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Mhm. Hi, everyone. Um, hope you've had a good day. Um, I'm Vani. I'm one of the session hosts for today. If people can hear me, can they please say something in the chart? Yeah. Ok. What did he play with? Oh, and talk again. We'll also wait for a few minutes. Perfect. Thanks. We'll also wait for a few minutes. We'll start a free pass just so that, um, some more people come along. Um, and then I will pass the stage on to a, about a three puffs. Sounds good. Mhm. And. Mhm. Ok. So we've had a few more people join. I guess we'll get started just because we don't want to, um, run too late. So, hi guys. Thanks for coming to the palpitation session. Um, there's gonna be the teaching for 40 minutes and then afterwards we're gonna have a practice in the breakout room. So please do stay for that, really helpful um, to go through sort of cases and, um, learn how to do them in a style. Um, I'll be monitoring the chart. So if anyone has any questions then feel free to put them in there. But our will to be monitoring the chat, so I'll um leave it to you a well, thank you very much. So, yeah. Hi guys, I'm Aaron. Um, I'm 1/5 year medic from Manchester and today we're gonna be talking about palpitations and arrhythmias. Um I'll try and make it as interactive as possible. So if you could type your answers in the chat and things like that, that would be great. Um I have made this slide show slightly too long. Um So I'm gonna skip through some things, but hopefully cos palpitations is massive, but hopefully we'll get as much of it done as possible. Just checking. Can you all hear me? OK, we'll go with the silences. A yes. OK. Cool. Awesome cheers. Right. OK. So content, we'll skip through that basically with palpitation histories. Um Sorry with palpitations. What kind of osk stations might you get? So, number one, probably the most common is gonna be take a palpitation history and then from that produce differentials produce a management plan, you might get a mixed station. So it might be take a four minute history and then ecg interpretations and come up with a diagnosis and then in terms of you've got explanation stations. So explain the diagnosis of atrial fibrillation and S VT and then also counsel a patient who is due to start a Doac um such as Apixaban or someone who's due to start Warfarin. Um Unfortunately, we won't be able to cover, cover three and four today, we'll just touch on it. Ok. Cool. So, first of all, kind of what are palpitations? Could you just chuck in the chat very quickly? What kind, what are palpitations? Cos I know it's some kind of a definition that I sometimes got confused on. Yeah. So, palpitations is kind of, it's the definitions even more simpler and I took it from the NHS website. So, palpitations are when your heartbeat becomes more noticeable. So when we're talking to patients, it's just making sure that they kind of describe that and a heartbeat becoming more noticeable, can feel like thumping in your chest. It can be a faster heartbeat, it can be a slower heartbeat and then palpitations are a symptom of arrhythmia. I forgot that there were no transitions. So, um other symptoms of arrhythmias um could include all of the following. So, chest pain or chest discomfort, shortness of breath or dyspnea, dizziness or lightheadedness. And then we can also have fatigue, anxiety, sweating and syncope. So that's loss of consciousness. Um It's also important to consider that sometimes arrhythmias can actually be an incidental finding. So sometimes when a patient's admitted to hospital might find out that they've got fast af or when we're taking a manual BP, you can sometimes hear that irregular heartbeat. Um Yeah. So can anyone think of any risk factors of arrhythmias or palpitations and there's loads. So, chances are, if you chuck something in the group in the chat it'll probably be right. So, if you could just do that for a minute quickly. Ok. Yeah. Great hypertension is one of them. So any other health conditions that might cause? Yeah, heart failure. Awesome. Keep them coming. Keep on coming. There's loads and then we'll go through some of them. Yeah. Great. Myocardial infarction. Awesome. Any so when we're thinking about it? Yeah. Good. So when we're thinking about it, great. Keep going, I'll give it another minute. Caffeine. Nice, cool. Ok, we got loads, there are loads more but well done everyone. So I'll kind of split it up into modifiable, non modifiable and health conditions. So firstly, we'll go through modifiable and these are important things that you wanna be considering in your history. If they're mentioning they get palpitations you want to ask about kind of these things because then that's something that we can tell them to stop and then hopefully that will