II put that arrow there is that as you go down, it gets more specialized, you would need to involve your cardiology consultant. Um So the temporary pacing is basically trying to regulate the rhythm of the heart and trying to stimulate a contraction. Um either transcutaneously by using the pads and the defibrillator machine or transvenous and, and via sort of putting a temporary pacing wire in the heart until the patient gets their permanent pacemaker. These two procedures don't come without their complications and the transcutaneous pacing is very, very temporary. It's something that you could use for, you know, very little time until the cardiology consultant would ideally come in and put a pa pacing wire or a pacemaker in that patient. Um This is the A LS protocol. Um So I guess the question is um either the um patient patients with bradycardia, whether they're at risk of systole or not. Um So patients at risk of systole. So you've got either recent asystole, a patient with a two AV block, complete heart block with a QR S interval or a very prolonged ventricular p or looking at a pose of more than three seconds. So these are your red flagged or high risk patients really? So how you treat the bradycardia? So, that patient again is hemodynamically stable. I wouldn't rush to give them isoprenaline. I wouldn't rush to give them, um, um, you know, these type of medications or a pacing. Why? Or even, you know, do, do any form of escalation now because their BP is fine. I know their heart rate is quite on the lower side. I would definitely keep them on a monitor. I would definitely keep them in r research or in a monitored. But um I would stop the beta blockers. Be aware that it can take up to 2 to 3 days for the for the effect of the beta blockers to wear off. Obviously, correct the hypomagnesemia as well. So if there is any electrolyte derangement or any reversible causes, correct, that just a bit about isoprenaline, you know, we, we do, the only thing you need to know is that that medication is basically a beta agonist and it, it, it induces it, it basically is used in patients with a high grade A V block and or brady arrhythmias in general. It's used titrated based on the BP and the heart rate and, and you would only start them. And the nurses are quite aware to try and up titrate that in some hospitals. It's um mainly used in ICU and other hospitals. It can be used in the Coronary care unit. So it really depends on where you work, be where they can lead to tachy arrhythmias as Well, so back to our patients. What other considerations would you think of? So that's the last thing I'm going to discuss hopefully before we get to the break because I am aware that you guys um mu must uh must be due for a break. Now, what other things would you consider with that patient for the sake of time? I'll just uh I'll just go ahead. So CT head, we talked about a CT head. It is important in that patient and we'll discuss the guidance behind it. VT prophylaxis. Um We'll talk about VT prophylaxis and what, what it actually means. I think it's more relevant for those if you haven't worked in the NHS yet. Um But, but essentially it, something that you need to think about about that patient. Um It's basically, it's some sort of anticoagulation or an antiplatelet or some sort of a blood thinner that we give the patient whilst they are staying in hospital to try and prevent harm and prevent them from having venous thromboembolism by that. I mean, something like a DVT or a PE um in that patient, they were already on Apixaban. So I would hold that Apixaban until the CT head is back, the report is back and it ruled out a bleed. Um that patient is struggling at home and I'm noticing that whilst you, you guys have, have you, you've been brilliant trying to advise about medications and stuff, but just thinking about the next step, thinking about whether that patient would be managed at home when we we discharge her. And the answer is no, that patient would need OT which is occupational therapy and PT which is physiotherapy review. Also, more is social input physiotherapy are basically a team of uh specialized um practitioners who would look at the patient's mobility and functional status, try and give the patient some walking aids, try and do some exercises for the patient to try and help them walk and usually within the hospital setting. And if there are any concerns from that perspective, they would then liaise with the occupational therapist who basically go into the house, have a look, see if there are any stairs, if there are any um anything that they can help with or any modifications to, to the, to the home setting that they, they could do to try and help the patient manage themselves at home. A good example would be things like stairlifts rails to try and prevent them from falling and something like um specialized uh rails in the shower. Things like that family involvement. You would want to speak to the family of that patient again. Assuming they came to you at 2 a.m. in the morning, we'd want to update that family is actually the patient is quite unwell. They have a um severe of dysrhythmia or an irregular rhythm to their heart and it's quite slow and they might deteriorate, but we'll try and do the best we can to try and um that in a timely manner, speak to them about the involvement with the cardiology team, speak to them about all these things, try to involve the family. Last thing you want is the family being surprised about the fact that their loved ones have arrested in hospital and they