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MH SAQ practice ECGs

It is 1600 on Saturday afternoon. A 75 year old woman with a background of CRF on peritoneal dialysis and diet controlled diabetes presents with retrosternal chest pain radiating to neck and both arms which started 60 minutes previously. She is well functioning in the community and her only medications are irbesartan, calcium and vitamin D. She has no allergies. She is vitally stable and the following ECG is perfomed:

1. What are the diagnostic features on the ECG? (1 mark)

STE inferior leads STD aVR associated with q wave Widespread PR depression except elevation in aVR

2. If you were working at an urban major referral hospital with 24 hour on-call PCI capabilities, would you activate the PCI team – they have no access to the ECG and will act on your recommendation and outline your reasoning? (2 marks)

Yes, clinical picture of STEMI with ECG possible STEMI

3. If you were working at a rural emergency department would you give thombolysis considering that at this time the availability of transfer to PCI is 3 hours (2 marks)

No, ECG has features of pericarditis which is a contraindication to thrombolysis

5. List 10 features (4 history, 3 ECG and 3 other investigations) that would increase the diagnostic possibility of STEMI over pericarditis (5 marks)

Older age group Risk factors for ACS Short duration of pain Dull pain, not pleuritic Anatomically contiguous ST and J point elevation PR depression absent ECG changes rapidly with alteration of pain Biomarkers abnormal Pericardial effusion rarely present in acute STEMI Coronary angiography normal

Dunn p404

A 35 year old woman presents with palpitations and shortness of breath. On arrival her BP is 70/40 mmHg. An ECG is taken and is shown below.

a. What are 5 important features of the ECG?

Rate @ 240, Rhythm irregular (AF),rightward access, Delta waves, / fusion beats in severalleads esp lead 2 and V1

b. List three possible differential diagnoses.

AF RBBB, WPW with aberrancy, VT, Torsades

c. List the important steps in your immediate management.

Resus with full monitoring, supplemetal O2, iV access, fluid bolus, synchronised DC cardioversion 100J with sedation and analgesia

A 65 year old man is in your ED with a known overdose of Digoxin. An ECG has been performed and is shown below.

His U+E’s are Na+ 142 mmol/L, K+ 6.7 mmol/L, U50.1, Cr 502.

a. Describe 4 features of the ECG. (4 marks)

Supraventricular bradycardia ? slow AF as no visible p waves, T wave inversion and ST depression inferolaterally, reverse tick sign laterally, prominent u wave laterally,

b. Give 3 indications for digibind. (3 marks)

K+ > 5, digoxin level >15, ingested >10mg, ventricular tachyarrhythmia, haemodynamically unstable bradyarrhythmia, altered mantal status attributable to dig toxicity

c. List 3 other treatments for this patient and give reasons for using them. (3 marks)

Calcium gluconate- 10ml of 10% over 2 min to counteract the hyperkalaemiaCalcium chloride- 5 ml of 10% over 2 minSalbutamol nebuliser 5ml- increases intracellular K+ reabsorptionFast acting Insuline 10-15 iu in 500ml of 10% dextrose- increase K+ reabsorbtionAtropine 0.5 mg up to 3mg to reverse bradycardiaMagnesium in case of torsades de pointes

A 60 year old male presents to your ED complaining of chest pain for the last 2 hours. He has no known medication history and does not take any regular medications.

His ECG on arrival is below.

a. What is your interpretation of his ECG? (3 marks)

Inferior STEMI – (1 mark)Complete heart block – (1 mark)

1 mark for any of:Possible RV involvement (STE III>II)Possible posterior involvement (Flat ST depression V2-3)Bradycardia

b. The patient's blood pressure is 80 mmHg. Outline the key steps in managing his hypotension. (4 marks)

Main priority revascularisation - angioplasty / thrombolysis – (1 mark)Cautious fluid bolus -must acknowledge risk of pulm odema or use bolus <500ml –(1 mark)

1 mark each for any two of:Atropine - likely to be ineffectiveAvoid / cease GTNTranscutaneous pacingInotropes as listed below onlyIABP - only acceptable if preceded by revascularisation

c. The cardiology team have advised you to commence the patient on a vasoactive agent to improve his blood pressure. List 3 appropriate inotropes / vasopressors and their dosing in the table below. (3 marks)

Agent Dose1. Dopamine 3-5 mcg/kg/min to

maximum of 20-50 mcg/kg/min

2. Dobutamine 2-5 mcg/kg/min to maximum of 20 mcg/kg/min

3. Noradrenaline 2 mcg/min up titrate to response

1/2 mark for each correctly completed box.