make the palpitations or the arrhythmia go away. So I've gone for smoking infection, high caffeine intake, high alcohol intake, illicit drugs, especially our stimulants. So we've got like cocaine and amphetamines then being obese or overweight diet. So specifically in diet, there's a couple of things we've got um high fat intake and then we've also got low carbohydrate intake. I'm not particularly sure why, but those are risk factors for it. Um, rapid weight loss, dehydration is another important one, especially when you're seeing patients on the ward and then medications again. There's loads. Um, but some of the common ones are kind of antiarrhythmics and while that seems counterintuitive, sometimes giving people antiarrhythmics can cause another arrhythmia or it can sometimes make, um, their current arrhythmia a little bit worse. Um, cos they're not particularly lovely drugs, antibiotics. So, kind of, we're thinking about like Clarithromycin and things like that. Uh, tricyclic antidepressants, various other antidepressants, levothyroxine. The list is huge. Um, so when you're seeing someone on the wards, er or in GP, just kind of consider what drugs they're on and look on the B NF at any of them causing the palpitations, non modifiable. So you've got age. So the older you are, the kind of poorer your electrical conductive system in the heart is. Um so that's going to mean that we're more likely to get an arrhythmia ethnicity. So, Caucasian people are more likely to get atrial fibrillation, but people of Afro Carribean descendants are more likely to die from atrial fibrillation family history. So, if there's any congenital cardiac conditions that run in the family, so if someone comes in to your clinic and they say I've had palpitations and loss of consciousness and my dad died at the age of 40 of a sudden heart attack, then alarm bells should be ringing because you think there's some sort of heart condition going on there and then congenital cardiac conditions like tetralogy of falling health conditions. So basically any heart condition can increase the risk of an arrhythmia forming. Um So structural heart conditions, valvular heart conditions, heart failure, ischemic heart conditions, and then like hypertension, other ones, hyper and hypothyroidism. So, they're quite common and we need to be considering them whenever we're taking a history. Um and uh examining them and then diabetes, kidney disease, pregnancy is another common one anemia, which was mentioned and electrolyte imbalances cool. We're doing great. Ok. So together or I'll quickly run through kind of questions that I want to be thinking about when I'm taking a history for palpitations. Cos there is a lot and I think when you look at this, it can be quite overwhelming. But if you kind of stick to that this sort of structure, then um taking a history can be OK. Um So starting with Socrates, it's not as useful as it is in pain, but there's still some things I want to point out. So sight of the palpitations while it might seem like you're silly asking them, where are the palpitations? It is useful for them to sometimes point to it because the general public's anatomy is not always the best. And my friend asked me whereabouts is the bladder and kind of pointed to his left hip the other day. So kind of just making sure that you're confirming that it is in the right location. Um, onset kind of when does it come on? And if they're like, oh yeah, it comes on in the morning after I've had four cups of caffeine, then you're kind of already on to a winner character. Kind of, you could ask, how long does it last? Um, how bad is it? Does it radiate anywhere? Maybe not the most useful. Um, and then associated symptoms. So this is where we can get in like a chest pain, breathlessness. We can get in kind of any loss of consciousness here. And it's important when we're in our Aussies to not just say, have you got any other symptoms associated with this? It's important to show the examiner that, you know, kind of what specific risks you're looking for. So I would be considering chest pain, breathlessness, anxiety, sweating in the associated symptoms, time frame. How long has it been going on for? Has it been getting worse? Has it been getting better? And they might say, oh, yeah, it's ever since I've got a new job and I've been feeling really stressed. Um and then exacerbating alleviating factors. Um and then severity. So when you get it, how bad is it? And then you just want to wrap up your kind of Socrates with any other relevant histories within the presenting complaint, but then kind of the important things then is asking a complete cardiovascular history. So how far can you walk? Do you have P and D or son? Do you ever get any chest pain um or anything like that? And then thyroid