First assessment: the emergency setting.

First assessment: the emergency setting. • How ill? • Pain? Cardiac or pulmonary embolic • Level of consciousness • ?Forwards failure: colour, BP, urine output • Backwards failure: colour, breathing, crackles • Establish rhythm • Decide aims of treatment • Consider underlying causes (MI, PE, endocrine, bleeding, sepsis, poisoning….)

Bradyarrhythmias in the acute setting • CHB: • complication of MI • high in the His bundle: rate ~50 -60, with narrow complexes • low: rate ~15-40 with broad complexes • cannon waves • ?heart failure or BP well maintained • Atropine/isoprenaline • Pace

Bradyarrhythmias in the acute setting • New BBB • MI or PE • Normal rate • Bifascicular block (usually RBBB with L axis) as a risk for CHB • Split second sound • Usually no intervention • BFB in MI: consider prophylactic wire

Bradyarrhythmias in the acute setting • Beware: • hyperkalaemia (>7.0mM) hypermagnesaemia (often ARF). • Raised ICP • Hypothermia • Hypothyroidism

SV tachycardias • Atrial flutter • usually organic heart disease • atrial rate 280 to 350 • ventricular rate (usually block) ~150 • DC • Ia (disopyramide), Ic (flecainide, propafenone), III (amiodarone, sotalol) • Anticoagulation not usual

SV tachycardias • Atrial fibrillation • organic HD or thyrotoxicosis; occasionally alcohol • atrial rate >400; ventricular rate variable (120-180) • DC • Ia Ic III. • Anticoagulation usual

SV tachycardias • Junctional • usually no organic HD but often electrocardiographic abnormalities • AV node re-entry or Atrioventricular re-entry • 140-280, narrow complex regular • Vagus • Adenosine (bronchospasm) • Verapamil or -blocker

V tachycardias • VPB • in the setting of MI • early VPB (‘R on T’) • concern about degeneration into VT • VT • rate ~120-220, ill, hypotensive • a/v dissociation with canon waves • I, II or III (I think most people would use lignocaine). • DC

First assessment: the cold setting. • Age • History (presents with palpitation, LOC, pain, dyspnoea) • duration and periodicity • triggers • accompanying features (pain, dyspnoea, LOC, weight loss, sweats) • risk factors • Past history: HBP, MI, PVD, DM, thyroid • Drugs • Smoking • DOES THIS WARRANT EMERGENCY INVESTIGATION?

First assessment: the cold setting • Examination: • cardiovadscular: CCF, PVD, VHD • endocrine: hyper and hypothyroidism (DM) • metabolic: xanthalesmata

Investigation • TFT • Na, K, U, Cr, LFT/MCV • CXR (?tumour) • 12-lead • 24 h tape and cardiac event monitor • Echocardiography

Common syndromes • Sinus node disease • paroxysmal brady/tachy in elderly patient • Pacing • Anticoagulation • Paroxysmal AF • sotalol or amiodarone • ?anticoagulate or aspirin

Common syndromes • Paroxysmal re-entrant SVT • -blocker, IV, • I or III

First assessment: the emergency setting.