Perioperative case of arrhythmias
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This document discusses cardiac arrhythmias that can occur perioperatively. The most common perioperative cardiovascular abnormalities are cardiac arrhythmias. The pathogenesis can include re-entry, automaticity, ion channel mutations, or ectopic foci. Factors that can cause arrhythmias include patient characteristics like preexisting heart disease, anesthesia factors such as drugs or electrolyte imbalances, and surgery-related issues like vagal stimulation during dental procedures. Treatment depends on whether the arrhythmia is stable or unstable, regular or irregular, narrow or wide complex. Options include medications, cardioversion, defibrillation, or expert consultation. The document also reviews ischemic ECG changes that may occur with persistent ischemia.
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Importance for learners:
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Microbiology
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MDS
MD
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This document discusses 3 forms of cardiomyopathy:
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Dilated chambers.
Systolic dysfunction.
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Causes:
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Cardiovascular: ischaemia, HTN, valve disease. See 'Definition' above about why this isn't strictly speaking 'cardiomyopathy'.
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Here are the key points from the case:
- A 75-year-old post-menopausal woman presented with pneumonia and chest pain
- In the last 24 hours she experienced dyspnea and sputum production
- This physical stressor of pneumonia could potentially trigger Takotsubo cardiomyopathy in this high-risk demographic
- Her symptoms of chest pain could represent Takotsubo cardiomyopathy mimicking an acute coronary syndrome
- Further workup would be needed to evaluate for potential left ventricular dysfunction and regional wall motion abnormalities consistent with Takotsubo cardiomyopathy versus other causes of her symptoms.
Takotsubo
Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy, is a temporary heart condition where emotional or physical stress causes the heart muscle to become weakened or stunned. It most often affects postmenopausal women and can mimic symptoms of a heart attack. While the exact cause is unknown, it may involve coronary artery spasm or impaired cardiac function triggered by emotional stress. Patients typically experience chest pain and shortness of breath. Diagnosis involves EKG changes, elevated cardiac enzymes, and angiography showing normal coronary arteries with abnormal ventricle function. Most patients fully recover heart function within weeks, though complications in a small percentage can include heart failure, shock, or arrhythmias.
Sudden cardiac death
This document discusses sudden death and its causes. It begins by defining sudden death as any death occurring within 24 hours of symptom onset, which can be unpredictable or expected. The most common causes of sudden death are clinically silent degenerative diseases and failure to seek timely medical care. Autopsies aim to identify anatomical abnormalities, microscopic findings, toxicology results and other lab studies. Potential cardiac causes discussed include coronary artery disease, cardiomyopathies, valvular diseases and conduction abnormalities. Non-cardiac causes such as hemorrhage, neurological issues and miscellaneous conditions are also reviewed. The document concludes by emphasizing that sudden death can occur unexpectedly in individuals with cardiovascular disease.
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This document summarizes various cardiovascular manifestations that can occur in systemic diseases. It discusses how thiamine deficiency can cause heart failure and how supplementation can help. It also discusses protein-energy malnutrition and how it can affect the heart. Other conditions mentioned include hyperhomocysteinemia, obesity, carcinoid syndrome, pheochromocytoma, acromegaly, systemic lupus erythematosus, antiphospholipid antibody syndrome, systemic sclerosis, and rheumatoid arthritis; and their potential impacts such as cardiomyopathy, pericarditis, accelerated atherosclerosis, and pulmonary hypertension.
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This document summarizes information about several cardiac conditions:
- Hypertrophic obstructive cardiomyopathy (HOCM) is characterized by a thickened, non-dilated left ventricle with a familial incidence in 55% of cases. Symptoms include syncope, chest pain, and palpitations.
- Brugada syndrome is associated with sudden cardiac death and characterized by ECG abnormalities in leads V1-V3 and a 10% mortality per year without treatment.
- Wolff-Parkinson-White syndrome involves a short PR interval, wide QRS, and delta wave on ECG due to pre-excitation.
- Long QT syndrome increases the risk of torsades de
Takotsubo cardiomyopathy or so-called heart break syndrome
Takotsubo cardiomyopathy, also known as broken heart syndrome, is a weakening of the left ventricle that is usually triggered by severe emotional or physical stress. It causes chest pain and shortness of breath similar to a heart attack, but without blocked arteries. The left ventricle becomes ballooned in shape. Over 90% of reported cases involve postmenopausal women. While the exact causes are unknown, most patients experience full recovery within a few weeks, though there is a small risk of fatal complications like heart wall rupture.
Scd
The document discusses sudden cardiac death (SCD) in various populations. It notes that SCD accounts for 12-15% of natural deaths and almost 90% have cardiac causes. The peak ages for SCD are within the first year of life and between 45-75 years. The most common causes of SCD in children are congenital heart defects while in those over 35 it is coronary heart disease. Rare causes like hypertrophic cardiomyopathy also contribute to SCD in young adults. Exercise-related SCD is often due to congenital anomalies or premature heart disease in young and older athletes respectively.
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1. Stroke is defined as a clinical syndrome of rapid onset of focal deficits of brain function lasting more than 24 hours or leading to death. There are two main types - ischemic and hemorrhagic.
2. Ischemic strokes account for 80% of cases and result from arterial occlusion blocking blood flow. Hemorrhagic strokes can be either intracerebral hemorrhage from ruptured small arteries damaged by hypertension, or subarachnoid hemorrhage from ruptured aneurysms.