were just chatting to them before they left. So just keep them involved throughout the patient's admission and guidance about when to scan ahead. I'm not going to go through the guidance in detail. I'll leave you the link at the end of the stroke. I want you to know is that anyone who is taking any antiplatelet apart from aspirin or any anticoagulant who had a fall needs to have their head scanned within eight hours and the scan needs to be urgent. And if the patient is on these antiplatelets, for example, clopidogrel or tag, hold that until the patient's head is scanned and, and, and, and obviously they have to have some sort of loss of consciousness or a media since the head injury um as well. Well, confident confidentiality, comment, picture during family involvement. That's a very good question. Um I guess um you would, you would want to tell the patient. So what I normally do when I see the patient, if they have capacity, if they, if they are not confused, if they can, if they can speak to me, I would tell them at the end of our talk at the end of the history taking an examination. Are you happy for me to contact your next of kin and update them about your condition? If they say yes, then yes, I would do that. And on very rare occasions, we've been on not to discuss um things with the next of kin and if, if there are some complex family dynamics. Um So yeah, I agree with you. We would ideally ask the patient if the patient is too unwell or confused, I would make that decision. I would want to involve their family or their next of kin and to let them know. And if, if the patient is not able to make that decision for themselves, because if the patient does arrest, I would want to, I would call the next of kin anyway. So I would want to involve them early on unless the patient has got anything written or documented that they again don't want the next of kin to know and which I've only seen once in an end of life patient. Um And, and unfortunately, it's, it's one very complex situation. You don't need it a lot. But yeah, that's a very good point back to our topic. So, um um you know, that's the guidance of the, of the uh no CS about when to scan it, when to do a head scan. Quite helpful. If you're in an argument with the radiologist or the radiographers about why, why you want to scan that patient's head. And if the, if, if the patient is in doubt about whether they lost consciousness um and the oral anticoagulations or, and blood thinner or sorry, blood antiplatelet, apart from aspirin monotherapy, then you would do a head scan. Um This is a very good uh chart that basically talks about the um how to assess an elderly patient because in the UK, a lot of patients, a very huge proportion are above 60 years of age. And the geriatric population here is, is quite, quite a significant proportion and you need to try and think broadly. So you could see that in your assessment, the physical bit is just one pillar. You have the socioeconomic, the environmental state of the patient, the functional status of the patient, their mobility and balance their mental state or function and their medications and you have to assess all of that. Um And as we said, you have to create a problem list and tailor your treatment plan based on that patient's needs not just treat the af or the infection, you have to think about how they are like at home and where they need support. Last thing you want is that that patient goes home, struggling to walk and then she comes in next day with a brain bleed because of a fall down the stairs, for example, or a spinal fracture. You don't want these things to happen. So just think broadly and um the social history is as important as your hi history of presenting. Um This is called a Comprehensive Geriatric Assessment Toolkit. Um It's um designed by the Royal College of uh sorry, the, the Society of um um Geriatricians and I've put the link in there um as well as it's quite helpful for you to think broadly when seeing a geriatric patient in the A&E or, or under the medical tape, start the chain of action. And don't think that I'm too junior to make decisions about, you know, whether they need social care or whether they need ot pt, please put that in your plan early on. Don't wait for the consultant to make that plan. Uh Some of the consultants, you know, would, would obviously think about that um early on, but you get different scope of, of consultants on the take and it wouldn't be much easier if you start that plan early on. And if you get the physiotherapy team to see them early on. So put that in your plan, think about it um as, as early as you can when you're clerking or seeing a patient um either in A&E or, or under the medical team. Um I'm going to probably take a short break here. I'm not sure what you guys think and I just think it might ii did lots of talking, I feel that you guys might, might be fed up at that point. So, uh I'm just going to take a short break. 10 minutes shall we say? And then I'll come back. I'll just type in that message in the group as well. Um To make sure that everyone is aware about the ten-minute break. I hope that was useful so far and I'll see you all in 10 minutes in the meantime. Um II know this is a bit overdue, but I'm going to send you guys a link, um, which might be helpful, um, to, to try and gauge your ideas about the, the topic. So I'll, uh, I'll just leave it on the chat and I ideally you should have said that at the beginning. But if you're happy to fill it now, that would be great and see you guys in 10 minutes.