Taken from Tintinalli's Emergency Medicine 7th Edition Chapter 54 Table 54-5 Pg 388 with Milrinone excluded.

Consistent with management advice in Dunn Emergency Medicine Manual 5th Edition Vol 1 Chpt 28 Pg 440

A 16 year old boy with a congenital heart problem presents to ED with episodes of syncope.

This is his ECG.

a. Describe the ECG. (5 marks)

Paced rhythm rate 75 bpmLoss of capturePeriod of ventricular standstillOccasional ventricular ectopic/escape beatsP waves rate 75 – 100 bpm, complete heart block

b. Name 5 potential causes for this appearance. (5 marks)

Lead breakage or displacement causing pacemaker failureFibrosis causing pacemaker failureElectrolyte abnormalityToxicological causes – Ca channel/B blocker/digoxin toxicityFailure to capture/needs check of threshold for capture

Source: Fellowship VAQ 2013.1

An elderly man collapses and is unresponsive at a shopping centre.

He receives prompt BLS from bystanders, then defibrillation from an AED prior to the arrival of the ambulance 10 minutes post-arrest. He is found to be in VF and does not revert with defibrillation by the ambulance crew. He is transported to the ED, where he is still pulseless and the monitor shows this rhythm.

What are your immediate actions? (8 marks)

Assume leadership, delegate rolesEnsure continuous BLS provided throughoutManual biphasic shock 200JContinue CPR 2 minutesDuring CPR:Check electrode positionSecure IV accessAdrenaline 1mg and repeat after second shock and every second loopCorrect reversible causes (4Hs,4Ts)Advanced airwayAmiodarone 300mg after 3rd shockPost-resuscitation care/12-lead ECG/reperfusion

From ARC Resuscitation guideline, online, accessed 5/8/2014

A 3 month old girl is brought in to ED with pallor and lethargy for the past hour. She has had fevers and URTI symptoms for the past 3 days.

Her observations are as follows:GCS 15/15 but floppy/lethargicHR 250 /minBP 75/45 mmHgCRT 2 secondsSat 95 %ATemp 38.2 °C

This is her ECG.

a. What is the most likely diagnosis? (1 mark)

SVT

b. What are 2 features of the ECG that support this diagnosis? (2 marks)

Rate is extremely fast – too fast for sinus tachycardiaNarrow complexNo P waves seen

c. List 3 treatment options in the order of escalation that you would perform them. (3 marks)

Vagal manouveurs – dunk head in ice water or cold face cloth dropped on face Adenosine IV 100mcg/kg (can double dose Q2min up to 400mcg) (Amiodarone IV 5mg/kg over 30 min)DCCV cardioversion – sync 0.25-0.5J/kg (with sedation)

d. List 4 investigations you would perform in the ED and their justification. (4 marks)

BSL/glucose – prolonged tachycardia could cause hypoglycaemia, hypoglycaemia as cause of floppiness FBC – anaemia leading to circulatory collapse, inc or dec WCC (sepsis)Electrolytes/renal function – potassium/calcium/magnesium – deficiencies leading to arrhythmiaCXR – look for cardiomegaly/signs of CHD/myocarditis, signs of LVF, focal infection Septic screen (blood culture, urine, consider LP) – sepsis as cause of SVT Urine toxicology screen – as cause of arrhythmia

A 24 year old women who is 10 weeks pregnant presents with suspected pulmonary embolus.

a. List five clinical features that would increase her likelihood of having PE. (5 marks)

utilise Well's criteria - 5 of clinical evidence DVT, alternative dx less likely Cf PE, tachycardia, immobilisation/surgery - recent/within 4/52, haemoptysis, active Ca

b. Describe the utility of the following investigations in this patient. (5 marks)

Investigation Utility1 D Dimer Can effectively exclude PE in low risk patients however more

false positives in normal pregnancy (rises with gestation)2 CXR May provide alternative diagnosis - pneumonia, LVF3 Lower limb US If positive can avoid CTPA/VQ and radiation risks; negative

scan cannot exclude PE4 CTPA High rates of nondiagnostic studies in pregnancy (35%) Cf.

