Med viva/revision for Anaes M.Med Part 2

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Med viva/revision for Anaes M.Med Part 2

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Med viva/revision for Anaes M.Med Part 2

  1. 1. Diagnosis?
  2. 2. Define QT interval
  3. 3. Define QT interval Time from the start of the Q wave to the end of theT wave.
  4. 4. What does the QT interval represent?
  5. 5. What does the QT interval represent? It represents the time taken for ventricular depolarisation and repolarisation.
  6. 6. How does QT relate to the heart rate?
  7. 7. How does QT relate to the heart rate? QT interval is inversely proportional to heart rate
  8. 8. Why does QT needs to be corrected?
  9. 9. Why does QT needs to be corrected? This allows comparison of QT values at different heart rates and improves detection of patients at increased risk of arrhythmias.
  10. 10. So what is it corrected to?
  11. 11. So what is it corrected to? Corrected QT interval (QTc) estimates the QT interval at a heart rate of 60 bpm.
  12. 12. What is the problem with prolonged QTc?
  13. 13. What is the problem with prolonged QTc? An abnormally prolonged QT is associated with an increased risk of ventricular arrhythmias, especiallyTorsades de Pointes.
  14. 14. What is normal QTc?
  15. 15. What is normal QTc? < 440ms in men < 460ms in women
  16. 16. Name me a formula for calculation.
  17. 17. Name me a formula for calculation. QTC = QT / √ RR
  18. 18. What is the formula called?
  19. 19. What is the formula called? Bazett’s formula
  20. 20. What is the limitation of Bazett’s formula?
  21. 21. What is the limitation of Bazett’s formula? It over-corrects at heart rates > 100 bpm under-corrects at heart rates < 60 bpm, (but provides an adequate correction for heart rates ranging from 60 – 100 bpm).
  22. 22. Name some causes of prolonged QTc
  23. 23. Name some causes of prolonged QTc Hypo-MCT MI High ICP Drugs
  24. 24. Does hypokalemia cause prolonged QTc?
  25. 25. Does hypokalemia cause prolonged QTc? Technically no. U wave may cause apparent prolonedQTc. But risk ofTdP not there. Severe hypokalemia = asystole, remember?
  26. 26. Name some drugs which cause prolonged QTc.
  27. 27. Name some drugs which cause prolonged QTc. Ondansetron Droperidol Diphenhydramine Erythromycin Amiodarone
  28. 28. What is shortened QTc?
  29. 29. What is shortened QTc? < 350ms
  30. 30. Names some causes
  31. 31. Name some causes Hypercalcaemia Digoxin Congential short QT syndrome
  32. 32. Any problems with short QT?
  33. 33. Any problems with short QT? increased risk of paroxysmal atrial and ventricular fibrillation sudden cardiac death.
  34. 34. BREAK
  35. 35. Diagnosis? 70 year old male. Hypertension.Otherwise asymptomatic.
  36. 36. Brugada
  37. 37. Problem with Brugada?
  38. 38. Problem with Brugada? Sudden cardiac death
  39. 39. Brugada Sign  Coved ST segment elevation >2mm in >1 ofV1-V3  followed by a negativeT wave
  40. 40. How many types of Brugada?
  41. 41. How many types of Brugada? 3 types: Type 1: Brugada Sign + Clinical criteria (DocumentedVT orVF. Family history of sudden cardiac death at <45 years old .Coved-type ECGs in family members. Inducibility ofVT with programmed electrical stimulation. Syncope. Nocturnal agonal respiration.) Type 2:Type 2 has >2mm of saddleback shaped ST elevation Type 3: morphology of either type 1 or type 2, but with <2mm of ST segment elevation
  42. 42. Pathophysiology of Brugada?
  43. 43. Pathophysiology of Brugada? Mutation in the cardiac sodium channel gene.
  44. 44. Treatment of Brugada?
  45. 45. Treatment of Brugada? AICD implantation
  46. 46. What anaesthetic drug to use with caution in Brugada?
