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Cardiology cases[1]

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Fifth year teaching

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Cardiology cases[1]

  1. 1. Arrhythmias Sion Williams F1 5 th year teaching March 2011 BSUH
  2. 2. <ul><li>“ My boding heart pants, beats, and takes no rest, </li></ul><ul><li>But, like an earthquake, shakes thee on my breast” </li></ul><ul><li>Venus and Adonis </li></ul><ul><li>William Shakespeare </li></ul><ul><li>1593 </li></ul>
  3. 3. Overview <ul><li>Aim </li></ul><ul><ul><li>Revision of basics </li></ul></ul><ul><li>Classification of arrhythmias </li></ul><ul><li>2 Case studies </li></ul><ul><li>Rhythm strip quiz </li></ul>
  4. 4. Classification of arrhythmias Arrhythmias Simple bradycardia Heart block Narrow complex QRS < 120ms Broad complex QRS > 120ms SVT AF/flutter Sinus tachycardia VT VF Bradycardia Tachycardia HR < 60 HR > 100
  5. 5. Case 1 <ul><li>A 69 year old man presents to A+E with sudden onset shortness of breath with palpitations. He then goes on to develop chest pain. </li></ul><ul><li>Differentials? </li></ul><ul><ul><li>Cardiac </li></ul></ul><ul><ul><li>Respiratory </li></ul></ul><ul><ul><li>GI? </li></ul></ul><ul><li>Important history questions? </li></ul><ul><li>Nature of palpitations </li></ul><ul><li>Big 6 </li></ul><ul><ul><li>past cardiac history </li></ul></ul><ul><ul><li>diabetes </li></ul></ul><ul><ul><li>smoking </li></ul></ul><ul><ul><li>hypertension </li></ul></ul><ul><ul><li>Hypercholesterolaemia </li></ul></ul><ul><ul><li>family history </li></ul></ul>
  6. 6. Examination <ul><li>Obs: </li></ul><ul><li>HR 170 </li></ul><ul><li>BP 80/44 mmHg </li></ul><ul><li>Sats 84% </li></ul><ul><li>RR 22 </li></ul><ul><li>CVS fast- no murmurs </li></ul><ul><li>Resp </li></ul><ul><li>Abdo </li></ul><ul><li>soft, non-tender, BS present </li></ul><ul><li>What next? </li></ul>
  7. 7. <ul><li>What does it show? </li></ul>
  8. 8. <ul><li>Other investigations? </li></ul><ul><ul><li>Bloods </li></ul></ul><ul><ul><ul><li>U+Es </li></ul></ul></ul><ul><ul><ul><li>Troponin </li></ul></ul></ul><ul><ul><ul><li>Mg </li></ul></ul></ul><ul><ul><ul><li>TFTs </li></ul></ul></ul><ul><ul><li>CXR </li></ul></ul><ul><ul><li>Echocardiogram </li></ul></ul>
  9. 9. Management- Acute AF <ul><li>Resuscitate </li></ul><ul><ul><li>A: ensure patency </li></ul></ul><ul><ul><li>B: Sit up, oxygen </li></ul></ul><ul><ul><li>C: IV access </li></ul></ul><ul><li>Then? </li></ul><ul><ul><li>Haemodynamically unstable AF- emergency cardioversion </li></ul></ul><ul><ul><ul><li>If <48hrs </li></ul></ul></ul><ul><ul><ul><li>Chemical- IV amiodarone </li></ul></ul></ul><ul><ul><ul><li>Electrical- escalating shocks under GA </li></ul></ul></ul><ul><ul><ul><li>If >48 hrs- TOE to rule out thrombus </li></ul></ul></ul>
  10. 10. Case 2 <ul><li>A 75 year old gentleman is incidentally noticed by his GP to have an irregular heart rate on 2 consecutive visits. An ECG is shown below. His past medical history includes a previous MI. </li></ul><ul><li>Should we treat? </li></ul><ul><li>What are the treatment objectives? </li></ul><ul><li>What scoring system can we use? </li></ul>
  11. 11. <ul><li>Rate control </li></ul><ul><li>Older, non-symptomatic etc… </li></ul><ul><ul><li>1. B-blocker </li></ul></ul><ul><ul><li>+/- digoxin </li></ul></ul><ul><ul><li>+/- amiodarone </li></ul></ul><ul><li>Rhythm control </li></ul><ul><li>Younger </li></ul><ul><li>Symptomatic e.g. CCF </li></ul><ul><li>Secondary to now corrected aetiology </li></ul><ul><ul><li>1. Cardioversion- electrical vs chemical </li></ul></ul><ul><ul><li>2. AV node ablation </li></ul></ul><ul><li>Anticoagulation </li></ul><ul><li>Scoring system? </li></ul>Management- Chronic AF
  12. 12. CHADS-2 <ul><li>C ongestive heart failure 1 </li></ul><ul><li>H ypertension 1 </li></ul><ul><li>A ge > 75 1 </li></ul><ul><li>D iabetes mellitus 1 </li></ul><ul><li>S troke- previous 2 </li></ul><ul><li>0 = aspirin </li></ul><ul><li>1 or 2 = warfarin or aspirin </li></ul><ul><li>3 or more = warfarin </li></ul>
  13. 13. <ul><li>Arrhythmias quiz </li></ul>
  14. 14. <ul><li>A 72 year old man complains of feeling faint with new onset palpitations. He is sitting up in bed talking to his daughter. His ECG is shown below. </li></ul><ul><li>What does the rhythm strip show? </li></ul><ul><li>What is the first line treatment? </li></ul>
  15. 15. <ul><li>A 56 year old postman presents to accident and emergency with breathlessness and palpitations. He is responsive, with a blood pressure of 122/70. His peripheral capillary refill time is 4 seconds, and his central capillary refill time is less than 2 seconds. Lead II of his ECG is shown below. </li></ul><ul><li>a. What does the rhythm strip show? </li></ul><ul><li>b. What is the first line treatment? </li></ul>
  16. 16. <ul><li>A 77 year old lady is admitted to accident and emergency with central crushing chest pain. She suddenly collapses and the attached cardiac monitor shows the rhythm below. </li></ul><ul><li>a. What does the rhythm strip show? </li></ul><ul><li>b. Treatment? </li></ul>
  17. 17. <ul><li>A 74 year old lady presents to accident and emergency with new onset confusion and breathlessness. Lead II of her ECG is shown below </li></ul><ul><li>a. What does the rhythm strip show? </li></ul><ul><li>b. Treatment </li></ul><ul><li>i) short term </li></ul><ul><li>ii) long term? </li></ul>
  18. 18. <ul><li>5. The following are all types of heart block. Please identify. </li></ul><ul><li>i) </li></ul><ul><li>ii) </li></ul><ul><li>iii) </li></ul><ul><li>iv) Easy way to remember treatment? </li></ul>
  19. 19. James…

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