VQ. Increased lifetime risk of breast ca. Comparable radiation. Useful if CXR abnormal/underlying lung disease

5 VQ First line imaging investigation. Low rates nondiagnostic VQ in pregnancy (4%). Not useful if CXR abnormal.

c. The patient has been diagnosed with pulmonary embolism. What are the ECG changes below? (1 mark)

TWI V1-4, III, AVF

d. What do the ECG changes suggest? (1 mark)

acute right ventricular strain/right ventricular dilation likely due to massive PE

e. The patient becomes hypotensive. List 4 treatment options (2 marks)

fluids, inotropes, thrombolysis, embolectomy

A 58 year old man with a PPM presents to your rural ED with palpitations intermittently for 8 hours.

His observations are:

P 60 /minBP 123/54 mmHgSats 96 % RAGCS 15

An ECG is done and is shown below.

a. What is the ECG diagnosis? (2 marks)

Failure to sense (spikes occurring after native QRS during absolute refractory period)

b. List 4 possible causes. (4 marks)

battery weak, lead damage, electrolyte imbalance, myocardial ischaemia; fibrosis at lead tip; dislodgment of lead ; sensitivity needs adjusting

c. Outline the major consideration of arranging his disposition. (4 marks)

Rural hosp ; no immed risk unless begins trying to pace on T wave , then risk VF. ThusObtain receiving hosp cardiology advice firstneeds TF to centre with PPM facilitiesurgency depends on cause (thus initial screen in rural ED )needs to be escorted by paramedics able to respond if arrhythmia and remain monitoredDepending on location and timing road vs air

A 55 year old man comes into ED with a history of gastroenteritis for 4 days.

His ECG is shown below.

a. What is the most important abnormality? (1 mark)

Long QT

b. List 3 important features to obtain from the history of presenting complaint. (2 marks)

Medication history esp macrolides; antipsychotics; antihistamines, antiarrhythmics, antidepressants; diuretics History of known QTc congen Comorbid disease contributing eg thyroid dysfunction; IHD, myocarditis renal dis Extent of GI losses: dehydration etc Severity of illness: abdo pain, fevr; blood in stool

c. List the most likely cause in this context and then 2 alternate differentials. (2 marks)

Likely hypo K (Mg or Ca); DDx drug use with impaired excretion eg ARF ; medication interaction; overdose; congenital cause; alcoholism (hypoMg);

d. List and justify your immediate management priorities. (5 marks)

At risk for arrhythmia Monitored bed IV access urgent VBG Avoid any meds that prolong QT Replace volume; monitor progress with UO, thirst, obs Replace electrolytes via IV infusion eg K+ 10mmol/hr Symptomatic Rx: antiemesis, analgesia Have Mg ready

A 68 year old woman presents with central chest heaviness and nausea. An ECG is performed and is shown below.

Her vitals are:BP 120/70 mmHgPR 60 /minRR 18 /minSaO2 99 % RA GCS 15

a. List the 4 most important features on this ECG. (2 marks)

No model answer provided

b. List 3 arrhythmias associated with these ECG findings. (3 marks)


c. You are 3 hours away from the nearest cardiac catheter facility. Describe how this might change your management approach. (3 marks)


d. List 2 important management differences between an inferior ST-elevation myocardial infarction and an anterior ST-elevation myocardial infarction. (2 marks)


A 48 year old man presents with dizziness and palpitations. An ECG is performed and is shown below.

The patient’s vitals are:BP 100/60 mmHgRR 18 /minGCS 15

a. What is the diagnosis? (1 mark)


b. List 3 features on this ECG which supports your diagnosis. (3 marks)


c. The patient’s BP drops to 70/40 mmHg and he becomes confused. Describe your 2 most important management priorities at this time. (4 marks)


d. Is implantable defibrillator an option in this patient? Justify your answer. (2 marks)


This 77 year old man presents with chest pain and dizziness on the background of Type II diabetes mellitus and a permanent pacemaker (PPM) for a sick sinus syndrome 3 years earlier. A recent PPM check was normal.