  47. 47. What anaesthetic drug to use with caution in Brugada? Propofol!
  48. 48. BREAK
  49. 49. Diagnosis
  50. 50. Inferior infarct + posterior infarct
  51. 51. What else should you look out for?
  52. 52. What else should you look out for? RV infarct and heart block Inferior infarct: must look for posterior infarct (V1-3) Inferior infarct: must look for RV infarct
  53. 53. How to diagnose RV infarct with ECG?
  54. 54. How to diagnose RV infarct with ECG? rV4
  55. 55. Describe the position of rV4
  56. 56. Describe the position of rV4 V4 position on right side
  57. 57. What is significant change in rV4 to be called an RV STEMI?
  58. 58. What is significant change in rV4 to be called an RV STEMI? 0.5 mm or half a square. Why?
  59. 59. How does the management of RV infarct differ from LV infarct?
  60. 60. How does the management of RV infarct differ from LV infarct? Fluid responsive therefore fluid loading may help BP. Avoid nitrates.
  61. 61. Describe other lead positions you can place
  62. 62. Describe other lead positions you can place V7,8,9
  63. 63. Where areV7,8 and 9 placed?
  64. 64. Where areV7,8 and 9 placed? Posterior, below scapula along 6th IC space
  65. 65. What isV7,8,9 good for?
  66. 66. What isV7,8,9 good for? Diagnosis of posterior infarct.
  67. 67. What is the recommended door to balloon time?
  68. 68. What is the recommended door to balloon time? 60 min
  69. 69. What is the difference between BMS and DES?
  70. 70. What is the difference between BMS and DES? Bare metal – more thrombogenic but epithelization more rapid. Earlier thrombosis Dual anti-platelet shorter. DES – less thrombogenic but epithelization slower Less thrombosis Dual anti-platelet longer.
  71. 71. Recommended BMS DAP duration
  72. 72. Recommended BMS DAP duration 4 weeks
  73. 73. BREAK
  74. 74. Diagnosis?
  75. 75. Patient’s asymptomatic. Management?
  76. 76. Patient’s asymptomatic. Management? Refer EPS
  77. 77. ECG repeated: BP 120/80.Tx?
  78. 78. Stable Vagal maneuvers Amiodarone Fleclanide Procainamide
  79. 79. ECG repeated: BP 70/40.Tx?
  80. 80. Unstable Synchronized cardioversion
  81. 81. Data Intepretation  34 yo female intubated and ventilated following a prolonged generalized tonic-clonic seizure. Initial non- contrast CT brain shows bilateral intracerebralhaemorrhages. ABG and GBC post intubation:
  82. 82. Data Intepretation  List the abnormalities on the ABG and give the most likely cause in each case.
  83. 83. Data Intepretation  Metabolic acidosis – lactic acidosis induced by prolonged seizure  Respiratory acidosis / inadequate compensation – inappropriate mechanical ventilation  Increased A-a gradient – aspiration pneumonitis or neurogenic pulmonary oedema
  84. 84. Data Intepretation  Give three possible diagnoses for her presentation based on the history and investigations.
  85. 85. Data Intepretation  TTP / HUS  Eclampsia  Vasculitis
  86. 86. Difference betweenTTP and HUS?
  87. 87. Difference betweenTTP and HUS? TTP : more brain, adult female HUS: more kidneys, kids, related to E. coli
  88. 88. BREAK
  89. 89. Data Intepretation  68-year-old male with chronicAF is noted to have the following coagulation profile:  What is the likely diagnosis?
  90. 90. Data Intepretation  68-year-old male with chronicAF is noted to have the following coagulation profile:  What is the likely diagnosis?  Supratherapeuticwarfarinisation
  91. 91. Data Intepretation  68-year-old male with chronicAF is noted to have the following coagulation profile:  What are possible causes of supratherapeuticwarfarinisation?