questions. So, uh thyroid questions that we're considering are kind of any recent weight loss or weight gain. Have you been sleeping? Well, have you been feeling anxious? Have you noticed any skin or hair changes? Um, have you been going to the toilet and have you been having diarrhea? Um, so those are the sorts of questions that I quickly want to be asking when I'm considering a kind of thyroid history in terms of palpitations. So next one, past medical history, past surgical history, while I'm talking about past medical history, can anyone think of any relevant surgeries that we want to be considering when we're taking this sort of history? Can you just pop that in the chat? So in terms of past medical history, we are thinking about kind of what we talked about on the previous slide. Um, so kind of all of those kind of conditions there. And again, when I'm in the exam, I wanna be asking a couple of specific past medical histories so that I'm showing the examiner, I know what the risk factors are here. So I wanna be asking about heart conditions in particular, I wanna ask about thyroid and then I wanna be asking about like hypertension and diabetes cos I think as well. It's useful on the ward to ask specific questions. Cos I often ask patients, do you have any past medical conditions? They'll go no. And then I'll say what medications are you on? And they'll give me a list of 10 medications. So it's useful to kind of show the specifics. So no point anything in the chat. But in terms of past surgical history, there's kind of two I'm thinking of and that's the thyroid and that's any previous cardiac surgery. Um, and then medications again, relating to kind of the stuff we talked about previously, family history. Again, we're thinking about kind of cardiac conditions and thyroid conditions. There are main ones that we want to be considering. And again, in the exam, I would be asking the patient, do you have any history of heart conditions? Do you have any history of thyroid conditions and then broaden it out to um to l like b more broad conditions um lifestyle really important. So here we just wanna make sure we're asking about diet. We'll always normally ask about alcohol and smoking intake, but it's important here to ask about illicit drugs. Um And then also something that I often forget is caffeine. So caffeine is a big risk factor for it and make sure that we're not forgetting our caffeine. And don't just necessarily say caffeine say, how many teas do you drink a day? How many coffees do you drink a day? Do you drink Red Bull or anything like that? Cool. Am I going at an ok pace for everyone? I hope so. So once we've done our history, we're gonna want to do our examination. So if we're talking about palpitations history, it's, we're gonna wanna do a cardiovascular exam and I've kind of just written out on the next slide, some things that we might want to look out for on that. So, nails and in the exam, as long as we back up while we're doing things for. So, for example, with nails and splinter hemorrhages, infective people with infective endocarditis who have splinter hemorrhages, they're presenting complaint isn't necessarily gonna be palpitations. But if you say in the exam, I understand that in fact of endocarditis is a risk factor for um palpitations and arrhythmias, then you're still gonna get the marks on that and you should look like you know what you're doing and then clubbing for congenital heart conditions and then cinch. So when we go into the hands, we're gonna wanna kind of be assessing a capillary refill. Is the patient septic um radial pulses? What's their rate and rhythm like? Is their rhythm regular? Have they got a tachycardia, radio, radial delay and radio femoral delay. And then we're also gonna wanna be looking at things like tar staining and xantha mater. So I had a net J BP raised for heart failure going on to palpate the carotids and then looking for like XR asthma and all those other things palpate. Apex B. Is there any uh cardiomegaly thrills and heaves and then auscultate just for evidence of valvular pathologies as these are a big risk factor for lots of the arrhythmias and then considered dynamic maneuvers and auscultate the lungs. And then also we might want to consider er evidence of DVT. So just have a quick squeeze of the calves. And then is there any evidence of peripheral or sacral edema? Um consider a hy hydration status exam as well and take other basic observations. So just a side note whenever we finished our examination and they say, what further things would you like to do? Always say a full set of observations. Um, in the context of palpitations, we just want to make sure that they're not incredibly tachycardic. Um Are they septic? Have they got a temperature? All those kind of things