An ECG is performed and is shown below.

a. List 2 important abnormalities on this ECG. (2 marks)


b. What is the likely pacing mode shown in this ECG? (1 mark)


c. List 3 common pacing modes in use in Australia and the common clinical circumstances they are used in. (3 marks)


d. Describe your immediate management priorities in this patient. (4 marks)


A 46 year old man is brought to your ED by ambulance following an overdose of unknown medications. He has had a brief generalized seizure en route.

On arrival his observations are:GCS 12BP 85/60 mmHgTemp 37.0 °CO2 Sat 100 % on 8 L/min O2

His ECG is shown below:

a. Describe the ECG. (5 marks)


b. What are the first 5 things you would do to manage the patient? (5 marks)


A 36 year old man presents to the ED complaining of 3 hours of gradual onset central chest discomfort. The pain is heavy, worse on deep inspiration and radiates to his back. He is a smoker, denies the use of recreational drugs and has no other significant past medical history. His father had an MI at age 62 years. An ECG is performed and shown below:ECG Quiz 5ECG Quiz 5

Pericardial dz, diffuse ST eleva) List your two most likely differential diagnoses: (2 marks)

Pericarditis

Acute MI ?Pulmonary Embolus/dissection also acceptable

b) List 3 investigations that could be performed to enable differentiation between these two possible diagnoses with justifications for each. (6 marks)

Fever–pericarditis more likelyPericardial effusion/tamponade signs –muffled HS, raised JVP (pericarditis)

Pericardial rub –pericarditis more likley

PE ->pleural rub, tachypnoea, hypoxia, calf swelling

Dissection –r/r delay. Rfem delay, AR murmur, focal neurol, unequal BP armsc) Name 2 treatment interventions you would initiate for one of the possible diagnoses (2

marks):

_____ Pericarditis –nsaid, analgesia, drain tamponade Acute myocardial ischaemia –aspirin, clopidogrel, clexane, GTN PE; clexane, oxygen___ Dissection –aggressive BP reduction, beta blockade, analgesia…__________________________

A 48 year old man has been brought to the ED with chest pain and dizziness for the last 1hour.His vital signs are:GCS 14 E4 V4 M6BP 80/45 mmHgO2 sats 99% 6L O2 via maskTemp 36.5 degreesHis ECG is shown below.

1. What is your diagnosis of the rhythm displayed in the ECG? (1 mark)_________________________________________________________________________2. List 3 supportive features from the ECG. (3 marks)___________________________________________________________________________________________________________________________________________________________________________________________________________________________3. List 4 likely causes of this problem. (4 marks)___________________________________________________________________________________________________________________________________________________________________________________________________________________________4. List 3 management steps you will undertake in the ED. Provide doses whereappropriate. (6 marks)_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________1.VT2.Broad complex QRSTachycardia rate approx 180Presence of capture beats3.Cardiac IschaemiaElectrolyte – hypokalaemia, hypomagenesemiaDrug – eg tricyclicsPrimary arrhythmiaCongenitalCardiomyopathiesInfiltrative diseases(3 of 4 to pass)4.Sedate – fentanyl 25mcg boluses, midazolam 0.5 – 1mg bolusesSynchronized DC cardioversion – 100 – 200JCorrect underlying causeTotal pass 8/14 – corrects to 5.5/10

A 35 year old woman has been brought to your hospital by ambulance. Her husband arrived hometo find her unconscious on her bed. She had written a suicide note. An overdose is suspected,although no empty medication packets could be found.Her vital signs are:GCS 8 (E1 V2 M5)BP 75/45 mmHgO2 sats 99% 15L O2 via non-rebreatherTemp 36.0 degreesAn ECG is performed.