  92. 92. Data Intepretation  68-year-old male with chronicAF is noted to have the following coagulation profile:  What are possible causes of supratherapeuticwarfarinisation?  Overdose  Drug interaction  Change in diet
  93. 93. Data Intepretation  68-year-old male with chronicAF is noted to have the following coagulation profile:  What are possible drug interactions causing high INR in this patient?
  94. 94. Data Intepretation  68-year-old male with chronicAF is noted to have the following coagulation profile:  What are possible drug interactions causing high INR in this patient?  Antibiotics  Omeprazole  Amiodarone
  95. 95. Data Intepretation  68-year-old male with chronicAF is noted to have the following coagulation profile:  What is the likeliest mechanism for antibiotics to cause high INR in this patient?
  96. 96. Data Intepretation  68-year-old male with chronicAF is noted to have the following coagulation profile:  What is the likeliest mechanism for antibiotics to cause high INR in this patient?  Vitamin K metabolism altered due to change in gut flora.
  97. 97. Data Intepretation  68-year-old male with chronicAF is noted to have the following coagulation profile:  What is the likeliest mechanism for omeprazole to cause high INR in this patient?
  98. 98. Data Intepretation  68-year-old male with chronicAF is noted to have the following coagulation profile:  What is the likeliest mechanism for omeprazole to cause high INR in this patient?  Liver enzyme inhibition
  99. 99. Data Intepretation  68-year-old male with chronicAF is noted to have the following coagulation profile:  Outline your management of this patient if not bleeding.
  100. 100. Data Intepretation  68-year-old male with chronicAF is noted to have the following coagulation profile:  Outline your management of this patient if not bleeding.  Stop warfarin  Vitamin K in as low a dose as possible  Consider FFP or factor concentrate if high risk of bleeding
  101. 101. Data Intepretation  68-year-old male with chronicAF is noted to have the following coagulation profile:  How much FFP should be given?
  102. 102. Data Intepretation  68-year-old male with chronicAF is noted to have the following coagulation profile:  How much FFP should be given?  At least 10-15ml/kg.
  103. 103. Data Intepretation  ABG obtained from a patient admitted to the ICU after a suicide attempt.  What anomaly do you notice in the blood gas report?
  104. 104. Data Intepretation  ABG obtained from a patient admitted to the ICU after a suicide attempt.  What anomaly do you notice in the blood gas report?  Hypercapnia / resp acidosis.  Metabolic acidosis
  105. 105. Data Intepretation  ABG obtained from a patient admitted to the ICU after a suicide attempt.  Anything about the P50?
  106. 106. Data Intepretation  ABG obtained from a patient admitted to the ICU after a suicide attempt.  Anything about the P50?  A left shifted curve despite a high PCO2 and a low pH.
  107. 107. Data Intepretation  ABG obtained from a patient admitted to the ICU after a suicide attempt.  List 2 other investigations you would perform to elucidate the cause of the anomaly.
  108. 108. Data Intepretation  ABG obtained from a patient admitted to the ICU after a suicide attempt.  List 2 other investigations you would perform to elucidate the cause of the anomaly.  CoHb  Measure temperature  Measure 2,3 DPG
  109. 109. Data Intepretation  ABG obtained from a patient admitted to the ICU after a suicide attempt.  How can you treat carbon monoxide poisoning?
  110. 110. Data Intepretation  ABG obtained from a patient admitted to the ICU after a suicide attempt.  How can you treat carbon monoxide poisoning?  Supportive  100% oxygen
  111. 111. BREAK
  112. 112. Diagnosis?  55 year old man presents with chest pain and shortness of breath following vomiting four hours earlier.
  113. 113.
  114. 114. Pneumothorax and pleural effusion on right side.
  115. 115. This CXR and history: diagnosis?
  116. 116. This CXR and history: diagnosis? Boerhaave’s syndrome
  117. 117. Management?
