Arrhythmias-jaynstein (EKG cases) Flashcards
Pt is a 64 year old man with a history of HTN and DM-II who presents to your primary care office for evaluation of a near syncopal episode that occurred a week ago. He has no complaints today. Before you even step into the room, your fabulous MA has already obtained an EKG which she hands you; even better, she even has pulled up his prior EKG for you to review. Old EKG: NSR, New EKG: LBBB with appropriate discordance Based on the Pt’s presentation, what is the workup? (what labs must be ordered?)
Based on pt presentation–> A 64 yo with co-morbidities should be worked-up extensively! -SEND TO ER -EKG, trop, CXR, HTN work-up (BMP, UA), echo, holter monitor, ? infectious work-up
New LBBB with symptoms (i.e. syncopal episode) what is the treatment?
Pts with a new LBBB require complete cardiac evaluation, and those with a LBBB and near-syncope or syncope may require a pacemaker** -A new LBBB needs hospital admission and cardiology eval -Cardiology consult
Pt with new onset LBBB with near syncopal/or syncopal episode is at a significantly increased risk of ______
cardiac death within the next year (progresses to complete heart block). -GET a cardiology consult immediately
New onset LBBB: outpatient plan?
New LBBBs need to be sent to the ER if symptomatic, or be discussed with cardiology if asymptomatic to ensure adequate plan is made.
Causes of new LBBB (lsit ex’s)
-Aortic stenosis -Dilated cardiomyopathy -Acute MI -Extensive CAD -Primary disease of the cardiac electrical conduction system -Long standing HTN leading to aortic root dilatation and subsequent aortic regurgitation -Lyme disease -Myocarditis
Sx’s of new LBBB:
**Many asymptomatic -Fatigue, decreased exercise intolerance, near/syncope -Sxs may be secondary to underlying cause
____% of Pts with LBBB have HF
1/3
what criteria is used to evaluate for potential MI in new onset LBBB? (list the name and the criteria)
*sgarbossa criteria Concordant ST elevation > 1mm in leads with a positive QRS complex (score 5)
Concordant ST depression > 1 mm in V1-V3 (score 3)
Excessively discordant ST elevation > 5 mm in leads with a -ve QRS complex (score 2)
Your patient is a 78 year old female with a long standing history of a-fib, mechanical mitral valve replacement, high cholesterol, osteoporosis, depression, and urinary frequency, who presents to your primary care clinic for her annual exam. Her medications include: Coumadin 5mg QOD, Simvastatin 20mg QD, Celexa 20mg QD, Tylenol PRN, Vitamin D and Calcium supplementation.
On today’s visit, her vital signs are as follows: BP 134/86, HR 88, RR 18, Temp 98.6, O2 sat 94% RA.
Her EKG shows: _______
What is your next step?
EKG: shows Afib, rate controlled (ventricular rate?)
Work-up: Remember, she is here for her annual exam, she just so happens to have afib!
Additional questions do you have for this patient? (A fib Pt)
When is the last time she had her INR checked? Spontaneous bleeding? Any symptoms - CP, SOB, lightheadedness, syncope, etc. Compliant with meds? Last cardiac check-up?
If her INR comes back supratherapeutic at 6.2, what is your plan?
(CHEST guideline: INR between 5.0-9.0 with NO bleeding, ________)
5.0-9.0 NO bleeding – hold 1-2 doses
If her INR comes back subtherapeutic at 1.3, what is your plan?
Increase coumadin accordingly. Goal INR: 2.5-3.5 since pt has a mech valve with a fib. and re-check INR
-wait at least 2 days before rechecking INR
IF INR comes back >9.0 with no bleeding, what should you do?
STOP warfarin, follow INR and restart when therapeutic, maybe consider oral vitamin K (low dose 2.5mg PO)
Any elevated INR with “major bleeding” give _______
IV Vit K (10mg IV) and FFP, maybe PCC
. What patient education should you provide to patients on Coumadin?
- Warfarin should usually be started at a dose of 5 mg per day.
- Amiodarone, fluconazole, metronidazole, trimethoprimsulfamethoxazole, and many other drugs inhibit the metabolism of warfarin.
- The INR should be checked at least four times during the first week of therapy and then less frequently, depending on the stability of the INR.
- discuss the influence of dietary vitamin K (ie spinach in large volumes can lower INR)- warfarin=vit k antagonist
- warn Pt about their increased bleeding risk (i.e avoid trauma)
Can a Pt with a fib and a mechanical valve be switched to a DOAC?
DOAC contraindicated with mechanical valve — DOACs should not be used in patients with mechanical prosthetic heart valves. All patients with mechanical prosthetic valves require lifelong VKA (eg, warfarin) anticoagulation. Additional indications for anticoagulation, such as atrial fibrillation (AF), may require a higher goal INR than for the mechanical valve alone.
Dabigatran is specifically contraindicated in patients with mechanical heart valves.
You are working in a busy ER when the triage nurse tells you they just placed a patient in room 4 “who doesn’t look good” and asks to come immediately. The patient is a 55 year old man who appears anxious, pale, and diaphoretic. When you ask how he is feeling he replies “I don’t feel well” but cannot elaborate further. Your ER team quickly connects the patient to a cardiac monitor and obtains the following vital signs:
VS: BP 88/62, HR 43, RR 28, afebrile, 94%RA
His EKG: what does it show?
EKG: Sinus Bradycardia (symptomatic)
Causes of symptomatic sinus bradycardia:
SSS, medications (bb, opioids, dig, lithium, CCBs), AMI (15-25% of AMIs are bradycardic), increased intracranial pressure (stroke), hypothyroidism, hypothermia, hypoxia
symptomatic sinus brady:
-what other symptoms may be present?
SxS:
Related to underlying cause
Lightheadedness, presyncope or syncope, worsening of angina pectoris or heart failure, cognitive slowing, exercise intolerance, and generalized fatigue
What would you like to order for your work-up? (Symptomatic bradycardia in a 55yo man)
Is he stable or unstable?
Symptomatic bradycardia in a 55yo man needs a broad work-up – lean heavily on H&P
◦Trop, TSH, CBC, BMP, medication levels (if applicable), Mg, EKG….
◦Serial EKGs and continuous cardiac monitoring
◦Place pacer pads
**Unstable!!–> symptomatic, hypotension, chest discomfort, altered mental status, or shortness of breath
Symptomatic sinus brady Pt workup flow chartcase 3 flow chart
15 min later after 1 dose of atropine was given, (55 yo sinus brady symptomatic Pt)
EKG shows:
-inverted T waves in lead 3– indicates early ischemia that can progress so keep on monitoring
You are on shift in the ER and the next patient you sign up to see is a 38 year old female who presents complaining of a “racing heart.”
Her vitals sign are: BP 138/90, HR 158, RR 20, Afebrile, 97%RA.
Her EKG: shows?
EKG: shows SVT, hemodynamically stable
Additional questions do you have for this patient? (woman in SVT)
Has this ever happened before, current meds, caffeine intake, illicit drugs, LMP