called? Um I'm gonna skip through this just because we do not have too much time. Um But other exams you might want to do is kind of thyroid exam. Um And then neurological exam, if they mention weakness when they get the palpitations and then ent exam if they mention dizziness and especially when we're taking the history, it's important sometimes to kind of differentiate between dizziness and lightheadedness. Um, cos they can have very different differential diagnosis. Ok. Investigations. Um Let's start with bloods. Could people in the chat quickly talk about what bloods they wanna do and back up why they'd wanna do those bloods. So as long as you back it up, there's no wrong answer. Great. Yeah. And nice using these for electrolyte imbalances. Awesome. Any other bloods we'd want to do perfect. Yeah. Great. Cool. So, you've got quite a few bloods. So, once we've done our bloods, they've come back. Is there any other imaging or tests that we might want to do or consider chat them in the chat four? Yeah. Great. Mhm. Cool. Ok. We will move on. So, I've written some of the investigations that we might want to do here. So, full blood count for anemia and infection, usually these also wanna consider magnesium if we are suspecting on electrolyte imbalances, bone profile for calcium thyroid function as we talked about for induced af um cholesterol. Um if we're suspecting kind of ischemic heart disease and then other kind of cardiac ones that we might wanna consider as B MP drops and then ad dimer if we're suspecting a PE. So we mentioned E CG if the patient's saying I only get it for about 10 seconds once a day, we're probably not gonna be able to catch it on a 12th rhythm strip when they're at the GP. So something we might also want to consider is a 24 hour holter monitor. So this basically just takes an ECG for 24 hours and tries to catch any of the palpitations that the patient's having. Um OK, imaging. So then chest X ray, cardiac related cheap and easy. You never, they're never gonna mark you down for saying that if we're suspecting there's a structural heart problem, then an echocardiogram is also useful and if we're suspecting APA A C TPA, um if we're in the GP, we also need to be thinking is the patient well enough for them to get bloods next week and then an E CG or do they need to be seen in A&E quite acutely? And then also if we're suspecting something bad, does this patient need to be referred to cardiology? Cool. So let's move on to EC GS. So what are the actual arrhythmias basically? Um Am I getting at an ok pace for everyone? Sorry, I know there's quite a lot to cover. Um And does anyone have any questions so far? Well, I'll wait for people to type in the chat. I'll just talk about it. So narrow complex tachycardia. So when I talk about narrow complex tachycardia, I'm talking tachycardia's heart rate over 100 BPM. And then the narrow complex comes from the QR S which is uh less than three small squares on the rhythm strip or less than naught 0.12 seconds. Um There's four differential diagnosis when anyone mentions to you um a narrow complex tachycardia. So that can be useful on your written exams if they don't give you an E CG. But if they mention to you an irregular, irregular, irregularly, irregular, narrow complex tachycardia, then the diagnosis is most likely gonna be atrial fibrillation, four complex tachycardias, there's three of them, then we'll quickly talk about QT prolongation, heart blocks. And unfortunately, there's not gonna be time for ventricular topics if you're struggling on this as well, I would strongly recommend going on to zero finals. They've got a great, um, 20 minute video on or 20 minute, um, talk on all of the arrhythmias. I'm gonna quickly try and do that as well. Cool, so narrow complex tachycardias. There's four of them. We've got sinus tachycardia, which isn't technically um uh palpitation or arrhythmia. But, um, it's one of our four differentials for the narrow complex atrial fibrillation, supraventricular tachycardia and atrial flutter. And we'll just talk quickly, we'll have a look at those and talk about the management for each of them. Ok. So can people look on here and tell me which of the four diagnosis they think this is? I think it might look like there's a bit of ST elevation in some of the um leads, but don't worry about the ST elevation. Just think about which of the four diagnoses we've got sinus tach. Yeah. Awesome. Great. So sinus tachycardia, the rate is 100 and two, the rhythm is regular. There are pe waves present before each QR S complex. So we know it's sinus rhythm. Um The QR S is now a complex and it doesn't look like there's any ST elevation or T wave inversion. Um You could also mention, oh, there's no evidence of any bundle branch blocks or um anything like that. So, how do