  118. 118. Management? supplementary oxygen, IV fluid resuscitation, appropriate IV antibiotics, an appropriate size chest drain, urgent surgical referral
  119. 119. BREAK
  120. 120. Diagnosis?
  121. 121. What is the classical description of the patient?
  122. 122. What is the classical description of the patient? Lucid interval
  123. 123. Management?
  124. 124. BREAK
  125. 125. Case Scenerio  68 year-old man who had cardiac surgery 4 days previously.  He is intubated and ventilated and developed an increasing FiO2 requirement over the course of the day.
  126. 126. Xray yesterday
  127. 127. Xray today Diagnosis?
  128. 128. Left consolidation But did you see the right pneumothorax?
  129. 129. BREAK
  130. 130. For Fun:
  131. 131. Situsinversus
  132. 132. BREAK
  133. 133. Case  19 year old male admitted after a severeTBI.  Due to refractory intracranial hypertension he has been intubated, sedated and paralysed  You are called to the bedside because he has desaturated to 85% on 100% oxygen.
  134. 134. Describe? Diagnosis?
  135. 135. Left upper, Right lower collapse
  136. 136. Why is the patient hypoxic despite administration of 100% oxygen?
  137. 137. Why is the patient hypoxic despite administration of 100% oxygen? Shunt
  138. 138. How to manage?
  139. 139. How to manage? Bronchoscopy 
Recruitment manoeuvres
  140. 140. Describe how you recruit?
  141. 141. What are the complications of recruitment maneuvers?
  142. 142. What are the complications of recruitment maneuvers? Pneumothorax Hypotension Hypoxia Raised intracranial pressure
  143. 143. Long Case
  144. 144. Story  30 year old male.  ASA 2 smoker. History of childhood respiratory disorder but well since.  Admitted for right ankle fracture following mountain bike accident.  Underwent ORIF of right ankle fracture.  POD1: informs nurse of acute breathlessness and you are contacted for an assessment.
  145. 145. Story  Parameters  BP 115 / 75 mmHg  HR 95 / min  SpO2 97% on room air  Temperature 37.5 C  Medication chart  PO Paracetamol 1g qdsprn  PO Synflex 550 mg bdprn  PO Oxycodone 5 mg q2h prn  IV Ondansetron 4 mg tdsprn
  146. 146. What are your differentials?
  147. 147. Describe your approach
  148. 148. Describe your approach My primary approach is to treat the underlying pathophysiology by first elucidating the cause. I will d0 so by reassessing the History, performing a directed Physical Examination and ordering targeted Investigations.
  149. 149. What would you like to know about the history?
  150. 150. What will you be looking for in the your physical examination?
  151. 151. What will you be looking for in the your physical examination? Starting from the Head, I will look for …
  152. 152. How would you investigate this patient?
  153. 153. Data Intepretation  ABG (room air)  pH 7.47  pCO2 31  pO2 85  BE -2  HCO3 23  SpO2 97%  Interpret the ABG
  154. 154. Data Intepretation  FBC  TWC 12k  Hb 12g/dL  Platelets 151K  UE  Cr 65  K 4.3  Lactate 1
  155. 155. Data Intepretation
  156. 156. Story changes  Patient is progressively breathless. Unable to speak.  Wheezing worsens.
  157. 157. What treatments will you start?
  158. 158. What treatments will you start? Beta agonist Anticholinergics Magnesium Aminophylline Ketamine Volatile agents Steriods
  159. 159. Data Intepretation  ABG repeated:  pH 7.25  pCO2 52  pO2 65  BE-8  HCO3 23  SpO2 92%
  160. 160. Story continues  Patient worsens and consciousness drops.  You decide to intubate the patient.  Describe your intubation technique and choice of drugs.
  161. 161. Story continues  After intubation, describe you would ventilate this patient?
  162. 162. Data Interpretation  FBC  TWC 15 k  Hb11.9 g/dL  Platelets 255 K  UE  Cr 65  K 3.2  Lactate 8
  163. 163. END

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