1. List the main abnormalities on the ECG (3 marks)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________2. What group of drugs most commonly give this clinical picture? (1 mark)________________________________________________________________________________After a brief period, the patient begins to have a generalised seizure.3. List your initial management steps, including drugs, doses and end-points whereappropriate. (10 marks)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

1.Broad QRS – between 160-200ms (CRITICAL)Terminal right axis deviation of QRSAbsolute QT prolonged about 480msPass 2 of 32.Tri-cyclic anti-depressantsPass 13.Terminate seizure– midazolam 2.5mg aliquotsSerum alkalinisation aiming for pH 7.5 (2 steps below so 4 marks)Intubateo – ketamine 100mg, rocuronium 100mgIV HCO3o – initial bolus 100mmolIV N/S bolus– 1000mL repeat if needed, for systolic BP >90mmHg (MAP >65mmHg)Noradrenaline infusion if needed for BP goal(3% saline if refractory hypotension, aiming for Na 150)1 mark for each concept, 1 mark for action detailsPass 6 of 10Total pass 9/14 corrects to 6/10

A 68 year old woman has been brought to your tertiary ED by ambulance. She has had chest pain forthe last 3 hours.On arrival, her vital signs are:GCS 15BP 80/40 mmHgO2 sats 100% 6L O2 via Hudson maskHer ECG is given below.

1. Give the rate, rhythm and axis of the ECG. (3 marks)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________2. Give the main pathology identified on the ECG, with evidence. (3 marks)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________3. List your treatment steps, including drugs and doses where appropriate. (6 marks)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

1.(accelerated) Junctional rhythm, rate 75/min, axis normalPass 3 of 32.Inferior STEMI – ST elevation II, III, aVF, reciprocal depression lateral leads (I, aVL)Probable R sided involvement – STE III>IIST depression V1 – V5 – reflects possible posterior involvement or else this too is reciprocalPass 2 of 33.Fluid load – IV N/S 500mL, aiming for BP >90mmHgAnalgesia – IV morphine aliquots 2.5mgAspirin 300mgClopidogrel (or other) 300-600mgHeparin bolus 4000-5000UUrgent consultation with interventional cardiologist to arrange PCI for reperfusion(Marking all or nothing ie must have step and dose correct (no ó marks))Pass 4 of 6Total pass 9/12 corrects to 7.5/10

ECG SAQ 2

SAQ 2

A 47 year old lady presented to the emergency department with syncope and altered conscious state. She has a past medical history of hypertension, paroxysmal atrial fibrillation and depression.

Her observations in the emergency department are as follows:GCS 14 (E3, V5, M6)BP 60/40 mmHg

An ECG is taken on arrival and shown on the page opposite.

1. Describe her ECG giving three (3) positive and two (2) relevant negative findings

2. Describe four (4) different steps you would take to treat her hypotension.

3. List two (2) pros and two (2) cons of using activated charcoal for this patient.

SAQ 2 feedback – Jo KerrThe differential diagnosis for a sinusoidal, wide complex rhythm between 80-120bpm with QRST fusion includes

• Sodium channel blocker toxicity • Hyperkalemia• AIVR• Tachycardia with aberrant conduction (BBB)• Massive ST elevation

1. Positive findings• Broad QRS complex ( > 200msec)• Prominent R wave aVR• R/S ratio aVR > 0.7• Borderline tachycardia ( rate 96)• QTc 506 msec

• Relevant negatives• Expect sinus tachycardia with TCA (>120)• QT 400msec• No AV block ( p waves before all complexes aVF)

• TCA OD– cause fatal arrhythmia attributable to blockade of cardiac sodium channels, – causing prolongation of the cardiac action potential, refractory period, and

atrioventricular conduction. • Cardiovascular features

– sinus tachycardia, which is caused by anticholinergic activity and inhibition of norepinephrine uptake

– hypotension, which is caused by reduced myocardial contractility and peripheral vascular α-adrenergic blockade.

• ECG – prolongation of the PR, QRS, and QT intervals;– nonspecific ST-segment and T-wave changes;– atrioventricular block;– right-axis deviation of the terminal 40-ms vector of the QRS complex in the

frontal plane;– R wave aVR > 3mm or R:S ratio > 0.7– right bundle-branch block; and the Brugada pattern.