we manage this? Well, we want to manage and treat the underlying cause. So, examples of things that can cause sinus tachycardia, a shock sepsis. If they're taking illicit substances like cocaine, pain and pulmonary embolism. Cool. Next one, can people give me what this looks like? Apologies. It does not look like the resolution on that is the best. No. Yeah. Great. Well done. So this is atrial fibrillation and this is quite a common thing that you'll see in all the patients on the ward. So we've got narrow complex there again. Um There's no P waves and it looks like the rhythm is irregularly irregular. There is some T wave inversion in V two, but I wouldn't worry too much about that. Um And other than that, again, there's no axis deviation and there's no bundle branch blocks cool. So, yeah, we've written that there. So with a left axis deviation, I'd argue kind of you'd expect a broader, a wider kind of QR S complex on there. You might be on to something, but don't think it looks too bad. Um OK. So why do we need to treat it well? Cos they often can cause heart failure. Um And also because there's kind of uh instead of lamina flow, we've got kind of more turbulent flow in the atria, we're more likely to cause a thrombus. Um and that can lead to a stroke. So, can anyone think of kind of the two main things to do with the management? Do people know what I mean? When I say rate and rhythm control, OK, we'll go with the. So basically, rate control is we're gonna want to reduce the government, want make it. So it's not, there's not tachycardia, how we do that. There's kind of three main ways you need to think of it. So there's beta blockers. So Atenolol and Bisoprolol, the way I remember it is A and BS treat C but then any other beta blocker kind of that doesn't start with A or B um is not cardioselective. Whereas A and B are cardioselective beta blockers, then we want rate limiting calcium channel blockers. So not like our amLODIPine, we want like verapamil or something like that. And then if neither of those work, then we'll use digoxin. But that's a pretty nasty drug. Can anyone think in the group that if someone's on digoxin, how long after they take it? Do we measure their blood concentrations of it? Ok. No. So when we are measuring digoxin levels, we wanna measure them six hours at least six hours after the patient's taken their last dose. I'm pretty sure some places say 12, but it's at least six hours after we take it. So then rhythm control. Um basically nice recommends that everyone should get rate control except in the following. So new af so first presentations within 40 hours, heart failure or um they're hemodynamically unstable and symptoms despite being effectively rate controlled and then a reversible cause of their af and then we'll do synchronized DC cardioversion or we'll use medications for rhythm control. Cool. So everyone who has af also needs to be considered for anticoagulation, do people know the scores we use when we're thinking about anticoagulation? Yeah. Great. Chad Bask cook. So, Chad VSC, that is our school for atrial fibrillation stroke risk. And then whenever anyone gets a Chad VSC, we should do an orbit. It used to be has blood, but I think they're moving more towards an orbit now. Um And that's just a bleeding risk score for atrial fibrillation. Doac are first line. So you often hear people talking about a Pix Rivaroxaban, those sorts of things, they're pretty well tolerated and they're quite easy to monitor. So we start giving them instead of Warfarin now, unless Warfarin um is the medication that's indicated. So if they've got a prosthetic heart valve or a metal heart valve, can anyone think of one reason why some people are a bit apprehensive to start do ax? Yeah, so we're worried about severe bleeding good. So also compared to Warfarin with Warfarin, we can give Vitamin K and that will undo the Warfarin's effects. Whereas um Doac kind of antidotes are a little bit more expensive um and they're not frequently given. Um So that's some reasons as well why some people are a bit worried about starting a dork instead of war. Cool. Next one. Yeah. Awesome. Supraventricular tachycardia. So, we can see that there's no P waves here, still a NR S complex. Um And the rhythm looks regular and they're pretty tachycardic in this. Um So management of this. So I would have um put in a little how much adenosine do we give. But basically the acute management if someone comes in with um S VT is vagal maneuvers such as a carotid sinus massage. If that doesn't work cos it's, I don't think it works that well. Um Then we'll give adenosine and we give 6 mg, then we give 12 mg and then we give a further 12 mg. Um And you want to do that in a large ball cannula and flush it straight after and you also want to counsel the