3. The pathophysiology of ischemic stroke involves development of an ischemic core with immediate cell death surrounded by an ischemic penumbra of reversibly dysfunctional tissue that can potentially be salvaged by reperfusion
Cardiomyopathy
Cardiomyopathy refers to diseases of the heart muscle that weaken the heart's ability to pump blood. Dilated cardiomyopathy is characterized by the enlargement and weakening of the heart's main pumping chamber, the left ventricle. The major causes of dilated cardiomyopathy include infections, toxins, inherited conditions, and unknown causes. Symptoms include heart failure and arrhythmias. Diagnosis involves echocardiography and treatments focus on managing symptoms through medications, devices, and transplantation if needed.
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Takotsubo cardiomyopathy or so-called heart break syndrome
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Approach to a patient with stroke - Pathophysiology of stroke
Approach to a patient with stroke - Pathophysiology of stroke
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Perioperative case of arrhythmias
- 3. CARDIAC ARRHYTHMIAS ARE THE MOST FREQUENT PERIOPERATIVE CARDIOVASCULAR ABNORMALITIES
- 4. PATHOGENESIS • RE-ENTRY • AUTOMATICITY • MUTATIONS IN ION CHANNELS • ECTOPIC FOCI/ IRRITABLE FOCI
- 5. FACTORS AND CAUSES • PATIENT RELATED FACTORS • ANAESTHESIA RELATED FACTORS • SURGERY RELATED FACTORS
- 6. PATIENT RELATED FACTORS • PREEXISTING CARDIAC DISEASE • CENTRAL NERVOUS SYSTEM DISEASE –RAISED ICT • OLD AGE - DEGENERATIVE CHANGE IN ANATOMY
- 7. ANAESTHESIA RELATED FACTORS • INDUCTION – INTUBATION • LIGHT PLANE, HYPOXAEMIA, HYPERCARBIA • DRUGS • ELECTROLYTE IMBALANCE • CENTRAL VENOUS CANNULATION
- 8. SURGERY RELATED FACTORS • CARDIAC SURGERY • VAGAL STIMULATION ? • DENTAL SURGERY CAUSES PROFOUND STIMULATION OF ANS
- 9. ARRYTHMIAS WITH PULSE TACHYARRYTHMIAS NARROW COMPLEX WIDE COMPLEX BRADYARRYTHMIAS SINUS BRADYCARDIA SINUS ARRYTHMIA AV BLOCKS REGULAR SINUS TACHYCARDIA ATRIAL FLUTTER SVT JUNCTIONAL TACHY IRREGULAR ATRIAL FIBRILATION REGULAR MONOMORPHIC VT IRREGULAR VF POLYMORHMIC VT FIRST DEGREE SECOND DEGREE THIRD DEGREE
- 10. GENERAL MEASURES IN ALL ARRYTHMIAS
- 13. UNSTABLE TACHYCARDIA WITH PULSE UNSTABLE IF CAUSING: HYPOTENSION SIGNS TISSUE HYPOPERFUSION ALTERED MENTAL STATUS ISCHEMIC CHEST PAIN ACUTE CHF NARROW WIDE REGULAR ADENOSINE 50-100 J (MONOPHASIC/ BIPHASIC) SYNC CARDIOVERSION IRREGULAR BIPHASIC : 120 J(UPTO 200J) MONOPHASIC : 200 J (UP TO 360J) REGULAR 100 J (MONOPHASIC/ BIPHASIC) IRREGULAR DEFIBRILATION (NO SYNC) CONSIDER SEDATION 1. PROPOFOL 2. MIDAZ + FENTA 3. ETOMIDATE+FENTA
- 14. TACHYCARDIA WITH PULSE STABLE NARROW WIDE REGULAR VAGAL MANUEVER ADENOSINE NOT REVERT RATE CONTROL EXPERT CONSULTATION DRUGS IRREGULAR REGULAR AND MONOMORPHIC ADENOSINE NOT REVERT IRREGULAR AMIODARONE
- 15. DRUGS • ATROPINE 0.5mg ---3-5 mins---max 3mg • DOPAMINE INFUSION 2-10mcg/kg/min • EPINEPHRINE INFUSION 2-10mcg/min • ADENOSINE 6mg rapid(3mg cvp)---12mg • DILTIAZEM rule of 15 • ESMOLOL 0.5mg/kg----0.3mg/kg/min • SOTALOL 1.5mg/kg • AMIODARONE 150mgslow---1mg/kg/hr*6hr---.5mg/kg/hrfor18hr • LIGNOCAINE 1.5 mg/kg load----1.5mg/kg/hr
- 16. EXERCISE
- 17. ISCHEMIC ECG CHANGES SEQUENCE OF ECG DURING PERSISTENT ISCHEMIA LARGE PEAKED T WAVES (OR HYPERACUTE T WAVES) ST ELEVATION/DEPRESSION NEGATIVE T WAVES PATHOLOGIC Q WAVES
- 18. ST ELEVATION NEW ST ELEVATION AT THE J-POINT IN TWO CONTIGUOUS LEADS : ≥0.2 MV IN MEN OR ≥ 0.15 MV IN WOMEN IN LEADS V2–V3 AND/OR ≥ 0.1 MV IN OTHER LEADS.
- 19. ST DEPRESSION AND T-WAVE CHANGES NEW HORIZONTAL OR DOWN-SLOPING ST DEPRESSION >0.05 MV IN TWO CONTIGUOUS LEADS; AND/OR T INVERSION ≥0.1 MV IN TWO CONTIGUOUS LEADS WITH PROMINENT R-WAVE OR R/S RATIO ≥ 1