• Prolongation of the QRS duration >100 ms predicts a higher risk of arrhythmia

2. 1.IV FluidEg N/saline with estimated amount or end pointPlease Remember that PAEDIATRIC pts have mls/kg

2.Sodium Bicarbonate 50-100mmol IV stat then every 3-5 min until perfusing rhythm then continue (q 15-30min) aim QRS < 100msec3.Inotrope With example eg Adrenaline / Noradrenaline 4.Other ETT/hyperventilate/pH 7.5

Balloon pump/ECMO/BypassIntralipidInsulin Euglycemia RxRx for hyperK

Sage Adviceguidance or recommendations offered with regard to prudent action.

• Make sure you indicate clearly which part you are answering• Please don’t write

– Repeat as necessary– Repeat as required

You need to provide that information• If the question says 4 DIFFERENT steps

– Don’t write 3 different inotropes• DCR is not recommended for wide QRS from Na channel blockade or

hyperkalaemia

3. DO NOT USE• Cheap• Accessible • Easy to use• Messy• Interferes with resuscitation• Time consuming• Corneal abrasions

Single dose activated charcoalPro

• Useful if ingestion of potentially toxic amount of poison that is absorbed by charcoal. • Highly effective if < 1/24 from ingestion but if delayed gastric emptying extend out to

2-3 hrs.Con:

• Vomiting• compromised airway or GCS unless intubated• absent BS• charcoal resistant poison ( eg lithium)

Enhanced eliminationMultidose activated charcoalPro:

• increased effectiveness if large amount ingested or delay to drug dissolution ( SR, enteric coated, slow GI motility, formation of concretions) carbemazepine dapsone phenobarb quinine theophylline

• Effective for drugs with enterohepatic circulation, High binding capacity, small Vd, low protein binding, drug not ionized at physiological pH

Con:• ileus/ perforation/ obstruction• Decreased mental state or unprotected airway• More complications than single dose charcoal• Increased risk aspiration / obstruction/ perforation

ECG SAQ 15

SAQ 15

A 45 year old man presents with vague symptoms of central dull chest pain and mild shortness of breath on exertion for the past 3 days.

His observations are:

Temperature 37 oCBP 120/70 mmHgRR 18 /minO2 saturations 99% on room air

An ECG is taken and is shown on the opposite page

1. Interpret his ECG giving three (3) positive findings.

2. List four (4) differential diagnoses for this appearance on the ECG.

3. List three (3) features on assessment that would determine disposition.

Feedback – Pourya Pouryaha

READ the question first then START with the elephant on the ECG:Things to consider before answering this question:

READ the Question and answer THE QUESTIONtry to guess the sense (Flavour if you wish) of the question (what is it asking???—Ischemia/dysrhythmia/anything specific that I should know,…)Consider it as a real patient in front of you or in this case a nurse showing you an ECG in a busy shift —> what’s your immediate response ? —> I hope it is ‘’ Where is this patient ?? ‘’Have a systematic approach,don’t just look for findings (Always check calibration)for higher Marks give appropriate informations (Extras) ie instead of Sinus tachycardia you can easily calculate rate and write ST ~138bpm

ELEPHANT here : Electrical alternans ,Low Voltage,Sinus Tachycardia 138 bpm less important :prolong QTc ,poor R wave progression ,maybe non specific PR/ST-T changes

*** most candidate didn’t notice ‘’interpret ‘’ in part (a)*** don’t make up signs (bigeminy/ashman phenomenon,…)***answer the question and don’t waste your time ie: just positive findings are asked here,don’t write negativesinstead of : regular narrow complex tachycardia ,sinus wave with rate 138 bpm you can simply write: Sinus tachycardia Rate ~138 bp

***DDX for ECG appearance not Sinus tachycardia or cause of effusion;you can start from simple i.e. Obesity or more important ones for higher marks (here :pericardial effusion,…)

version A:

1 Pericardial effusion, Pleural Effusion 2 Emphysema

3 Pneumothorax or Pneumopericardium 4 Subcutaneous emphysema

5 Severe hypothyroidism (myxoedema)6 End-stage dilated cardiomyopathy7 Old large MI8 Infiltrative/restrictive diseases such as amyloidosis or hemochromatosis.