patient that they might have an in pending sense of doom. And then you can give calcium channel blockers, beta blockers. If that doesn't work, then synchronized DC cardioversion under sedation and then the long term is down there, but you're not expected to know too much of that. Cool. Just wanted to quickly touch on wolf Parkinson white, which is a broad complex t er broad complex but is also a type of supraventricular tachycardia. Um And this is basically where there's an accessory pathway um that causes kind of that repolarisation of the atria. Um And there's three kind of key things you wanna say when you're in your osk, do you wanna say there's a shortened pr interval? There's a wide QR S complex. And can you see that there's that kind of slurring upstroke on the QR S complexes that's called a delta wave? And that means that there's an accessory pathway. So kind of the management of this is radio frequency ablation. Um And then some of the associations are hoca mitral valve prolapse, epstein's amount anomaly and then thyrotoxicosis cool. So this is our final one of the narrow complex tachycardia. Um So would someone chuck it in the chat? What I think it is great be real flatter. So I've written some of that down, but the management's basically the same as AF and I think you'll get the slides at the end of this. So I've just copied the B NFS section on the management of atrial flutter and AF on there. Cool. Four complex tachycardias. I know we are running out of time. So I'm gonna quickly just shoot through them all. Um I hope that's ok. Um So there's three ventricular fibrillation. So as you can see, there's kind of various different amplitudes on the E CG. There's no real rhythm. It's irregularly irregular. The QR S is a broad complex. It just looks like a bit of a mess whenever you see this or if ever you're unfortunate enough to see this, you're calling double two, double two because this is a shockable rhythm. Um And you're getting someone much more senior than yourselves involved in this. Um Next one, ventricular tachycardia. So here you can see that kind of, it's regular but the ventricles that it's really fast. Um But there's still synchronicity to it. Um There's kind of two different styles of management here. So if they've got a pulse and they're hemodynamically stable, then you're gonna treat them with antiarrhythmic drugs such as amiodarone. And if sinus rhythm is not restored, then you're gonna give them DC cardioversion or pacing. Um And you're also gonna be, again getting someone much more senior than you involved in that. If it's pulseless, it's an arrested rhythm. We are going to be dialing double two, double two, um cool, just one caveat to this. Um I don't think it's never gonna come up in your oscopies cos it's quite kind of advanced. But if a patient's got a bundle branch block with S VT it and that in um a tachycardia, it can look a bit like this, but you're gonna treat it as a ventricular tachycardia unless it's known that they've got those conditions cool. And then the final one is a polymorphic ventricular tachycardia. Um The other one is Toss de Pois. I butchered that pronunciation, but they aren't the same thing necessarily. Um So ventri polymorphic ventricular tachycardia, we will treat the same as we would a ventricular tachycardia. But toad de Pois and you can see it kind of has irregularity to it and then the frequency gets lower and lower and then it goes back up again. Um And this is caused the most common cause is QT prolongation, which we'll talk about next. But if you see this, you're gonna give IV magnesium. And why we need to treat this is, is because it can frequently reoccur and it can degenerate into venal fibrillation. Ventricular fibrillation just wanted to quickly touch on shockable versus non shockable rhythms. Cos I know it's something that I struggled with. Um So there's only two shockable and that's ventricular fibrillation and pulseless ventricular tachycardia and then uh shockable ones, there's pulseless electrical activity. So what does this mean? Basically if they're in sinus rhythm, but they don't have a pulse, you can't shock it and or if they've got atrial fibrillation or something like that. Um But if there and then also Asystole, which is the flat life on your E CG cool QT prolongation. Um So unfortunately, I couldn't get the rhythm strip on here, but, and I don't have a pointer, but can you appreciate how far away those T waves are from the QR S complex? Um When we're measuring it as well, it's important to remember, it's from the beginning of the key wave to the end of the T wave. So when we're looking at these values, 440 milliseconds and 460 milliseconds, you're thinking that's almost half a second. That's quite a long time. But when you measure it from the beginning of the Q wave to the end of the T wave. Um It's quite a big amount if that makes sense. So what are some of the causes of it? There's loads, I think to keep it simple. Just remember your hypos. So hypocalcemia, hypokalemia, hypomagnesemia, hypothermia. And then also just know that loads of medications can cause it. So specifically anti psychotics or tricyclic antidepressants, there will be a section on the B NF about kind of medications that cause QT prolongation management treat the underlying cause reverse cardiology. Cool. We are almost there, apologies. It hasn't been as interactive as I would have liked it to be um heart blocks. There's four that we need to know. Um and how I kind of, it makes me remember it a little bit more easily is like thinking of the P and the QR S complex are in a relationship and in these relationships they're not getting on too well. So in a first degree heart block, the QR S complex is taking quite a long time to respond to the P wave. When I think of wen you Bach's phenomenon, which is a second degree one. I think the QR S complex wants the P wave back and then the other two kind of fall into place a little bit more third degree the P and the QR S complex is they should never have been in a relationship. That's kind of how I remember it. I don't know if that will help you, but that's helped me. So let's just have a quick look at them. So here we can see the pr interval is much longer. It's taking a long time for the QR S complex to respond to that P wave lots of the time. This is a normal variant in young, healthy er individuals, they should be counseled um on kind of what to look out for if things go wrong. Um And if it's severe, they'll require a pacemaker, second degree heart blocks. So can we see um the one at the top is wenk wax phenomenon? So can you see normal PPR interval? PR is getting longer? Pr is getting longer and then there's just a missed. Um and then on the uh Mobitz type two, um we can see P no QR S normal, normal, normal P no QR s. So that's how you're differentiating your second degree heart blocks. And that's just a confusing bit I think. But if you remember when P the um P wants QR S back, that's kind of might be an easy way to remember. So address the underlying causes pacing and pacemakers. This probably isn't the best E CG to show a complete heart block. But can you see it's just kind of all a little bit of a mess. So there's no P wave at the beginning and there's a QR S complex and then there's AP wave P wave and a long wait before QR S complex. It's just kind of a mess. They're not talking to each other. This is, are quite a sick patient. Um And they're gonna need an emergency um, pacemaker. They're often gonna be bradycardic as well. So we'd give them atropine. Um You can also give them isoprenaline, but that's quite specialist. Cool. Um And then that is kind of um a little pound people can use to remember it if they want to. Does anyone have any questions before? Kind of you go into your um OSK stations? I hope that was ok. There was quite a lot of content there. Um And it was hard to get it all in. So, apologies for that. I hope I didn't go too quickly. Um But yeah, if anyone's got any questions, chuck them in the chat now. Um And thanks very much for listening. I appreciate it is quarter to eight on a Tuesday. But yeah, thank you. Thanks a um So in terms, so how um how many people are staying for the OQ? Oh, also if you guys want slides, um I'm sending the link to the feedback form in the chat. If you fill out the feedback form, then you'll get uh access to the slides. Um So mhm If you're staying for Osk Practice, I'm just trying to see who all volunteers are here. So, yes, Isabel's here and then I think I saw Sophia as well. So there's two um volunteers and nine people staying. Um mm So are you, are, are you happy to stay, to facilitate? Sorry. Yeah, that's fine. I'm happy to stay and facilitate. That's fine. No worries. Yeah. Yeah. Ok. So in terms of who goes to which room? If um, a choke Adrian and bitter if you go to Isabelle's breakout room and then Isabelle if you want to, um, enter your breakout room and then Janella male and Meg if you want to head the Sofia's room and then Paul to here and Paul if you want to, I don't have a room with your name, Aaron. But if you, that's what I was going to ask if you want to go to Elena's room, Alina. Yeah, that's fine. Yeah, I will see you then. Cheers. Perfect. Thanks. If there's any questions, I'll, I'll be dipping in and out of the of the breakout room. So just let me know and I'll come back to the main stage. Are you guys who join back the main stage? Are you guys? Ok. Do you want to be allocated to a room? Sorry if I'm saying your name is wrong, Samia and Paul. If not, no worries, you're free to leave the event as well.