9 Obesity

Version B:

• “Low Power/Weak Battery”• Infiltrative diseases (Amyloid, Sarcoid, etc.)• End stage cardiomyopathy • Myxedema (severe hypothyroidism)• Conduction blockage• Fluid/Effusion (pericardial or pleural)

• Fat (obesity)• Air (COPD, PTX)

for higher mark use scoring system,validated criteria etc as a frame work and list according to priority, also give disposition options (ICU/HDU/Ward with telemetry/Home,…); for example in this question :

disposition according to haemodynamic situation and Pericardial effusion scoring index based on : 1.Echocardiographic assessment of haemodynamics 2.effusion Size on echo 3. aetiology of effusion (not all relevant in this case) a)infective - viral most common (coxsakie,CMV,Echo,HIV) - other: bacterial/ fungal /TB b)Uremia c) autoimmune (SLE,RA,..) d)malignancyLess relevant here but to consider: e)MI f)Trauma

score>4 —> will need pericardiocentesis

*** consideration of social circumstances and follow up

always consider discharge planning at the end,ie in this case if good F/u AND LOW Pericardial effusion scoring index <3 at initial presentation without haemodynamic compromise (clinically/radiologically)

SAQ 4 (STEMI)

A 48 year old male self presents to ED.

He is complaining of severe, heavy central chest pain with sweating, nausea and shortness of breath.The pain has been present for one hour.

You work in an ED that is 65 minutes from interventional services.Initial vital signs are:

BP 95/55,P 125 regular,SaO2 92 % on 6l via Hudson mask

His ECG on arrival is below.

1. Interpret the ECG giving three positive findings.

2. List five (5) drugs (with doses) needed within the first hour of arrival to ED.

3. Outline four factors that will determine definitive treatment of this patient

Answers

Q1. Critical LAD STEMI Widespread anterior ST depression Sinus tachycardia

(SAQ 4 contd…)

Q2. Oxygen: titrated to keep SaO2 > 95% Aspirin: 300mg orally stat GTN: 1-2 sprays sublingual, patch, infusion (50mg in 100mg normal saline titrated to pain and BP) 11a111b inhibitor: clopidogrel 600mg orally stat, prasugrel 60mg orally stat, ticagrelor 180mg orally stat Heparin versus clexane: heparin 5000 iu stat IV, clexane 1mg/kg s/c stat Morphine/fentanyl: morphine 0.1mg/kg titrated to effect IV, fentanyl 1µg/kg IV or intranasal titrated to

effect Anti-emetic: maxolon 10mg IV, ondansetron 4mg s/l Thrombolysis: tenectaplase dose adjusted to weight Inotrope: adrenaline, metaraminol, dobutamine as required.

Q3. Time from pain onset Haemodynamic stability Continuous pain post thrombolysis Non PCI centre and delayed transport: thrombolysis within 30 mins of making decision Time to reaching cath lab – optimal less than 90 mins if large area at risk but acceptable up to 120 mins Successful thrombolysis to angiography less than 24 hours

A 55yo male is BIBA with severe CP of 45 minutes duration. He has had oxygen, 600mcg of GTN, 300mg of oral aspirin followed by 250mls of NS for hypotension. ECG attached (assume standard

calibration and paper speed)

(a) What is the diagnosis from this ECG? (15%)(b) What are the most likely causes for acute hypotension in this setting? (30%)(c) What are the principal interventions for cardiogenic shock in AMI? (20%)(d) List 8 absolute contraindications to giving fibrinolytic therapy. (35%)

Answers 13(a) What is the diagnosis from this ECG? (15%)

Extensive STEMI: anterior and lateral, in the territory of the LMCA (LAD)Marking (a) 15% of total for question 13.Pass/fail (zero or 15%). Must include STEMI and the territory

and comment that it is large/extensive

(b) What are the most likely causes for acute hypotension in this setting? (30%)

Cardiogenic shock from large ischaemic muscle mass LV, tamponade from aortic dissection or free wall rupture, rupture of a papillary muscle, medications (GTN and narcotics), drug interaction with a phosphodiesterase inhibitor eg viagra.

Marking (b). 30% of total score for question 13.Fail (zero) if did not mention cardiogenic shock/large

ischaemic muscle mass.5% each cause listed up to 30%

(c) What are the principal interventions for cardiogenic shock in AMI? (20%)

Aspirin 300mgHeparin/enoxaparinClopidogrel 300-600mgSupport his BP with IV NS or Hartmanns (+/- vasopressors and inotropes, IABP debated)Oxygen, given that he is shockedUrgent revascularization. PCI preferred.

- Primary PCI if available (balloon deployment within 90 minutes of arrival for cardiogenic shock). Otherwise fibrinolysis if not C/I. (Time to Primary PCI balloon inflation is longer if > 3hours from symptom onset)

- Fibrinolysis if not C/I when there will be a delay to PCI , ie if (Door to balloon

time) minus (door to needle time) > hour- Secondary PCI, after primary fibrinolysis when Primary PCI will be delayed

Marking (c). 30% of the total score for question 13.Pass (15%): Supportive and specific therapies and concept

that PCI is preferred but at times fibrinolysis is indicated. Additional marks for specific time requirements.

Additional marks for clopidogrel and heparin, up to 30%

(d) List 6 absolute contraindications to giving fibrinolytic therapy. (35%) Haemorrhagic CVA (ever), or unknown type of CVA ever

Ischaemic CVA within 6 monthsCNS lesions (tumours, A/V malformations)CNS (< 3 months), major surgery/trauma/head injury (< 3 months)GIH < 1 monthKnown coagulation disorderAortic dissection

Marking (d). 35% of total for question 13.Pass ( 18%)= 4,Additional 9% for each extra up to 35%

Question 14:A 74yo, normally active and independent female presents with light headedness. PR 30bpm, BP 70/40. She is on no medications. She denies chest pain at any stage.

(a) What is the diagnosis from this ECG? (20%)(b) What are your options for managing this condition acutely? (40%)(c) Describe the steps in external pacing (40%)

Answers(a) What is the diagnosis from this ECG? (20%)

CHB (variable PR interval, widened QRS with RBBB pattern (Purkinge origin)Rate dependent (manifests with high atrial rate)

Marking. 30% of the total for question 14

Pass/fail (zero): CHB/3rd degree block

(b) What are your options for managing this condition acutely? Give pros and Cons (40%)

ReassurancePros – may work for rate dependent CHB such as this (avoids drugs)Cons – recurrence with elevated catecholamines, eg hypotension!

Atropine 300mcg – 1mgPros - generally well tolerated, useful if high vagal toneCons - Doesn’t always work

- blurred vision, dry mouth, confusion in the elderly- May make rate dependent CHB worse by increasing the atrial rate

GlycopyrolatePros - Better tolerated than atropine (less confusion)Cons - Doesn’t always work

- Availability- blurred vision, dry mouth- May make rate dependent CHB worse by increasing the atrial rate

AdrenalinePros - - effects May increase rate and contractility and

- - effects May increase BP and organ perfusion including coronary arteryCons - Doesn’t always work

- May make rate dependent CHB worse by increasing the atrial rate- Increased myocardial oxygen demand-

IsoprenalinePros - - effects May increase rate and contractility and less - effectsCons - Doesn’t always work

- Tachycardia and increased myocardial oxygen demand

External pacingPros – Will usually get capture

-quick and availableCons - Discomfort, requires sedation

Internal pacingPros – will usually get capture even when external pacing doesn’tCons – requires equipment and expertise that may not be available

- Central access risks (bleeding, deterioration during procedure, infection)

Marking. 40% of the total for question 14Pass = 30%. Requires Atropine, isoprenaline,

external and internal pacing and 1 pro and 1 con for each

Additional 10% each for Reassurance and for Adrenaline with at least 1 pro and 1 con

for each. Maximum 40%(c) Describe the steps in external pacing (40%)

Inform patient if consciousPads positioned correctlySelect pacing optionSelect synchronized if availableNominate mAmps: may elect to start at 30 and build up, or at 60-120mAmps and wean down depending on urgency to establish captureNominate rate 60-80bpmStart pacing and titrate analgesia (eg fentanyl IV)Ensure capture (palpate pulse/art line)Titrate mAmps, allow 50% above capture threshold

Marking. 30% of the total for question 14

Pass/fail (zero)Sound description, that must include nominates

mAmps and rate, ensures capture, provides analgesiaOverall pass 60%

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